Conditions: Small Cell Lung Cancer Lung Cancer Relapsed Small Cell Lung Cancer
Keywords: SCLC Lung Cancer Lung Disease Relapsed SCLC
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 14
Healthy volunteers: no

Brief summary:
The purpose of this study is to find out what effects (good and bad) immunotherapy treatment using the p53 vaccine (Ad.p53-DC) in combination with Nivolumab and Ipilimumab has on small cell lung cancer. Immunotherapy is a cancer therapy that uses the body's immune system to fight cancer cells.

This study can be divided into three different phases: initial Induction Immunotherapy, Maintenance Immunotherapy and Retreatment.

Detailed description:
During the Induction Immunotherapy phase (4 x 21 day cycles) of the study, participants will receive Ipilimumab and Nivolumab on Day 1 of each cycle for 4 cycles. Participants will receive the p53 vaccine on Days 1 and 15 of cycle 1 and then again on Day 8 of Cycle 2.

Beginning on Day 1 of Cycle 5 participants will start Maintenance Immunotherapy. During this phase of the study, participants will receive Nivolumab only on Day 1 of every 4 week period. Participants will also receive the p53 vaccine three additional times (every 4 weeks over a 12 week period). During Maintenance Immunotherapy you will continue to receive Nivolumab only on Day 1 of each additional 4 week period that you take part until your disease progresses.

The Retreatment phase of the study may be available to participants whose doctor feels they would benefit from retreatment and if they qualify for this retreatment. During retreatment, participants would receive the combination of Ipilimumab and Nivolumab or Nivolumab alone every three weeks for a maximum of one additional year.

P53 Vaccine production

The p53 vaccine will be made by inserting the p53 gene (a gene is a hereditary unit of all living organism within a cell) into a subset of the participant's own white blood cells. The insertion of the gene into their white blood cells will occur in the laboratory, after their cells have been extracted from their body through a procedure called leukopheresis (similar to dialysis).

Arms:
arm 1: Combination immunotherapy with Ipilimumab and Nivolumab plus a Dendritic Cell based p53 Vaccine (Ad.p53-DC). Induction Immunotherapy, followed by Maintenance Immunotherapy and potentially Retreatment. During retreatment, participants would receive the combination of Ipilimumab and Nivolumab or Nivolumab alone every three weeks for a maximum of one additional year.

Interventions: intervention 1: Nivolumab intervention 2: Ipilimumab intervention 3: Dendritic Cell based p53 Vaccine
Intervention descriptions: intervention 1: Nivolumab (BMS-936558) is an anti-PD-1 antibody. It works by attaching to and blocking a molecule called PD-1. Induction Immunotherapy Phase (4 x 21 days cycles): Nivolumab on Day 1 of each cycle for 4 cycles. Maintenance Immunotherapy beginning on Day 1 of Cycle 5: Nivolumab only on Day 1 of every 4 week period. Participants will continue to receive Nivolumab only on Day 1 of each additional 4 week period that they take part until their disease progresses. The Retreatment phase of the study may be available to participants whose doctor feels they would benefit from retreatment and if they qualify for this retreatment. intervention 2: Ipilimumab is an antibody (a type of human protein) that is approved to treat patients with metastatic melanoma. In this study, the use of ipilimumab is investigational. Induction Immunotherapy Phase (4 x 21 days cycles): Ipilimumab on Day 1 of each cycle for 4 cycles. The Retreatment phase of the study may be available to participants whose doctor feels they would benefit from retreatment and if they qualify for this retreatment. intervention 3: Dendritic Cell based p53 Vaccine (Ad.p53-DC). The p53 vaccine will be made by inserting the p53 gene (a gene is a hereditary unit of all living organism within a cell) into a subset of the participant's own white blood cells. The insertion of the gene into their white blood cells will occur in the laboratory, after their cells have been extracted from their body through a procedure called leukopheresis (similar to dialysis). Induction Immunotherapy Phase (4 x 21 day cycles): Participants will receive the p53 vaccine on Days 1 and 15 of cycle 1 and then again on Day 8 of Cycle 2. Maintenance Immunotherapy beginning on Day 1 of Cycle 5: p53 vaccine three additional times (every 4 weeks over a 12 week period).

Protocol document:
Prot_SAP_000.pdf: 
 
Combination Immunotherapy with Ipilimumab and Nivolumab plus a Dendritic 
Cell based p53 Vaccine (Ad.p53-DC) in patients with relapsed Small Cell Lung 
Cancer (SCLC) 
 
NCT03406715 
 
Version 8 
September 19, 2018 


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SPONSOR: Moffitt Cancer Center 
 
Protocol Title: 
Combination Immunotherapy with Ipilimumab and Nivolumab 
plus a Dendritic Cell based p53 Vaccine (Ad.p53-DC) in patients 
with relapsed Small Cell Lung Cancer (SCLC) 
 
BMS Protocol Number: 
CA209-9KN  
 
Moffitt Protocol Number:    MCC 19163 
 
MultiVir Protocol Number: MVIR-Adp53DC-001 
 
 
 
Principal Investigator: 
Alberto Chiappori, MD 
 
 
 
 
Senior Member 
 
 
 
 
Thoracic Oncology Department 
 
 
 
 
Moffitt Cancer Center 
 
 
 
 
12902 Magnolia Drive 
 
 
 
 
Tampa, FL 33612 
 
 
 
 
Phone: 
813-745-3050 
 
 
 
 
Fax:  
813-745-3027 
 
 
 
 
Email:  
alberto.chiappori@moffitt.org 
 
    
Version/Date: 8/September 19, 2018 
   
 
 
Amendment/date: 
7/September 19, 2018 
 
 


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TABLE OF CONTENTS – INDEX 
 
1.0 
TRIAL SUMMARY ..................................................................................................... 6 
2.0 
TRIAL DESIGN ........................................................................................................... 7 
2.1 
Trial Design .............................................................................................................. 7 
2.2 
Trial Diagram ............................................................................................................ 7 
3.0 
OBJECTIVES & HYPOTHESES ................................................................................ 7 
 
General Scientific Hypothesis……………………………………………………...7 
3.1 
Primary Objectives & Hypotheses ............................................................................ 8 
3.2 
Secondary Objectives & Hypotheses ........................................................................ 8 
4.0 
BACKGROUND & RATIONALE .............................................................................. 8 
4.1 
Background/Introduction .......................................................................................... 8 
4.1.1 Overview of Small Cell Lung cancer .................................................................... 8 
4.1.2 p53 as a Target for Cancer Immunotherapy.......................................................... 8 
4.1.3 
Anti-p53 Dendritic Cell Based Immunotherapy………………………………9 
4.2 
Vaccine (Ad.p53-DC) Immunotherapy .................................................................... 9 
4.2.1 Manufacturing of Ad.p53-DC ............................................................................... 9 
4.2.2 Preclinical Animal Studies with Ad.p53-DC ...................................................... 10 
4.2.3 Preclinical Experiments Using Human T cells ................................................... 11 
4.3 
Phase I/II Clinical Trial of Ad.p53-DC in SCLC ................................................... 11 
4.3.1 Study Design and Patient Characteristics  .......................................................... 11 
4.3.2 Ad.p53-DC Dose and Safety  .............................................................................. 12 
4.3.3 Immune Response to Ad.p53-DC  ...................................................................... 12 
4.3.4 Clinical 
Efficacy 
of 
Ad.p53-DC 
and 
Enhanced 
Effect 
on 
Salvage 
Chemotherapy…………………………………………………………………………..13 
4.4 
Improved Ad.p53-DC Immunotherapy Strategy………………………………….13 
4.4.1    Role of MDSCs in the Immune Response………………………………………13 
4.4.2 Rationale for the Use of ATRA in Combination with Ad.p53-DC……………..14 
4.4.3 Randomized Phase II Clinical Trial in SCLC…………………………………..14 
4.5 
Checkpoint Inhibitors Immunotherapy…………………………………………...18 
4.5.1 Nivolumab……………………………………………………………………....18 
4.5.2    Ipilimumab…………...…………………….…………………………………...19 
4.6      Study Rationale…………………………………………………………………...19 
4.6.1    Rationale for Immuno-Oncology Therapeutic Approaches in SCLC…………19 
4.6.2    Rationale for Nivolumab/Ipilimumab Combination in SCLC…………………..20 
4.6.3    Rationale for the Use of ipi-Nivo in Combination with Ad.p53-DC…………21 
5.0 
METHODOLOGY ..................................................................................................... 22 
5.1 
Entry Criteria .......................................................................................................... 22 
5.1.1 Diagnosis/Condition for Entry into the Trial ...................................................... 22 
5.1.2 Subject Inclusion Criteria.................................................................................... 22 
5.1.3 Subject Exclusion Criteria .................................................................................. 23 
 5.1.4    Women and Minorities……………………………………………………….24 
 5.1.5    Women of Childbearing Potential……………………………………………24 
5.2 
Trial Treatments ...................................................................................................... 25 
5.2.1 Dose Selection/Modification .............................................................................. 25 
5.2.1.1    Dose Selection…………………………………………………………...25 


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5.2.1.2    Dose Modification………………………………………………….……25 
5.2.2 Timing of Dose Administration .......................................................................... 27 
5.2.3 Trial Blinding/Masking ....................................................................................... 28 
5.3 
Randomization or Treatment Allocation ................................................................ 28 
5.4 
Stratification ............................................................................................................ 28 
5.5 
Concomitant Medications/Vaccinations (allowed & prohibited) ........................... 28 
5.5.1 Acceptable Concomitant Medications ................................................................ 28 
5.5.2 Prohibited Concomitant Medications.................................................................. 28 
5.6 
Rescue Medications & Supportive Care ................................................................. 29 
5.6.1 Supportive Care Guidelines ................................................................................ 29 
5.7 
Diet/Activity/Other Considerations ........................................................................ 30 
5.7.1 Diet ...................................................................................................................... 30 
5.7.2 Contraception ...................................................................................................... 30 
5.7.3 Use in Pregnancy ................................................................................................ 31 
5.7.4 Use in Nursing Women ....................................................................................... 31 
5.8 
Subject Withdrawal/Discontinuation Criteria ......................................................... 31 
5.8.1 Discontinuation of Study Therapy after CR ....................................................... 32 
5.9 
Subject Replacement Strategy ................................................................................ 32 
5.10 
Clinical Criteria for Early Trial Termination .......................................................... 32 
5.11 
Assessment of Outcomes………………………………………………………….33 
5.11.1   Safety Assessments…………………………………………………………..33 
5.11.2   Clinical Efficacy……………………………………………………………..33 
5.11.3   Immunological Efficacy……………………………………………………..34 
5.11.4 Biomarker Testing …………………………..…………………………………34 
6.0 
TRIAL FLOW CHART .............................................................................................. 35 
 
6.1 
Second Phase Flow Chart ………………………………………………..….37 
7.0 
TRIAL PROCEDURES .............................................................................................. 39 
7.1 
Trial Procedures ...................................................................................................... 39 
7.1.1 Administrative Procedures .................................................................................. 39 
7.1.1.1   Informed Consent……………………………………………………...39 
7.1.1.1.1    General Informed Consent………………………………………….39 
7.1.1.2   Inclusion/Exclusion Criteria……………………..……………………….39 
7.1.1.3   Medical History…………………………………………………………..40 
7.1.1.4   Prior and Concomitant Medications Review……………………………..40 
7.1.1.4.1 
Prior Medications…………………………………………………….40 
7.1.1.4.2 
Concomitant Medications…………………………………...……….40 
7.1.1.5   Disease Details and Treatments…………………………………………….40 
7.1.1.5.1 
Disease Details……………………………………………………….40 
7.1.1.5.2 
Prior Treatment Details………………………………………………40 
7.1.1.5.3 
Subsequent Anti-Cancer Therapy Status…………………………..40 
7.1.1.6   Assignment of Screening Number………………………………………..40 
7.1.1.7   Assignment of Randomization Number…………………………………….41 
7.1.1.8   Trial Compliance (Medication/Diet/Activity/Other)….……………………41 
7.1.2 Clinical Procedures/Assessments ........................................................................ 41 
7.1.2.1   Adverse Event (AE) Monitoring……………………………………………41 
7.1.2.2   Full Physical Exam……………………………………………………….41 


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7.1.2.3   Directed Physical Exam…………………………………………………….41 
7.1.2.4   Vital Signs…………………………………………………………………..42 
7.1.2.5   Eastern Cooperative Oncology Group (ECOG) Performance Scale……..42 
7.1.2.6   Tumor Imaging and Assessment of Disease……………………………...42 
7.1.2.7   Laboratory Procedures/Assessments……………………………………..42 
7.1.2.8   Pharmacokinetic/Pharmacodynamic Evaluations………………………...44 
7.1.3 Other Procedures- Leukopheresis ....................................................................... 44 
7.1.4  Withdrawal/Discontinuation…………………………………………………...44 
7.1.5 
Tumor Tissue Collection and Correlative Studies Blood Sampling…………...45 
7.1.5.1   Evaluation of p53-specific immune response against TAAs ........................ 45 
7.1.5.1.1     Analysis of IFN-γ production by PBMC ............................................ 45 
7.1.5.1.2 
Analysis of cell proliferation and IL-2 production…………………45 
7.1.5.2   Determination of the relationship between MDSC numbers and anti-p53 T 
cell responses………………………………………………………………………..45 
7.1.5.3   Analysis of other immune cells…………………………………………..46 
7.1.5.4   Immunohistochemical Stains……………………………………………..46 
7.1.6  Visit Requirements ............................................................................................. 46 
7.1.6.1   Screening……………………………………………………………………46 
7.1.6.1.1 
Screening Period…………………………………………………..…46 
7.1.6.2   Treatment Period……………………………………………………………46 
7.1.6.3   Post-Treatment Visits……………………………………………………….47 
7.1.6.3.1    Safety Follow-Up Visit……………………………………………..47 
7.1.6.4   Follow-up Visits………………………………………………………….47 
7.1.6.4.1 
Survival Follow-up………………………………………………...47 
7.1.6.5 Second Course Phase (Retreatment Period)……………………………….47 
7.2 
Assessing and Recording Adverse Events .............................................................. 47 
7.2.1 Definition of an Overdose for This Protocol and Reporting of Overdose to 
the Sponsor and to BMS ..................................................................................... 49 
7.2.2 Reporting of Pregnancy and Lactation to the Sponsor and to BMS ................... 49 
7.2.3 Immediate Reporting of Adverse Events to the Sponsor and to BMS ............... 51 
7.2.3.1   Serious Adverse Events…………………………………………………..51 
7.2.3.2   Events of Clinical Interest…………………………………………………..51 
7.2.4 Evaluating Adverse Events ................................................................................. 51 
7.2.5 Sponsor Responsibility for Reporting Adverse Events ...................................... 51 
7.3 
Safety Stopping Criteria…………………………………………………………51 
8.0 
STATISTICAL ANALYSIS PLAN ........................................................................... 55 
8.1 
Statistical Analysis Plan Summary ......................................................................... 55 
8.1.1   Study Design……………………………………………………………...……..55 
8.2 
Statistical Analysis Plan .......................................................................................... 55 
8.2.1 Sample size……………………………………………………………………...55 
8.2.2 Analysis of Primary and Secondary Endpoints…………………………………55 
8.2.3 Toxicity…………………………………………………………………………55 
8.2.4 Laboratory Correlative Studies…………………………………………………55 
9.0 
LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL 
SUPPLIES................................................................................................................... 56 
9.1 
Investigational Product ........................................................................................... 56 


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9.1.1   Clinical Supplies provided by BMS as summarized in Table 7……………….56 
9.1.2   Clinical Supplies provided by Moffitt Cell Therapy Facility……………………56 
9.2 
Packaging and Labeling Information ...................................................................... 56 
9.3 
Clinical Supplies Disclosure ................................................................................... 56 
9.4 
Storage and Handling Requirements ...................................................................... 56 
9.5 
Returns and Reconciliation ..................................................................................... 57 
10.0 
DATA SAFETY MONITORING PLAN ................................................................... 57 
10.1 
Risk to Subjects ...................................................................................................... 57 
10.1.1 Human subject involvement and characteristics ................................................. 57 
10.2 
Recruitment and Informed Consent ........................................................................ 57 
10.3 
Protection Against Risk .......................................................................................... 58 
10.4 
Importance of the Knowledge to be Gained ........................................................... 58 
10.5 
Data Safety and Monitoring Plan ............................................................................ 58 
10.6 
Scientific Review Committee (SRC) ...................................................................... 58 
10.7 
PI Responsibility ..................................................................................................... 59 
10.8 
The Protocol Monitoring Committee (PMC) .......................................................... 59 
10.9 
Suspension/Termination ......................................................................................... 59 
 
10.10 Monitoring of the Study and Regulatory Compliance ............................................ 60 
10.11 Internal Monitoring Plan ......................................................................................... 60 
10.12 Protocol Modifications ........................................................................................... 60 
10.13 The Institutional Review Board (IRB) .................................................................... 60 
10.14 Patient Privacy ........................................................................................................ 60 
10.15 Records Retention ................................................................................................... 61 
10.16 Compliance with Trial Registration and Results Posting Requirements ................ 61 
11.0 
APPENDICES ............................................................................................................ 62 
11.1 
ECOG Performance Status ..................................................................................... 62 
11.2 
Common Terminology Criteria for Adverse Events V4.0 (CTCAE) ..................... 62 
11.3 
Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 Criteria for 
Evaluating Response in Solid Tumors .................................................................... 62 
11.4 
Pharmaceutical 
Information 
for 
Ad.p53-DC 
Vaccine………………………………………………………………………63 
11.5 
Management Algorithm ………………………………………………………….64 
11.6 
BMS Guidelines for Adverse Event Reporting …………………………………..72 
12.0 
REFERENCES…………………………………………………................................79 
. 


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1.0 TRIAL SUMMARY 
 
 
 
 
Abbreviated Title 
Combination Immunotherapy in Relapsed SCLC 
Trial Phase 
Phase II 
Clinical Indication 
SCLC, 
progressive 
after 
first-line 
(platinum-based) 
chemotherapy 
Trial Type 
Single arm 
Type of control 
Historical 
Route of administration 
Ipilimumab – Intravenous 
Nivolumab – Intravenous 
Ad.p3-DC – Intradermal/Subcutaneous 
Trial Blinding 
Open label 
Treatment Groups  
Ipilimumab-Nivolumab + Ad.p53-DC vaccine 
Number of trial subjects 
41 
(39 + 10% screen failures) 
Estimated 
enrollment 
period 
2.5 years 
Estimated duration of trial 3 years 
Duration of Participation 
3 years 
 
 
 
 


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2.0 
TRIAL DESIGN 
 
2.1 
Trial Design 
Here we propose a phase II trial where relapsed (progressive), SCLC patients after treatment 
with first line (platinum-based) chemotherapy (after disease progression) will receive 
Ad.p53-DC in combination with ipilimumab and nivolumab to assess the impact of this 
combination immunotherapy regimen on clinical outcomes. We hypothesize that this 
combination immunotherapy strategy will improve overall disease response or control and/or 
survival in this population. 
 
2.2 
Trial Diagram 
 
3.0 
OBJECTIVE(S) & HYPOTHESIS 
 
General Scientific Hypothesis: 
Inhibition of the PD-1 receptor pathway with an anti PD-1 inhibitor (nivolumab) and the 
CTLA-4 receptor pathway with an anti CTLA-4 inhibitor (ipilimumab) will enhance the p53-
specific cytotoxic immune response (IR) elicited by a p53-based DC vaccine (Ad.p53-DC) 
and this improvement will translate into improved outcomes (disease control rate [DCR], 
progression free survival [PFS], overall survival [OS], overall response rate [ORR]) in 
patients with relapsed (progressive) SCLC, after standard, platinum-doublet, first line 
chemotherapy. 
 


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3.1 
Co-Primary Objective(s) & Hypothesis(es) 
• To determine the DCR of patients with relapsed (progressive) SCLC (after standard, first 
line platinum-doublet chemotherapy) treated with combination immunotherapy (Ad.p53-
DC plus ipilimumab-nivolumab) 
• To determine the safety of combination immunotherapy with Ad.p53-DC plus 
ipilimumab-nivolumab in patients with relapsed (progressive) SCLC 
 
3.2 
Secondary Objective(s) & Hypothesis(es) 
• To determine the PFS, OS and ORR of combination immunotherapy with Ad.p53-DC 
plus ipilimumab-nivolumab in patients with relapsed (progressive) SCLC 
• To determine the immune response (IR) of combination immunotherapy with Ad.p53-DC 
plus ipilimumab-nivolumab in patients with relapsed (progressive) SCLC 
 
 
4.0 
BACKGROUND & RATIONALE 
 
4.1 
Background/Introduction 
 
4.1.1 Overview of Small Cell Lung Cancer 
In the United States, 224,390 new cases of lung cancer were diagnosed and 158,080 patients 
with lung cancer died in 20161, with small cell lung cancer (SCLC) accounting for 13-15% of 
them. SCLC typically disseminates early, with 70-80% of patients diagnosed with metastatic 
disease or extensive stage, (ES)-SCLC), and is initially also chemo-responsive, so that 
considerable survival improvements are achieved with (first-line) chemotherapy2-4.  
 
Etoposide-platinum remains the preferred first-line treatment and the standard against which 
new therapies are measured. By this standard, patients with ES-SCLC achieve overall 
response rates (ORR) of ≥ 70% and complete response rates of 20-30%, but rarely survive 
beyond 2 years (10-20%), with median survival times (MST) ranging from 7-10 months 2-4. 
The ORR to second-line therapy is also very disappointing and dependent on the previous 
chemotherapy response. Patients with “platinum-sensitive” disease (ORR = 20-25%) 
progress ≥ 90 days after initial chemotherapy, whereas those with “platinum-resistant” (ORR 
≤ 10%) disease progress sooner than 90 days after initial chemotherapy5-7.  
 
Clearly, new therapies are urgently needed, and evidence suggests that immunotherapy may 
have a potential role in SCLC, including if used in conjunction with chemotherapy8-12. 
 
4.1.2 p53 as a Target for Cancer Immunotherapy 
The p53 tumor suppressor gene plays a central role in the control of cell growth and 
differentiation. Normally, p53 is a short-lived protein localized in the nuclei of cells.  
Approximately 50% of all human cancers and >90% of patients with SCLC have altered p53 
function, mostly as a result of single-point mutations or abnormalities in degradation of wild-
type (wt) p53. This leads to accumulation of mutant (mu) or wt-p53 protein (whereas normal 
tissues have low to undetectable levels) and expression of p53-derived epitopes on the 
surface of tumor cells in the context of MHC class I13.  
 


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Furthermore, since mutant forms of p53 can result in oncogenic gain of function14,15 it is 
unlikely that they can escape anti-p53 cytotoxic T lymphocytes (CTLs) by restoring wt-p53 
status (no antigen-loss variants). Thus, p53 has many characteristics of an “ideal” tumor-
associated antigen (TAA), which makes it a very attractive candidate target for immune 
recognition and anti-p53-based cancer immunotherapy. 
 
4.1.3 Anti-p53 Dendritic Cell-Based Immunotherapy  
Different approaches to p53-based cancer immunotherapy have been explored. The role of 
wt-p53 peptide sequences in the induction of antitumor CTL responses has been investigated 
in both human and animal in vitro studies, with encouraging results13,16-20. However, peptide-
based approaches assume knowledge of precise HLA types and the peptides present on 
particular tumors, leading to several limitations21,22, such as technical difficulties with 
generating custom mutant-specific peptides.   
 
These difficulties can be circumvented with the use of TAA proteins and dendritic cells 
(DCs). DCs are the most potent antigen presenting cells (APCs) and the most effective in 
inducing a primary CTL response. There are numerous methods of loading DCs with a 
variety of different TAAs, and animal models show that the approach of using viral vectors 
to introduce these TAAs into DCs is practical, safe, and effective23-25. Because cells with mu-
p53 usually overexpress the protein and because there is a large human experience in 
melanoma with targeting overexpressed but not mutant proteins such as MAGE and MART, 
a much more practical approach would be to develop a strategy that targets the non-mutant 
portions of the p53 overexpressed in tumors. 
 
Therefore, we have focused on utilizing DCs transfected with the full-length p53 gene. The 
rationale for this approach is based on 1) the assumption that multiple MHC class I and II 
matching p53-derived epitopes are present on the surface of DCs, eliminating the need for 
selecting matching patients as well as providing conditions for activation of CD4+ T cells, 
and 2) the fact that previous studies have demonstrated that each of the different minimal 
epitopes combined in a single fusion protein can be recognized by specific CTLs26. 
 
4.2 
Vaccine (Ad.p53-DC) Immunotherapy 
Adenovirus (Ad) provides a high-level transduction efficacy for many cell types, regardless 
of their mitotic status27, and replication-defective Ad (deletions in the E1 region) has been 
safely injected into patients28. Successful transduction of DCs with model antigens has been 
reported, and transduced DCs have effectively presented the recombinant protein antigens29-
31. In this case, DCs were infected with an adenoviral construct containing wt-p53 to generate 
Ad.p53-DC.   
 
4.2.1 Manufacturing of Ad.p53-DC 
DCs were prepared from peripheral blood mononuclear cells (PBMC) collected by 
leukapheresis, separated over a Ficoll density gradient, washed, and cryostoraged in liquid 
nitrogen in the Cell Therapy Core at the H. Lee Moffitt Cancer Center.  
 


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Preparation of the DC and their characterization was described previously32,33. Briefly, after 
thawing, PBMCs were placed in X-VIVO-15 medium (Biowhittaker, Walkersville, MD) in 
tissue culture flasks at a concentration of 1.3-1.7 × 106 cells per cm2. After 2-hr culture non-
adherent cells were removed and the flasks 
were recharged with X-VIVO-15 medium 
supplemented 
with 
5ng/ml 
GM-CSF 
(Immunex), 
and 
5ng/ml 
IL-4 
(R&D 
Systems, Minneapolis, MN). The flasks 
were incubated for 48 hours, at which time 
additional cytokine supplemented medium 
was added to the flasks. The flasks were 
then incubated for an additional 72 hours. 
The non-adherent and loosely adherent cells 
were collected and infected with Ad.p53 and 
incubated for 2 hours after which X-VIVO-
15 medium was added for a 106 cells/ml 
concentration and cells incubated for an 
additional 46 hours.  
 
The optimal viral particle to cell ratio used 
was 15,000:1 as determined for our previous study32. The vaccine release criteria included: 
(a) negative Gram’s staining; (b) negative Mycoplasma test by PCR analysis; (c) maximum 
endotoxin concentration of 5 EU/mL; and (d) a mature DC-p53 expressing phenotype. DC 
phenotype was defined as lineage (CD3, CD14, CD19, CD20, CD56) negative, HLA-DR 
positive, CD86 positive, and p53 positive cells. Intracellular staining for p53 was performed 
using the kit from Caltag, Burlingame, CA. DC vaccines in 1 ml were injected intradermally 
into 4 separate sites (0.25 ml at each site) in bilateral proximal upper and lower extremities 
(in the regions of the axillary and inguinal nodal basins) three times after the baseline blood 
samples were drawn and at 2 week intervals. 
 
4.2.2 Preclinical Animal Studies with Ad.p53-DC 
To determine the optimal dose of Ad.p53 vector that produces the highest level of human p53 
expression with the least amount of 
toxicity to the DCs, mice were given a 
human p53-transduced DC vaccine34,35. 
We found that infecting murine DCs with 
the Ad.p53 vector at a multiplicity of 
infection (MOI) of 50-200 viral particles 
per cell (vp/cell) did not adversely affect 
DC viability.  MOI in excess of 500 
significantly 
reduced 
DC 
viability.  
However, transduction of DCs at an MOI 
of 100 produced very good transduction 
efficiency, with 40-45% of the DCs 
becoming positive for p53. Similarly, 
infecting human DCs with the Ad.p53 
MethA sarcoma-bearing BALB/c mice were treated with 
6x10
5
activated Ad.c- or Ad.p53-DCs 4 times on days 0, 5, 11, and 
17. Four mice treated with Ad.p53-DCs rejected their tumor. 
Tumor growth in 2 remaining mice is shown. 


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vector at a MOI of 10,000-20,000 vp/cell did not adversely affect DC viability and showed 
better transduction efficiency with the higher dose. At a MOI of 40,000 vp/cell, DC viability 
was adversely affected despite transduction rates similar to the lower doses. Thus, 20,000 
vp/cell was the MOI chosen to manufacture Ad.p53-DC.  
 
 Additionally, T cells recovered from immunized mice contained significant numbers of 
CTLs that could specifically kill tumor cells previously modified to express the human p53 
gene, and Ad.p53-DC-immunized mice developed a significant CTL response to murine p53, 
probably due to the significant homology between murine and human p53.  Ad.p53-DC-
induced anti-p53 CTL response resulted in protection of mice from challenges with tumor 
cells that overexpressed human or murine p53.  Furthermore, tumors that were established in 
mice prior to immunization exhibited significantly slowed growth as a result of the 
immunization with Ad.p53-DC34,35. 
 
4.2.3 Preclinical Experiments Using Human T Cells 
To determine whether this response was sufficient to recognize and eliminate tumor cells in 
cancer patients, peripheral blood-derived T cells and autologous DCs were obtained from 3 
healthy volunteers and 9 cancer patients, all of whom were HLA-A2 positive36. T cells were 
in vitro primed with Ad.p53-DC and then tested for their ability to kill (HLA-A2-positive) 
target cells with normal to low or overexpressed levels of p53 protein.  
 
Selective CTL killing of p53-overexpressing cells but not of cells with normal p53 
expression levels was generated in blood from all 3 healthy donors and 8 cancer patients.  
Furthermore, when cells that expressed normal to low levels of p53 were forced to 
overexpress p53 by gene transfection, they became sensitive to Ad.p53-DC-primed CTLs. 
Additionally, when an excess of NK cell-sensitive target cells or an anti-CD4 antibody was 
added to the cytotoxicity assays, very little effect or a small decrease in cytotoxicity activity 
was seen. Conversely, when anti-CD8 was added, we observed a very significant decrease in 
cytotoxicity, demonstrating that neither NK nor CD4 cells but CD8-positive CTLs are the 
relevant effector cells primed with Ad.p53-DC.  
 
4.3 
Phase I/II Clinical Trial of Ad.p53-DC in SCLC 
p53 gene mutations and p53 protein overexpression are present in ≥ 90% of SCLC cases37,38. 
With many characteristics of an “ideal” TAA present, p53 is an attractive candidate for 
cancer immunotherapy. Therefore, an approach where an adenoviral vector carrying the 
intact human wt-p53 gene is used to overexpress the p53 protein in autologous DCs and that 
allows endogenous processing mechanisms to select and present the appropriate p53 peptides 
for each individual’s HLA type encourages the use of these transduced cells (Ad.p53-DC) as 
a vaccine. 
 
4.3.1 Study Design and Patient Characteristics 
The trial was designed to assess the clinical and immune response of SCLC to Ad.p53-
DC32,33. Fifty-four patients (24 male, 30 female) with extensive stage disease (initial or 
recurrent) were enrolled. All had previously been treated with chemotherapy. Patients with 
stable disease or better underwent leukopheresis 8 weeks after the last dose of chemotherapy 
to manufacture Ad.p53-DC. Patients received 3 doses of Ad.p53-DC intra-dermally every 2 


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weeks. If after reassessment, stable disease or better persisted, 3 more monthly doses of 
Ad.p53-DC were given. 
 
4.3.2 Ad.p53-DC Dose and Safety 
The number of p53+ DCs (Ad.p53-DC dose) was evaluated using flow cytometry. The initial 
goal was to escalate the dose from 5 × 106 to 5 × 107 p53+ DC. However, generation of >5 × 
106 p53+ DC per dose was difficult to achieve (on average, 7.7 × 107 DCs and 8.6 × 106 p53+ 
DCs were generated per dose and ≥107 p53+ DCs were generated in < 10% of cases). Thus, 
to maintain consistency throughout the trial, the single doses of p53+ DC were not escalated 
beyond 5 × 106
 cells. On average, each patient received 3.8 × 106 p53+ DCs per dose. 
However, 5 patients received <106 p53+ DCs because of production difficulties.  
 
Ad.p53-DC toxicities were infrequent and mostly mild. Only 2 patients experienced grade 2 
toxicities (1 fatigue, 1 arthralgia), and Ad.p53-DC was never withheld. The most frequent 
toxicities were grade 1 arthralgia/myalgia (9 patients), fatigue and injection site erythema (5 
patients each), and injection site pain (4 patients). Occurrence of toxicities was independent 
of the number of Ad.p53-DC doses received. 
 
4.3.3 Immune Response to Ad.p53-DC 
The p53-specific immune response was evaluated by ELISPOT using autologous PBMCs 
infected with a canary pox virus (ALVAC) containing wt-p53 or empty vector as control. 
The number of γ-interferon producing cells was evaluated using an automated ELISPOT 
reader39. In 12 HLA-A2-positive patients, immune responses were tested with p53-derived or 
control HLA-A2 matched peptides pulsed onto autologous PBMCs and tetramers.  
 
Response was considered significant if ≥ 2 SD higher than the response to ALVAC or 
peptide controls. Increase over baseline (pre-Ad.p53-DC) was considered significant if p53-
specific responses (post-Ad.p53-DC) were ≥ 2 SD higher than p53-specific responses pre-
Ad.p53-DC and at least 2 SD higher than responses to ALVAC or peptides. Because the 
generation of a p53-specific T-cell response not only depends on the quality of antigen 
stimulation but also on the functional activity of T cells and DCs in the host, they were also 
tested. 
 
Full immune response evaluation was possible in 43 patients. Overall, 18 patients (41.8%) 
had a statistically significant p53-specific response using ALVAC and 7 of 12 patients 
(58.3%) using p53-derived peptide. Three patients with a significant response to Ad.p53-DC 
using the p53-derived peptide were not tested with ALVAC (technical reasons). The baseline 
p53-specific immunity level was similar in Ad.p53-DC responsive and non-responsive 
patients. The level of the p53-specific immune response decreased 2 months after completing 
Ad.p53-DC, coinciding with the start of additional chemotherapy.   
 
Presence and functional activity of DCs were both decreased, and the p53-specific immune 
response to Ad.p53-DC did not correlate with T cell functional activity, presence of Tregs, or 
pre-existing levels of DC activity. Because myeloid-derived suppressive cells (MDSC) are 
implicated in the host’s immunosuppressive state40,41, we examined patients for the presence 
of these cells. Pre-Ad.p53-DC MDSC (Lin-HLA-DR-CD3+) levels were elevated compared 


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to control donors (p=0.01). Post-Ad.p53-DC levels increased even further (p=0.002). All 
patients with normal levels of MDSCs prior to Ad.p53-DC developed a p53-specific immune 
response compared to only 33% of patients who had elevated levels of MDSC (p=0.012). 
 
4.3.4 Clinical Efficacy of Ad.p53-DC and Enhanced Effect on Salvage Chemotherapy 
Two patients (3.7%) achieved a partial response (PR), and 13 had stable disease with 
Ad.p53- DC. All but 5 patients developed progressive disease (PD), and response data were 
available for 33 patients who received additional chemotherapy post-Ad.p53-DC 
progression. The ORR for all 33 patients treated with “second”-line chemotherapy was 
51.5% and 45.5% for the 22 platinum-resistant 
patients. The MST (from the date of the first 
Ad.p53-DC dose) for platinum-resistant patients 
was 10.5 months (95% CI = 5.3-14.4) and 8.8 
months (95% CI = 5.2-11.8) for all 54 patients.  
 
We also evaluated the relation between immune 
response to Ad.p53-DC and clinical response to 
second-line chemotherapy. Eleven of 14 patients 
(78.6%) with a positive immune response 
experienced a clinical response to second-line 
chemotherapy compared to 5 of 15 patients 
(33.3%) with a negative immune response 
(p=0.014). Patients with a positive immune 
response had a trend toward improved survival; 
however, the difference did not reach statistical 
significance (MST = 12.6 vs. 8.2 months, p = 
0.131)33. 
 
4.4 
Improved Ad.p53-DC Immunotherapy Strategy 
 
4.4.1        Role of MDSCs in the Immune Response  
It is now fully appreciated that tumor-specific immune responses in cancer are inhibited. 
Large numbers of different factors have been implicated in this process, including regulatory 
T cells (Treg), myeloid cells, various soluble factors and cytokines, inhibitory molecules 
expressed by immune and tumor cells, etc.42-44. Among these factors MDSC play a prominent 
role.  
 
MDSC are a heterogeneous group of pathologically activated immature myeloid cells and 
myeloid precursors with potent immune suppressive activity45-48. Two major groups of 
MDSC have been identified: polymorphonuclear (PMN) and mononuclear (M) MDSC. 
These cells share common features (immature myeloid cells with immune suppressive 
activity) but differ in morphology, phenotype, and mechanisms of suppressive activity46. In 
cancer patients, these MDSC have partially overlapping phenotype that can be identified 
using several markers, which largely depends on the type of tumor. In most tumors, immune 
suppressive MDSC are defined as Lin-HLA-DR-CD33+ or CD33+CD14-CD11b+ cells that 
can be further sub-divided into CD15+ PMN-MDSC and CD15- M-MDSC. In some tumors, 


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most notably melanoma, M-MDSC are defined as CD14+HLA-DR-/lo49,50.  MDSC are 
characterized by potent immune suppressive activities in both antigen-specific and non-
specific experimental systems.  
 
The association between tumor progression and the presence of MSDC in cancer patients 
was demonstrated in a number of studies. In patients with solid tumors, a significant 
correlation between circulating MDSC and clinical cancer stage was observed. Among stage 
IV patients, those with extensive metastatic tumor burden had the highest percent and 
absolute number of MDSC51. Patients with lower levels of circulating MDSC at baseline and 
on the last cycle of chemotherapy had significantly higher probability of a pathologic 
complete response52.   
 
Increased circulating MDSC correlated with clinical stage and pathological grade in patients 
with bladder cancer53,54 and pancreatic cancer55. Recently, first report linked clinical response 
to vaccination to accumulation of MDSC in patients with renal cell cancer56.  Experiments in 
mice demonstrated that elimination of MDSC with antibodies or different compounds could 
substantially improve antitumor immune responses, which resulted in antitumor effect46. 
However, no data are available testing the hypothesis that depletion of MDSC can improve 
the effect of cancer vaccines or another immune therapeutic modality in cancer patients.  
 
4.4.2 Rationale for the Use of ATRA in Combination with Ad.p53-DC 
Because all-trans-retinoic acid (ATRA) causes differentiation of acute promyelocytic 
leukemia (APL) cells and lineage features between MDSCs and APL cells are comparable, 
the effect of ATRA on DC differentiation and function was tested in patients with metastatic 
renal cell carcinoma57. As expected, patients had a substantially increased proportion of 
MDSCs, decreased presence of DCs, and decreased MDSC/DC ratio. Treatment with ATRA 
significantly decreased the presence of MDSC and improved MDSC/DC ratio to control 
levels. Patients had profound defects in the ability to respond to tetanus toxoid and to 
stimulate allogeneic T cells and treatment with ATRA improved those defects as well, 
although not significantly.  
 
Gr-1
+ cells (analogous to human MDSC) inhibit antigen-specific T cell response and are 
present in excess in tumor-bearing mice. ATRA differentiates these cells in vitro and 
removes their immunosuppressive effect58,59. Furthermore, in vivo administration of ATRA 
to tumor-bearing mice dramatically reduces the presence of Gr-1
+ cells and improves the 
effect of tumor vaccines60. Similarly, in vitro treatment of human MDSCs with ATRA results 
in their differentiation (2/3 become DC-like and 1/3 myeloid)61. These data confirm the effect 
of ATRA on DCs and MDSCs and strongly suggest a valuable role in cancer 
immunotherapy.  
 
4.4.3  
Randomized Phase II Clinical Trial in SCLC 
Previously we demonstrated that: (1) Ad.p53-DC was safe and induced immune responses 
(IR ~ 40-50%), (2) lack of IR was related to immunosuppressive myeloid derived 
suppressive cells (MDSCs), (3) a high rate of objective tumor regressions was seen in 
patients treated with chemotherapy after vaccination, particularly if a positive IR was 


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obtained and (4) ATRA reduces the number of MDSCs and enhances IR. However, 
confirmation of this evidence required a prospective, comparative (randomized) trial62. 
 
Thus, we designed and recently completed a randomized phase II study to address the 
question of whether combination of Ad.p53-DC with ATRA improved the clinical outcome 
of patients. Our hypotheses were 1) salvage chemotherapy in combination with Ad.p53-DC 
results in a substantial improvement in clinical outcomes, and 2) ATRA, by reversing the 
immunosuppressive influence of MDSCs, substantially improves the p53-specific immune 
response to Ad.p53-DC and hence clinical outcomes. 
 
Patients with ES-SCLC were enrolled to this randomized phase II study. The trial was 
registered at ClinicalTrials.gov (NCT00617409). All patients provided a written informed 
consent and treatment protocol was approved by University of South Florida Institutional 
Review Board. After receiving initial chemotherapy, (4-6 cycles of a standard 
platinum/etoposide regimen as first-line chemotherapy), patients were enrolled and 
randomized. 
 
Additional eligibility included; stable disease (SD) or better with Eastern Cooperative 
Oncology Group (ECOG) performance status of 0 to 1, and adequate organ function were 
screened for initial registration 
approximately 4-6 weeks after 
the 
completion 
of 
first-line 
chemotherapy. 
Prophylactic 
cranial irradiation (PCI) was 
permitted. 
 
Eligible 
patients 
were 
randomized in a 1:1:1 ratio to 
one of three treatment arms: Arm 
A 
(control 
patients 
or 
observation), Arm B: (patients 
treated with Ad.p53-DC vaccine 
only), or Arm C (patients treated 
with 
Ad.p53-DC 
vaccine 
in 
combination with ATRA).  Each 
vaccine consisted of 2-5 × 106 
Ad-p53 DCs. Cells were injected 
intradermally, at two-week intervals for three times (three vaccine doses).  
 
Patients were restaged approximately 2 weeks after the 3rd vaccine dose. Patients without 
signs of disease progression (PD) underwent a second leukapheresis and then vaccinated 3 
more times at 4-week intervals.  Patients on Arm C also received 150 mg/m2 ATRA for 3 
days prior to each vaccine administration (followed by vaccine administration on the next 
day). This scheduling was based on our previous data57 that demonstrate persistence of the 
ATRA effect on MDSC for minimum 2 weeks.  
 


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All patients were followed until PD at which time they received salvage or second line 
chemotherapy with single agent paclitaxel (200 mg/m2 IV every 3 weeks, 4-6 cycles). 
 
The primary objective was 
to evaluate the efficacy of 
second line paclitaxel in the 
two experimental regimens 
(Arms B and C). Objective 
response (OR) to paclitaxel 
in 
each 
arm 
was 
the 
endpoint of the study. An 
optimal two-stage design 
was used in planning of this 
study63 because it has been 
successfully 
applied 
in 
randomized phase II trials to 
rank experimental agents64. 
The control arm was used to examine consistency with historical control data and to assure 
that patients entering the phase II trial are comparable to historical controls.. Using the 
optimal two-stage design, if 3 responses were observed in the first 9 patients, the second 
stage would accrue 14 additional patients. 
 
To assess immune response, PBMCs were collected from patients at different time points 
during the treatment (Fig. 1) and kept frozen in liquid nitrogen. All samples from one patient 
were analyzed simultaneously to reduce inter-experimental variability. PBMCs were thawed, 
incubated overnight in 
complete 
medium 
(RPMI-1640 
supplemented 
with 
antibiotics and 10% 
FBS) and then used in 
experiments. 
Cell 
viability was greater 
than 
80%. 
T-cell 
responses 
were 
assessed using IFN-γ 
ELISPOT 
after 
infection 
with 
a 
recombinant 
canarypox 
virus 
(ALVAC) containing 
wild-type 
p53 
or 
empty vector (obtained from Aventis Pasteur, Toronto, Canada), and incubation for 48 hours. 
Empty ALVAC virus served as a control.  
 


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The initial infection step was performed in serum free media (supplemented with cytokines) 
for 90 minutes after which, complete media was added. In IFN-γ ELISPOT assay 2 × 105 
PBMCs were seeded in triplicates or quadruplicates in 96-well plates pre-coated with an anti-
IFN-γ antibody. To ascertain that T cells are functionally competent for each sample we 
prepared additional controls (unstimulated or PHA (5µg/ml) stimulated cells), and the plate 
was further incubated for 36 hours. The number of IFN-γ producing cells was evaluated as 
described previously32 using an automated ELISPOT reader (Cellular Technology, Ltd, OH).  
 
54 patients were enrolled during the first stage, 18, 19 and 17 in arms A, B and C 
respectively. Median age (range) = 62 (43-74). Male/female = 31/23, ECOG PS 0/1 = 14/40. 
Median # of vaccines was 3 (range 0-6) and total # vaccines administered was 114. AEs 
associated with vaccine were mild and no grade 3-4 AE was vaccine related. OR to vaccine 
was observed in 3/36 patients. OR to paclitaxel (or other second line treatment) was seen in 
1/11, 2/12 and 3/14 patients for arms A, B and C respectively. Only arm C moved to stage 
two. An additional 15 patients have been accrued to the Arm C second stage of the trial and 
their study data and results is currently being collected for the proposed protocol analysis62. 
 
Pre-treatment levels of MDSC populations in 
patients from all three arms was similar 
(p>0.07). Treatment of patients from arm B 
with vaccine alone did not affect the 
proportion of MDSC (Fig. 2), whereas in 
patients treated with ATRA the presence of 
Lin-HLA-DR-CD33+ MDSC decreased more 
than two-fold (p=0.02). The proportion of 
CD11b+CD14-CD33+ MDSC decreased less 
dramatically but also significantly (p=0.03). 
No significant differences were observed in the 
proportion of conventional DC and Treg65. 
 
Next, we evaluated the p53-specific immune 
response using IFN-γ ELISPOT assay. Prior to 
start of the treatment no patients had detectable 
p53 
specific 
response. 
Consecutive 
measurements did not show positive p53 
responses in any of the arm A patients. 
After three immunizations, 3 out of 15 
tested patients (20%) from arm B met 
the criteria for p53-specific immune 
response, which was not significantly 
different from arm A (p=0.22). In 
contrast, in arm C 5 out of 12 patients 
(41.7%) had detectable p53 response, 
which was significantly higher than in 
control group (p=0.012) (Fig. 3)65.  
The proportion of p53-specific IFN-γ 
0
2
4
6
8
10
12
14
16
Arm A
Arm B
Arm C
Number of patients 
Non-
responders
Figure 1 


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positive cells CD4+ and CD8+ T cells was evaluated using intracellular cytokine staining. 
Prior to the treatment no statistically significant differences between the arms were seen 
(p>0.07). The immunization significantly increased the proportion IFN- γ positive CD8+ and 
CD4+ T cells. The proportion of granzyme B (GrzB) positive CD8+ T cells was increased 
only in patients from arm C but not from arm B65.  
 
To evaluate the possible link between the immune response to vaccination and the clinical 
outcome, patients in arms B and C were split based on the presence of p53 specific responses 
after vaccination. Patients who did not develop immune response had median survival of 
11.7 months, as compared with 16.4 months in patients who developed p53 immune 
responses (hazard ratio 0.52, 95% CI 0.22-1.22) (p=0.1). Patients with brief immune 
response had the same median survival as non-responders (11.1 months vs. 11.7 months). In 
contrast, patients who had p53 immune response at least two months after completion of the 
vaccination had median survival of 41 months (hazard ratio 0.26 (0.09-0.74), p=0.03) 
suggesting that improving upon the immune response obtained through this strategy could 
manifest in clinical outcome improvement for patients (internal data not yet published). 
 
4.5 
Checkpoint Inhibitors Immunotherapy 
 
4.5.1 Nivolumab 
Nivolumab is a fully humanized, IgG4 (kappa) isotype monoclonal antibody (mAb) that 
binds PD-1 on activated immune cells and disrupts engagement of the receptor with its 
ligands PD-L1 (B7-H1/CD274) and PD-L2 (B7-DC/CD273), thereby abrogating inhibitory 
signals and augmenting the host antitumor response. PD-1, (CD279), a 55-kDa type I 
transmembrane protein, is a member of the CD28 family of T-cell co-stimulatory receptors 
that also includes CD28, CTLA 4, ICOS, and BTLA. PD-1 contains an intracellular 
membrane proximal immunoreceptor tyrosine inhibitory motif (ITIM) and a membrane distal 
immunoreceptor tyrosine-based switch motif (ITSM).  
 
Two ligands specific for PD-1 have been identified: PD-L1 (B7-H1/CD274) and PD L2 (B7-
DC/CD273). PD-L1 and PD-L2 have been shown to down-regulate T cell activation on 
binding to PD-1 in both murine and human systems. PD-1 delivers a negative signal by the 
recruitment of SHP-2 to the phosphorylated tyrosine residue in the ITSM in its cytoplasmic 
region. PD-1 is primarily expressed on activated T cells, B cells, and myeloid cells. Further 
evidence for a negative regulatory role of PD-1 comes from studies of PD-1-deficient mice. 
PD 1-deficient mice develop various autoimmune phenotypes, including dilated 
cardiomyopathy, a lupus-like syndrome with arthritis and nephritis, and accelerated diabetes 
mellitus.  
 
The emergence of these autoimmune phenotypes is dependent on the genetic background of 
the mouse strain, and many of these phenotypes emerge at different times and show variable 
penetrance. In addition to the phenotypes of null mutations, PD-1 inhibition by antibody-
mediated blockade in several murine models has been found to play a role in the 
development of autoimmune diseases such as encephalomyelitis, graft-versus-host disease, 
and type I diabetes. Taken together, these results suggest that PD-1 blockade has the potential 
to activate anti-self T-cell responses, but these responses are variable and dependent on 


Protocol: 
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various host genetic factors. Thus, PD-1 deficiency or inhibition is not accompanied by a 
universal loss of tolerance to self-antigens. 
 
Preclinical animal models of tumors have shown that blockade by PD-1 by mAbs can 
enhance the anti-tumor immune response and result in tumor rejection. Antitumor activity by 
PD-1 blockade functions in PD-L1-positive tumors as well as in tumors that are negative for 
the expression of PD-L1. This suggests that host mechanisms (i.e., expression of PD-L1 in 
antigen-presenting cells) limit the antitumor response. Consequently, both PD-L1 positive 
and negative tumors may be targeted using this approach. In humans, constitutive PD-L1 
expression is normally limited to macrophage-lineage cells, although expression of PD-L1 
can be induced on other hematologic cells as well, including activated T cells. However, 
aberrant expression of PD-L1 by tumor cells has been reported in a number of human 
malignancies. PD-L1 expressed by tumor cells has been shown to enhance apoptosis of 
activated tumor-specific T cells in vitro. Moreover, the expression of PD-L1 may protect the 
tumor cells from the induction of apoptosis by effector T cells. Additional details are 
available in the Nivolumab Investigator Brochure.  
 
4.5.2 Ipilimumab 
Ipilimumab is a fully humanized, IgG1 (kappa) isotype mAb that binds to the CTLA-4 
antigen expressed on a subset of T cells from human and nonhuman primates. CTLA-4 is a 
negative regulator of T-cell activity. Ipilimumab binds to CTLA-4 and blocks the interaction 
of CTLA-4 with its ligands, CD80/CD86. Blockade of CTLA-4 has been shown to augment 
T-cell activation and proliferation, including the activation and proliferation of TILs. 
Inhibition of CTLA-4 signaling can also reduce Treg cell function, which may contribute to a 
general increase in T-cell responsiveness, including the anti-tumor response. 
 
4.6 
Study Rationale 
 
4.6.1 Rationale for Immuno-Oncology Therapeutic Approaches in SCLC 
SCLC has classically been associated with immune-mediated paraneoplastic processes, such 
as cerebellar degeneration, limbic encephalitis and Lambert-Eaton myasthenic syndrome 66. 
For example, antibodies generated against human neuronal RNA-binding proteins (e.g. Hu), 
which are expressed on neurons and SCLC tumors, leads to an encephalomyelitis67. 
Interestingly, SCLC patients that present with these ‘early’ paraneoplastic syndromes have a 
more favorable prognosis68,69, suggesting that an underlying immune response is being 
generated against these onconeural antigens.  
 
Proof of an active immune environment in SCLC has been described in a few analyses of 
patient samples. First, analysis of sixty-four SCLC tumors demonstrated that a wide range of 
CD45+ cells infiltrated the tumor, an average of 40 immune cells/field, and that high CD45+ 
counts were associated with a better prognosis70. Secondly, a separate study found that 
various tumor-infiltrating lymphocyte (TIL) subsets were present in SCLC brain metastases 
and that programmed death ligand 1 (PD-L1) was heterogeneously expressed71. Finally, 
evaluation of peripheral blood cells in 35 SCLC patients demonstrated a high CD4+ effector 
T cell to T regulatory (Treg) cell ratio in patients with LD-SCLC vs. ED-SCLC72. This 
implies that in some respect, SCLC pathology integrates with the immune response.  


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Furthermore, SCLC is known to have one of the highest mutational loads73, which is thought 
to be a reflection of myriad insults inflicted by carcinogens from smoking. Additionally, 
comprehensive genomic profiling of SCLC tumors has identified that the vast majority lack 
functional p53 (90%) and Rb1 (65%) 74. This universal genetic aberration facilitates poor 
genomic stability 75, thus perpetuating the generation of tumor-associated antigens (TAAs).  
 
Interestingly, recent studies have highlighted that the clinical efficacy of cytotoxic T-
lymphocyte-associated antigen 4 (CTLA-4) and programmed death 1 (PD-1) blockade in 
melanoma and non-small cell lung cancer (NSCLC), respectively, are partially driven by the 
mutational burden of the tumor and the presence of neoantigens 76,77. Thus, the high 
mutational burden in SCLC may facilitate enhanced immune recognition. Though SCLC 
pathology appears to be intertwined with the immune response and is predisposed by a 
substantial mutational load, prior evidence indicates that major histocompatibility complex 
(MHC) surface expression is reduced in SCLC 78,79, which may preclude robust immune 
recognition.   
 
4.6.2 Rationale for Nivolumab/Ipilimumab Combination in SCLC 
In a phase I/II study of nivolumab and nivolumab/ipilimumab for treatment of recurrent 
SCLC (CA209032), participants who were platinum sensitive or refractory and had 
progressive disease were enrolled regardless of tumor PD-L1 status or number of prior 
chemotherapy regimens 80. This open-label study randomized participants to nivolumab 3 
mg/kg IV every 2 weeks or nivolumab + ipilimumab (1 + 1 mg/kg, 1 + 3 mg/kg or 3 + 1 
mg/kg) IV every 3 weeks for 4 cycles followed by nivolumab 3 mg/kg every 2 weeks. The 
primary objective was objective response rate. Other objectives were safety, PFS, OS and 
biomarker analysis.  
 
All participants had prior platinum-based first-line treatment and progression after the most 
recent treatment regimen. Baseline characteristics were typical for a SCLC population with 
respect to age, smoking history, and gender.  
 
Safety. While the incidence of drug-related adverse events (AEs) in the nivolumab 1 mg 
kg/ipilimumab 3 mg/kg cohort (79% any grade, 30% grade 3-4) was higher than in the 
nivolumab monotherapy group (53% any grade, 13% grade 3-4), the treatment 
discontinuation rate for treatment-related AEs was only 11% (nivolumab 1 mg/kg / 
ipilimumab 3 mg/kg): 5 patients with diarrhea, myasthenia gravis [subsequently developing 
complications with fatal outcome], pneumonitis, cardiomyopathy, and 1 patient with 
hypothyroidism, hyperglycemia, and increased ALT levels).  
 
The most frequent (≥10%, any grade) drug-related AEs were diarrhea, fatigue, rash, pruritus, 
hypothyroidism, rash maculo-papular, nausea, hyperthyroidism, and increased lipase levels. 
One treatment-related death in the nivolumab 1 mg/kg / ipilimumab 3 mg/kg cohort occurred. 
This participant developed myasthenia gravis (reported as grade 4) after treatment start and 
suffered from complications resulting in death. Limbic encephalitis was reported in 3 
participants, which resolved with immunosuppressive treatment in 2 cases. Another 
participant had a minor response to immunosuppressive treatment and eventually died due to 
the underlying tumor disease. 


Protocol: 
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Efficacy. Patients treated at the recommended phase III dose of ipilimumab 3mg/kg and 
nivolumab 1mg/kg (n=61) were noted to have an overall response rate (ORR) of 23%, and 
the disease control rate (CR + PR + SD) was 44%. Objective responses were long lasting, 
with a median duration of response of 7.7 months in the nivolumab 1mg/ipilimumab 3 mg 
combination group. The median PFS was 2.6 months (95% CI: 1.4, 4.1) The median OS was 
7.7 months (95% CI: 3.6, 18) in the nivolumab 1 mg /ipilimumab 3 mg combination group, 
which compares favorably with historical controls 81.  There is an ongoing phase III 
randomized, placebo-controlled study (CA209-451) evaluating PFS and OS among patients 
with ED-SCLC with at least stable disease after 4 cycles of EP chemotherapy.  More than 
800 patients are to be randomized to placebo, nivolumab 240 mg delivered every 2 weeks, or 
ipilimumab 3 mg + nivolumab 1 mg combination therapy for 4 cycles followed by 
nivolumab 240 mg every 2 weeks until progression. Patients will be carefully monitored on 
this protocol, and we expect results from our study with comparable inclusion criteria to be 
available in the coming years.   
 
4.6.3 Rationale for the Use of Ipi-Nivo in Combination with Ad.p53-DC 
The efforts in cancer immune therapy are focused on increasing the frequency of CTL-
mediated tumor destruction by applying cancer vaccines, adoptively transferred antigen-
specific T cells, inhibitors of check-point blockade (CTLA4, PD-1) or other immune 
therapeutics82. However, even in tumor-bearing mice, once tumors are established these 
interventions have relatively limited efficacy, and the rate of clinical responses in cancer 
patients, although encouraging, remains relatively low83,84.  
 
Ad.p53-DC has demonstrated to be safe and to produce specific cytotoxic immune responses 
in patients with SCLC. However, the impact on clinical outcomes is still insufficient and 
strategies that further improve the vaccine driven immunotherapy results are necessary. 
Depletion of MDSC with ATRA, substantially improved the immune response to Ad.p53-DC 
vaccination supporting an approach of immunotherapy combinations to enhance the effect of 
immune mediated anti-cancer interventions.  
 
Nivolumab monotherapy and nivolumab plus ipilimumab showed antitumour activity with 
durable responses and manageable safety profiles in previously treated patients with SCLC. 
In the phase I/II trial (CA209-032), in participants with heavily pretreated SCLC, nivolumab 
monotherapy showed an ORR of 10%, whereas the combination of nivolumab-1 and 
ipilimumab-3 demonstrated an ORR of 30% 80.  
 
Thus, combining these 3, individually safe, partially effective and potentially synergistic 
strategies into one single strategy is a reasonable approach that deserves clinical testing. Here 
we propose a phase II trial where ES-SCLC patients with recurrent disease (previously 
treated with first line chemotherapy) will receive Ad.p53-DC in combination with 
ipilimumab and nivolumab to assess the impact of this combination immunotherapy regimen 
on clinical outcomes. We hypothesize that this combination immunotherapy strategy will 
improve overall disease response or control and/or survival in this population. 
 
 


Protocol: 
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5.0 METHODOLOGY 
 
5.1 
Entry Criteria 
 
5.1.1 Diagnosis/Condition for Entry into the Trial 
1) Histologic or cytologic diagnosis of SCLC 
2) Recurrence to at least one prior treatment with a platinum containing regimen 
(cisplatin or carboplatin) including limited stage (LS) and ES initial presentations. 
NOTE: 
 In patients with SCLC the most frequent platinum containing doublet 
used is etoposide-carboplatin. However, etoposide-cisplatin and irinotecan or 
topotecan combined with either carboplatin or cisplatin are platinum doublet 
regimens that can sometimes be used and thus would be allowed for the purposes of 
trial enrollment and eligibility. 
3) Excluded are patients who upon relapse may be still considered for a salvage 
concurrent chemo-radiation approach 
 
5.1.2 Subject Inclusion Criteria 
In order to be eligible for participation in this trial, the subject must: 
1. Be willing and able to provide written informed consent/assent for the trial. 
2. Be ≥ 18 years of age on day of signing informed consent. 
3. Have measurable disease based on RECIST 1.1.   
4. Have a performance status of 0 - 1 on the ECOG Performance Scale. 
5. Demonstrate adequate organ function as defined in  
6. Table 1, all screening labs should be performed within 30 days of treatment initiation.   
 
Table 1  Adequate Organ Function Laboratory Values 
System 
Laboratory Value 
Hematological 
 
Absolute neutrophil count (ANC) 
≥1,000 /mcL 
Platelets 
≥75,000 / mcL 
Hemoglobin 
≥8 g/dL 
Renal 
 
Serum creatinine OR 
Measured or calculateda CrCl 
(GFR can also be used in place of 
creatinine or CrCl) 
≤2.0 X upper limit of normal (ULN) OR 
 
≥60 mL/min for subject with creatinine levels ≤ 1.5 X 
institutional ULN 
Hepatic 
 
Serum total bilirubin 
≤ 1.5 X ULN OR 
 
Direct bilirubin ≤ ULN for subjects with total bilirubin levels > 
1.5 ULN 
AST (SGOT) and ALT (SGPT) 
≤ 2.5 X ULN  OR 
≤ 5 X ULN for subjects with liver metastases 
Albumin 
>3.0 mg/dL 
Coagulation 
International Normalized Ratio (INR) or 
Prothrombin Time (PT) 
 
Activated Partial Thromboplastin Time 
(aPTT) 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
aCreatinine clearance (CrCl) should be calculated per institutional standard. 
7. Life expectancy of  > 4 months 


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8. Favorable tumor p53 biomarker profile defined by ≥ 50% p53 positive tumor cells by 
immunohistochemistry. Tumor p53 biomarker evaluations may be performed with 
either original or recurrent tumor although samples from recurrent disease are 
preferred.   
9. Female subject of childbearing potential should have a negative urine or serum 
pregnancy within 72 hours prior to receiving the first dose of study medication.  If the 
urine test is positive or cannot be confirmed as negative, a serum pregnancy test will 
be required.   
10. Female subjects of childbearing potential should be willing to use 2 methods of birth 
control or be surgically sterile, or abstain from heterosexual activity for the course of 
the study through 120 days after the last dose of study medication (Reference Section 
5.7.2).  Subjects of childbearing potential are those who have not been surgically 
sterilized or have not been free from menses for > 1 year.  
11. Male subjects should agree to use an adequate method of contraception starting with 
the first dose of study therapy through 120 days after the last dose of study therapy. 
 
5.1.3 Subject Exclusion Criteria 
The subject must be excluded from participating in the trial if the subject: 
1. Is currently participating and receiving study therapy or has participated in a study of 
an investigational agent and received study therapy or used an investigational device 
within 4 weeks of the first dose of treatment. 
2. Has a diagnosis of immunodeficiency or is receiving systemic steroid or any other 
form of immunosuppressive therapy within 7 days prior to the first dose of trial 
treatment. Therapy.  
NOTE: Systemic steroid doses of ≤ 10 mg of prednisone daily or its equivalent are 
allowed in patients receiving physiologic replacement steroid doses for both, 5.1.3.2 
and 5.1.3.8. 
3. Has a known history of active TB   (Bacillus Tuberculosis) 
4. Hypersensitivity to Ipilimumab and/or nivolumab or any of its excipients. 
5. Has had a prior anti-cancer monoclonal antibody (mAb) excluding any anti-PD-1 
and/or anti-PD-L1checkpoint inhibitor within 4 weeks prior to study Day 1 or who 
has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents 
administered more than 4 weeks earlier. 
6. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy 
within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at 
baseline) from adverse events due to a previously administered agent. 
- 
Note:  Subjects with ≤ Grade 2 neuropathy are an exception to this criterion 
and may qualify for the study. 
- 
Note:  If subject received major surgery, they must have recovered adequately 
from the toxicity and/or complications from the intervention prior to starting 
therapy.   
7. Has a known additional malignancy that is progressing or requires active treatment.  
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of 
the skin that has undergone potentially curative therapy or in situ cervical cancer. 
Other malignancies that remain without evidence of disease or recurrence, 2 years or 
more after curative therapy are also considered part of this exception. 


Pr ot oc ol: 
Versi o n 8. 0. Se pte m ber 1 9 , 2 0 1 8 
Pa ge | 2 4  
 
8.  Has  k n o w n  acti ve  ce ntr al  ner v o us  s yste m  ( C N S)  metastases  a n d/ or  carci n o mat o us 
me ni n gitis.    S u bjects  wit h  pre vi o usl y  treat e d  brai n  metastases  ma y  partici pate 
pr o vi de d  t he y  ar e  sta ble  ( wit h o ut  e vi de n ce  of  pr o gressi o n  b y  i ma gi n g  f or  at  least 2 
wee ks  pri or  t o  t he  first  d ose  of  trial  treat me nt  a n d  a n y  ne ur ol o gi c  s y m pt o ms  ha ve 
ret ur ne d t o baseli ne), h a ve n o e vi de nce of ne w or e nlar gi n g brai n metastases, a n d are 
n ot usi n g ster oi ds f or at least 7 da ys pri or t o trial treat me nt.   T his e x ce pti o n d oes n ot 
i ncl u de car ci n o mat o us me ni n gitis w hic h is e x cl u de d re gar dless of cli nical sta bilit y.   
9.  A n y dia g n osis of a ut oi m m u ne disease (c o nfir me d b y me dical rec or ds or a p pr o priate 
la b orat or y testi n g)  
1 0.  Has k n o w n hist or y of, or a n y e vi de nce of acti ve, n o n-i nfecti o us p ne u m o nitis. 
1 1.  Has a n acti ve i nfecti o n re q uiri n g s yste mic t hera p y.  
1 2.  Has a hist or y or c urre nt e vi de nce of a n y c o n diti o n, t hera p y, or la b orat or y a b n or malit y 
t hat mi g ht c o nf o u n d t he res ults of t he trial, i nterfere wit h t he s u bject’s partici pati o n 
f or  t he  f ull  d urati o n  of  t he  trial,  or  is  n ot  i n  t he  best  i nterest  of  t he  s u bject  t o 
partici pate, i n t he o pi ni o n of t he treati n g i n vesti gat or.   
1 3.  Has  k n o w n  ps yc hiatric  or  s u bsta nce  a b use  dis or d ers  t hat  w o ul d  i nterfere  wit h 
c o o perati o n wit h t he r e q uire me nts of t he trial.  
1 4.  Is  pr e g na nt  or  br eastfee di n g,  or  e x pecti n g  t o  c o ncei ve  or  fat her  c hil dre n  wit hi n  t he 
pr ojecte d  d ur ati o n  of  t he  trial,  starti n g  wit h  t he  pre -s cree ni n g  or  scree ni n g  visit 
t hr o u g h 12 0 d a ys after t he last d ose of trial treat me nt.  
 
1 5.  Has a k n o w n hist or y of H u ma n I m m u n o deficie n c y Vir us ( HI V) ( HI V 1/ 2 a nti b o dies). 
1 6.  Has k n o w n acti ve He patitis B (e. g., H Bs A g reacti ve) or He p atitis C (e. g., H C V R N A 
[ q ualitati ve] is detecte d). 
1 7.  Has recei ve d a li ve vacci ne wit hi n 3 0 da ys of pla n ne d start of st u d y t hera p y. 
N O T E :    Se as o n al  i nfl ue nz a  v acci nes  f or  i njecti o n  are  ge ner ally  i n activ ate d  fl u 
v acci nes  a n d  are  all o we d;  h o wever  i ntr a n as al  i nfl ue nz a  v acci nes  (e. g.,  Fl u -Mist ®) 
are live atte n u ate d v a cci nes, a n d are n ot all o we d. 
 
5. 1. 4 
W o me n a n d Mi n orities  
B ot h me n a n d w o me n a n d me m bers of all races a n d et h nic gr o u ps are eli gi ble f or t his trial.  
 
5. 1. 5  
W o me n of C hil d be ari n g P ote nti al 
A w o ma n of c hil d beari n g p ote ntial ( W O C B P) is defi ne d as a n y fe m ale w h o has e x perie nce d 
me narc h e  a n d  w h o  h as  n ot  u n der g o ne  s ur gical  sterilizati o n 
( h ysterect o m y  or  bilateral 
o o p h orect o m y)  a n d  is  n ot  p ost me n o pa usal.  Me n o pa use  is  defi n e d  as  1 2  m o nt hs  of 
a me n orr h ea i n a w o ma n o ver a ge 4 5 years i n t he a bse nce of ot her bi ol o gical or p h ysi ol o gical 
ca uses. I n a d diti o n, fe males u n der t he a ge of 5 5 years m ust  ha ve a ser u m f ollicle sti m ulati n g 
h or m o ne ( F S H) le vel > 4 0 mI U/ m L t o c o nfir m me n o pa use.  Fe males treate d wit h h or m o ne 
re place me nt  t hera p y  ( H R T)  are  li kel y  t o  ha v e  artificiall y  s u p presse d  F S H  le vels  a n d  ma y 
re q uire  a  was h o ut  peri o d  i n  or der  t o  o btai n  a  p h ysi ol o gic  F S H  le vel.  T he  d urati o n  of  t he 
was h o ut peri o d is  a f u n cti o n of t he t y pe  of H R T use d. T he d urati o n of t he was h o ut p eri o d 
bel o w are s u g geste d g ui deli nes a n d t h e i n vesti gat ors s h o ul d use t heir j u d g me nt i n c hec ki n g 
ser u m F S H le vels.  If t h e ser u m  F S H le v el is  > 4 0 mI U/ ml at  a n y ti me d uri n g t he w as h o ut 
peri o d, t he w o ma n ca n b e c o nsi der e d p ost me n o pa usal: 

1 w ee k mi ni m u m f or va gi n al h or m o nal pr o d ucts (ri n gs, crea ms, gels) 


Pr ot oc ol: 
Versi o n 8. 0. Se pte m ber 1 9 , 2 0 1 8 
Pa ge | 2 5  
 

4 w ee k mi ni m u m f or tra ns der m al pr o d u cts 

8 w ee k mi ni m u m f or oral pr o d ucts 
P os t me no pa usal  w o me n  ma y  c o nti n ue  H R T  after  F S H  testi n g  is  c o m plete d  a n d 
p ost me n o pa usal stat us is c o nfir me d. Ot her pare nt eral pr o d u cts ma y re q uire was h o ut peri o ds 
as l o n g as 6 m o nt hs. 
 
5. 2  
Tri al Tre at me nts  
T he treat me nt t o be us e d i n t his trial is o utli ne d bel o w i n Ta ble 2  
Ta ble 2 
Trial Treat me nt  
Dr u g  
D ose  
P ote nc y  
D ose 
Fre q ue nc y  
R o ute of 
A d mi nistrati o n  
Re gi me n  
Treat me nt Peri o d  
Use  
I n d u cti o n I m m u n ot hera p y 
I pili m u ma b 
3 m g/ k g  
Q 3 W  
I V i nf usi o n 
Da y 1  x 4 c ycl es  
I n v esti gati o n
al 
Ni v ol u ma b  
1 m g/ k g  
Q 3 W  
I V i nf usi o n 
Da y 1  x 4 c ycl es  
I n v esti gati o n
al 
A d. p 5 3 -D C  
1 -5 x 1 0 6 
via ble p 5 3 + 
D C  
Q 2 W  
I D i njecti o n 
x 3 per st u d y 
cale n dar  
I n v esti gati o n
al 
Mai nte na nce I m m u n ot hera p y  
Ni v ol u ma b  
4 8 0 m g  
Q 4 W  
I V i nf usi o n 
Da y 1  x u ntil 
disease 
pr o gressi o n ( P D) 
I n v esti gati o n
al 
A d. p 5 3 -D C  
1 -5 x 1 0 6 
via ble p 5 3 + 
D C  
Q 4 W  
I D i njecti o n 
x 3 per st u d y 
cale n dar  
 
Trial treat me nt s h o ul d be gi n wit hi n 2 - 3 wee ks of t he le u k o p heresis. 
5. 2. 1  D ose Selecti o n/ M o dific ati o n  
 
5. 2. 1. 1  D ose Selecti o n  
T he  r ati o nale  f or  selecti o n  of  d oses  t o  be  us e d  i n  t his  trial  is  pr o vi de d  i n  Secti o n  4. 0 – 
Bac k gr o u n d a n d Rati o nal e.   
 
Details o n pre parati o n a n d a d mi nistrati o n of i pili m u ma b a n d ni v ol u ma b are pr o vi de d i n t he 
I n v esti gat or Br o c h ure. D etails o n pre parati o n a n d a d mi nistrati o n of A d. p 5 3 -D C are pr o vi de d 
i n A p pe n di x 1 1. 4.   
 
5. 2. 1. 2  D ose M o dific ati o n  
A d. p 5 3- D C  
T here  will  n o  pr e -pla n n e d  d ose  m o dificati o ns  f or  t he  vacci ne  A d. p 5 3 -D C.  H ol di n g  o ne 
i n di vi d ual vacci ne ( A d. p 5 3-D C) d ose or c o m plete disc o nti n uati o n of vacci ne d oses will be at 
t he  discreti o n  of  t he  treati n g  p h ysici a n  a n d  i n  c o or di nati o n  wit h  t he  st u d y  pri nci pal 
i n vesti gat or a n d s p o ns or. 


Protocol: 
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Temporal of permanent discontinuation of Ipi-Nivo or Nivo due to adverse events, will not 
preclude continuation and/or completion of vaccine administration as planned per protocol. 
 
Ipilimumab-Nivolumab (Ipi-Nivo) or Nivolumab (Nivo) 
Adverse events (both non-serious and serious) associated with Ipi-Nivo or Nivo exposure 
may represent an immunologic etiology.  These adverse events may occur shortly after the 
first dose or several months after the last dose of treatment. Ipi-Nivo or Nivo must be 
withheld for drug-related toxicities and severe or life-threatening AEs as per Table 3 below.  
 
See Section 11.6 Management Algorithms for supportive care guidelines, including use of 
corticosteroids. 
 
NOTE: 
In cases of an unexpected or unforeseen discrepancy between the guidelines 
or instructions in Table 3 (below) and Section 11.6 Management Algorithms, 
the latter guidelines/instructions should prevail for the purposes of patient 
management on protocol. 
 
Table 3 
Dose Modification Guidelines for Drug-Related Adverse Events 
Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting Treatment 
Discontinue Subject 
Diarrhea/Colitis 
2 
 
Toxicity resolves to Grade 0-1. 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
AST, ALT, or 
Increased Bilirubin 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose. 
3-4 
Permanently discontinue 
(see exception below)1 
Permanently discontinue 
Type 1 diabetes 
mellitus (if new 
onset) or 
Hyperglycemia 
T1DM or  
 
Hold IPI-NIVO OR NIVO for new onset 
Type 1 diabetes mellitus or Grade 3-4 
hyperglycemia associated with evidence of 
beta cell failure.  
 
Resume IPI-NIVO OR NIVO when patients are clinically and 
metabolically stable. 
3-4 
Permanently discontinue 
Permanently discontinue 
Hypophysitis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
Hyperthyroidism  
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
Hypothyroidism 
2 
Therapy with IPI-NIVO OR NIVO can be 
continued while treatment for the thyroid 
disorder is instituted 
Therapy with IPI-NIVO OR NIVO can be continued while 
treatment for the thyroid disorder is instituted. 
3-4 
Permanently discontinue 
Permanently discontinue 
Infusion Reaction 
3-4 
Permanently discontinue 
Permanently discontinue 
Pneumonitis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 


Protocol: 
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Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting Treatment 
Discontinue Subject 
Renal Failure or 
Nephritis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
All Other Drug-
Related Toxicity2 
Any Severe 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
Note: Permanently discontinue for any severe or Grade 3 drug-related AE that recurs or any life-threatening event. 
1 For patients with liver metastasis who begin treatment with Grade 2 AST or ALT, if AST or ALT increases by greater than or equal to 50% relative to baseline 
and lasts for at least 1 week then patients should be discontinued. 
2 Patients with intolerable or persistent Grade 2 drug-related AE may hold study medication at physician discretion.  Permanently discontinue study drug for 
persistent Grade 2 adverse reactions for which treatment with study drug has been held, that do not recover to Grade 0-1 within 12 weeks of the last dose.   
 
Dosing interruptions are permitted in the case of medical / surgical events or logistical 
reasons not related to study therapy (e.g., elective surgery, unrelated medical events, patient 
vacation, and/or holidays). Subjects should be placed back on study therapy within 3 weeks 
of the scheduled interruption, unless otherwise discussed with the Sponsor. The reason for 
interruption should be documented in the patient's study record. 
5.2.2 Timing of Dose Administration 
Trial antibody (checkpoint inhibitor treatment should be administered after all 
procedures/assessments have been completed as detailed on the Trial Flow Chart (Section 
6.0).  Trial treatment may be administered up to 7 days before or after the scheduled day due 
to any medical or administrative/logistical reasons. 
 
All trial treatments will be administered on an outpatient basis. 
Induction Immunotherapy:  
• Ipilimumab, 3 mg/kg IV q3w x4 cycles 
• Nivolumab, 1 mg/kg IV q3w x4 cycles. 
 
Maintenance Immunotherapy:  
• Nivolumab, 480 mg (flat dose) IV q4weeks until PD.  
 
Sites should make every effort to target infusion timing to be as close  as possible (60 min for 
nivolumab and 90 min for ipilimumab).  However, given the variability of infusion pumps 
from site to site, a window of -10 minutes and +15 minutes is permitted (i.e., infusion time is 
60 or 90 minutes: -10 min/+15 min, respectively).  
 
The Pharmacy Manual contains specific instructions for the preparation of the Ipi-Nivo or 
Nivo infusion fluid and administration of infusion solution. 
 
Ad.p53-DC (2-5x106 DC depending on manufacture cell number yield) will be administered 
as an intradermal injection as per the trial schema, every 2 weeks x 3 after the first 
leukopheresis (induction immunotherapy) and in cases of persistant SD upon restaging, again 
every 4 weeks x 3 after the second leukopheresis (maintenance immunotherapy). 


Protocol: 
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5.2.3 Trial Blinding/Masking 
This is an open-label trial; therefore, the Sponsor, investigator and subject will know the 
treatment administered. 
 
5.3 
Randomization or Treatment Allocation 
Not applicable 
 
5.4 
Stratification 
Not applicable 
 
5.5 
Concomitant Medications/Vaccinations (allowed & prohibited) 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial.  If there is a clinical indication for one of these or other medications 
or vaccinations specifically prohibited during the trial, discontinuation from trial therapy or 
vaccination may be required.  The investigator should discuss any questions regarding this 
with the BMS Clinical team.  The final decision on any supportive therapy or vaccination 
rests with the investigator and/or the subject's primary physician.  
 
5.5.1 Acceptable Concomitant Medications 
All treatments that the investigator considers necessary for a subject’s welfare may be 
administered at the discretion of the investigator in keeping with the community standards of 
medical care.   
 
All concomitant medications received within 28 days before the first dose of trial treatment 
and 30 days after the last dose of trial treatment should be recorded.  Concomitant 
medications administered after 30 days after the last dose of trial treatment should be 
recorded for SAEs and ECIs as defined in Section 7.2. 
 
5.5.2 Prohibited Concomitant Medications 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase (including retreatment for post-complete response relapse) of this trial: 
• Antineoplastic systemic chemotherapy or biological therapy  
• Immunotherapy not specified in this protocol 
• Chemotherapy not specified in this protocol 
• Investigational agents other than Ipi-Nivo 
• Radiation therapy  
o Note:  Radiation therapy to a symptomatic solitary lesion or to the brain may 
be allowed at the investigator’s discretion.   
• Live vaccines within 30 days prior to the first dose of trial treatment and while 
participating in the trial.  Examples of live vaccines include, but are not limited to, the 
following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and 
typhoid vaccine.  
• Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
event of clinical interest of suspected immunologic etiology.  The use of physiologic 
doses of corticosteroids may be approved after consultation with the Sponsor. 


Protocol: 
Version 8.0. September 19, 2018 
Page | 29  
 
Subjects who, in the assessment by the investigator, require the use of any of the 
aforementioned treatments for clinical management should be removed from the trial.  
Subjects may receive other medications that the investigator deems to be medically 
necessary. 
 
The Exclusion Criteria describes other medications which are prohibited in this trial. There 
are no prohibited therapies during the Post-Treatment Follow-up Phase. 
 
5.6 
Rescue Medications & Supportive Care 
 
5.6.1 Supportive Care Guidelines 
Subjects should receive appropriate supportive care measures as deemed necessary by the 
treating investigator.  Suggested supportive care measures for the management of adverse 
events with potential immunologic etiology are outlined below and in greater detail in 
Section 11.6. Where appropriate, these guidelines include the use of oral or intravenous 
treatment with corticosteroids as well as additional anti-inflammatory agents if symptoms do 
not improve with administration of corticosteroids.    
 
Note that several courses of steroid tapering may be necessary as symptoms may worsen 
when the steroid dose is decreased. For each disorder, attempts should be made to rule out 
other causes such as metastatic disease or bacterial or viral infection, which might require 
additional supportive care. The treatment guidelines are intended to be applied when the 
investigator determines the events to be related to Ipi-Nivo.  
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or 
skin photography as part of evaluation of the event.  
• Management of Infusion Reactions: Signs and symptoms usually develop during or 
shortly after drug infusion and generally resolve completely within 24 hours of 
completion of infusion.  
 
Table 4 below shows treatment guidelines for subjects who experience an infusion 
reaction associated with administration of Ipi-Nivo. 
 
Table 4 
Infusion Reaction Treatment Guidelines 
NCI CTCAE Grade 
Treatment 
Premedication at subsequent 
dosing 
Grade 1 
Mild reaction; infusion interruption 
not indicated; intervention not 
indicated 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
None 
Grade 2 
Requires infusion interruption but 
responds promptly to symptomatic 
treatment (e.g., antihistamines, 
NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated for 
< =24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
If symptoms resolve within one hour of stopping 
drug infusion, the infusion may be restarted at 
Subject may be premedicated 1.5h 
(± 30 minutes) prior to infusion of 
IPI-NIVO OR NIVO  with: 
 
Diphenhydramine 50 mg po (or 
equivalent dose of antihistamine). 
 
Acetaminophen 500-1000 mg po 
(or equivalent dose of antipyretic). 


Protocol: 
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NCI CTCAE Grade 
Treatment 
Premedication at subsequent 
dosing 
50% of the original infusion rate (e.g., from 100 
mL/hr to 50 mL/hr).  Otherwise dosing will be 
held until symptoms resolve and the subject 
should be premedicated for the next scheduled 
dose. 
Subjects who develop Grade 2 toxicity despite 
adequate premedication should be 
permanently discontinued from further trial 
treatment administration. 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly responsive 
to symptomatic medication and/or 
brief interruption of infusion); 
recurrence of symptoms following 
initial improvement; hospitalization 
indicated for other clinical sequelae 
(e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or ventilatory 
support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued from 
further trial treatment administration. 
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period of drug 
administration. 
 
 
5.7 
Diet/Activity/Other Considerations 
 
5.7.1 Diet 
Subjects should maintain a normal diet unless modifications are required to manage an AE 
such as diarrhea, nausea or vomiting. 
 
5.7.2 Contraception 
IPI-NIVO OR NIVO may have adverse effects on a fetus in utero.  Furthermore, it is not 
known if IPI-NIVO OR NIVO has transient adverse effects on the composition of sperm.  
Non-pregnant, non-breast-feeding women may be enrolled if they are willing to use 2 
methods of birth control or are considered highly unlikely to conceive.  Highly unlikely to 
conceive is defined as 1) surgically sterilized, or 2) postmenopausal (a woman who is ≥45 
years of age and has not had menses for greater than 1 year will be considered 
postmenopausal), or 3) not heterosexually active for the duration of the study.  The two birth 
control methods can be either two barrier methods or a barrier method plus a hormonal 
method to prevent pregnancy. Subjects should start using birth control from study Visit 1 
throughout the study period up to 120 days after the last dose of study therapy.  
 
The following are considered adequate barrier methods of contraception: diaphragm, condom 
(by the partner), copper intrauterine device, sponge, or spermicide.  Appropriate hormonal 
contraceptives will include any registered and marketed contraceptive agent that contains an 
estrogen and/or a progestational agent (including oral, subcutaneous, intrauterine, or 
intramuscular agents). 


Protocol: 
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Page | 31  
 
Subjects should be informed that taking the study medication may involve unknown risks to 
the fetus (unborn baby) if pregnancy were to occur during the study.  In order to participate 
in the study they must adhere to the contraception requirement (described above) for the 
duration of the study and during the follow-up period defined in section 7.2.2-Reporting of 
Pregnancy and Lactation to the Sponsor and to BMS.  If there is any question that a subject 
will not reliably comply with the requirements for contraception, that subject should not be 
entered into the study. 
5.7.3 Use in Pregnancy 
If a subject inadvertently becomes pregnant while on treatment with Ipi-Nivo the subject will 
immediately be removed from the study.  The site will contact the subject at least monthly 
and document the subject’s status until the pregnancy has been completed or terminated.  The 
outcome of the pregnancy will be reported to the Sponsor and to BMS without delay and 
within 24 hours to the Sponsor and within 2 working days to BMS if the outcome is a serious 
adverse experience (e.g., death, abortion, congenital anomaly, or other disabling or life-
threatening complication to the mother or newborn).   
The study investigator will make every effort to obtain permission to follow the outcome of 
the pregnancy and report the condition of the fetus or newborn to the Sponsor.   If a male 
subject impregnates his female partner the study personnel at the site must be informed 
immediately and the pregnancy reported to the Sponsor and to BMS and followed as 
described above and in Section 7.2.2. 
5.7.4 Use in Nursing Women 
It is unknown whether Ipi-Nivo is excreted in human milk.  Since many drugs are excreted in 
human milk, and because of the potential for serious adverse reactions in the nursing infant, 
subjects who are breast-feeding are not eligible for enrollment. 
5.8 
Subject Withdrawal/Discontinuation Criteria 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the 
discretion of the investigator should any untoward effect occur.  In addition, a subject may be 
withdrawn by the investigator or the Sponsor if enrollment into the trial is inappropriate, the 
trial plan is violated, or for administrative and/or other safety reasons.  Specific details 
regarding discontinuation or withdrawal are provided in Section 7.1.4 – Other Procedures. 
A subject must be discontinued from the trial for any of the following reasons: 
• The subject or legal representative (such as a parent or legal guardian) withdraws 
consent. 
• Confirmed radiographic disease progression 
Note: For unconfirmed radiographic disease progression, please see Section 5.2.2 
Note: A subject may be granted an exception to continue on treatment with 
confirmed radiographic progression if clinically stable or clinically improved, 
please see Section 7.1.2.7.1 
• Unacceptable adverse experiences as described in Section 5.2.1.2 


Protocol: 
Version 8.0. September 19, 2018 
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• Intercurrent illness that prevents further administration of treatment 
• Investigator’s decision to withdraw the subject 
• The subject has a confirmed positive serum pregnancy test 
• Noncompliance with trial treatment or procedure requirements 
• The subject is lost to follow-up 
• Administrative reasons 
 
The End of Treatment and Follow-up visit procedures are listed in Section 6 (Protocol Flow 
Chart) and Section 7.1.5 (Visit Requirements).  After the end of treatment, each subject will 
be followed for 30 days for adverse event monitoring (serious adverse events will be 
collected for 90 days after the end of treatment as described in Section 7.2.3.1).  Subjects 
who discontinue for reasons other than progressive disease will have post-treatment follow-
up for disease status until disease progression, initiating a non-study cancer treatment, 
withdrawing consent or becoming lost to follow-up.  After documented disease progression 
each subject will be followed by telephone for overall survival until death, withdrawal of 
consent, or the end of the study, whichever occurs first. 
5.8.1 Discontinuation of Study Therapy after CR  
Discontinuation of treatment may be considered for subjects who have attained a confirmed 
CR that have been treated for at least 24 weeks with maintenance Nivo and had at least two 
treatments with Nivo beyond the date when the initial CR was declared.   
 
Subjects who then experience radiographic disease progression may be eligible for up to one 
year of additional treatment with Ipi-Nivo (similar schedule) via the Second Course Phase at 
the discretion of the investigator if no cancer treatment was administered since the last dose 
of Ipi-Nivo or Nivo, the subject meets the safety parameters listed in the Inclusion/Exclusion 
criteria, and the trial is open.   
 
Concomitant administration of the Ad.p53-DC vaccine together with Ipi-Nivo or Nivo is 
desired and included as part of the Second Course Phase described above if feasible from a 
medical and logistical point of view.  
 
5.9 
Subject Replacement Strategy 
Subjects deemed not eligible will be replace and will not count towards achieving the trial 
sample size calculation 
5.10 Clinical Criteria for Early Trial Termination 
Early trial termination will be the result of the criteria specified below: 
1. Quality or quantity of data recording is inaccurate or incomplete 
2. Poor adherence to protocol and regulatory requirements 
3. Incidence or severity of adverse drug reaction in this or other studies indicates a potential 
health hazard to subjects 
4. Plans to modify or discontinue the development of the study drug 
 
In the event of BMS decision to no longer supply study drug, ample notification will be 
provided so that appropriate adjustments to subject treatment can be made. 


Protocol: 
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Page | 33  
 
 
5.11 
Assessment of Outcomes 
 
5.11.1 Safety Assessments.  
NCI CTCAE version 4 will be used to assess toxicities in all patients in this study.  
Careful toxicity assessments will be performed with standard laboratory studies (CBC, BUN, 
creatinine, electrolytes, and LFTs) before each treatment. In addition, a medical history and 
physical examination will be performed monthly.  
Three unusual toxicities can occur with anti-PD-1 therapy. These include induction of 
autoimmunity (nephritis, colitis, pneumonitis, and endocrinopathies). Careful, frequent 
clinical evaluation for the development of autoimmunity symptoms will be performed. 
Detailed plans for management of these toxicities will be present in the clinical protocol. 
Patients who develop uncontrolled grade 3/4 pneumonitis will permanently discontinue IPI-
NIVO OR NIVO. Patients will be treated in the Moffitt Clinical Research Unit, which is 
staffed by nurses experienced in the management of infusion reactions and cytokine release 
syndrome.  
We are also very experienced in managing the toxicities associated with immune checkpoint 
inhibitors as we have treated over 200 lung cancer patients with either anti-PD-1 or anti-PD-
L1 therapy since June 2011. All SAEs with a determination of SAE-relatedness to the 
investigational therapy will be reported as described in the data and safety-monitoring plan 
detailed in the protocol. 
5.11.2 Clinical Efficacy.  
Radiographic assessments will be performed at the end of vaccines 1-3 (“first 3 vaccines”) 
and twice in patients receiving vaccines 4-6 (“second three vaccines”). First, after vaccine 4 
and then, after all 6 vaccines. Subsequently, assessments will be done every 12 weeks.  
Response will be assessed primarily using the response evaluation criteria in solid tumors 
(RECIST v1.1). Response rate, overall survival, and progression-free survival will be 
determined. Subjects with progressive disease by RECIST but without rapid clinical 
deterioration may continue to be treated at the discretion of the investigator. 
The immune related (ir)RECIST will also be used secondarily for research purposes only. 
This is a modification of RECIST and allows measurement of response patterns unique to 
immune therapy, such as tumor progression of index lesions and appearance of new lesions 
prior to tumor regression85. Patients who are found to have stable disease (SD), partial 
response (PR), or complete response (CR) will continue on study until evidence of disease 
progression, intolerance, or withdrawal from study. 
5.11.3 Immunological Efficacy 
Criteria used to determine the presence of immune responses: Individual patient will be 
considered responders if at any time point the response in IFN-γ ELIPOT assay is higher than 
30 spots per 2 × 105 AND the response in IFN-γ ELISPOT to ALVAC p53 is more than 2 SD 


Protocol: 
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Page | 34  
 
higher than the response to corresponding ALVAC control at the same time point AND 2 SD 
higher than the corresponding response at the base line (before start of the treatment).s  
 
5.11.4 Biomarker Testing 
A pre-treatment tumor biospy will be performed (mandatory) and utilized to evaluate tumor 
p53 biomarker status. To be eligible for the study, patients must have a favorable tumor p53 
biomarker profile defined by ≥ 50% p53 positive tumor cells by immunohistochemistry. 
Tumor p53 biomarker evaluations may be performed with either original or recurrent tumor 
although samples from recurrent disease are preferred. 
   
The mandatory pre-treatment tumor biopsy specimen will be used to evaluate p53 protein 
expression using a CLIA-certified p53 assay.  If sufficient tumor sample remains available, 
additional immunohistochemistry evaluations will be performed for PD-1, PDL-1, PDL-2 
protein expression as well as tumor infiltration by immune cells expressing CD3, CD8, CD4, 
CD25, FoxP3, CD11b, and CD56.   
 
Tumor mutational burden will also be evaluated using Foundation One CDx, if possible 
depending on tissue availability. 
 
Simultaneously, all efforts will be made to collect archival tumor tissue from previous 
biopsies, either in the form of a FFPE block or unstained slides (ideally 5-10, but any number 
will be acceptable depending on availability).  


Protocol: 
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6.0 TRIAL FLOW CHART 
All laboratory studies, visits and procedures included in these Flow chart have a +/- 7 day window. This rule applies in addition to any 
existing window included for specific laboratory studies, visits or procedures at the discretion of the investigators. 
 
Scree
ning 
Leuko 
pheresi
s #1A,E 
Visit 
#1C,E 
Visit 
#2 
Visit 
#3 
Visit 
#4 
Visit 
#5 
Leuko 
pheresis 
#2B,E 
 
Visit 
#6D,E 
Visit 
#7 
Visit 
#8 
Visit 
#9 
Visit 
#10 
Visit 
#11 
Visit 
#12 
Visit 
#13,F + 
End  
of  
Study 
VisitG 
 
 
 
Induction Immunotherapy 
Maintenance Immunotherapy 
 
 
Wk  
-4 to 0 
Wk  
-3 to 0 
Wk 1 
C1 
D1 
Wk 3 
C1D15 
Wk 4 
C2D1 
Wk 5 
C2D8 
Wk 7 
C3D1 
Wk  
8 to 12 
Wk 10 
C4D1 
Wk 13 
C5D1 
Wk 15 
C5D15 
Wk 
17 
C6D1 
Wk 
19 
C6D1
5 
Wk 
21 
C7D1 
Wk 23 
C7D15 
Wk 25, 
+  
C8,+ 
D1 
 
ICF1 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H+P2 
X 
 
X 
 
X 
 
X 
 
 
X 
 
 
X 
 
 
X 
X 
MD3 visit 
X 
 
X 
 
X 
 
X 
 
 
X 
 
 
X 
 
 
X 
 
Mid-Level visit 
 
 
 
X 
 
X 
 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
CTC7 visit 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concurrent 
Medications 
X 
X ……………………………………………………………………………………………………………………………….… X 
X 
Adverse event  
(AE) evaluationCC 
X 
X ……………………………………………………………………..…………………………………………………………… X 
X 
CBC, diff 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
 
X 
X 
CMP 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
 
X 
X 
Mg 
X 
X4 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
LDH 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
PT/INR, PTT 
X 
X4 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 Thyroid studies13 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
EKG, U/A 
X 
X4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy test 
X 
X4 
 
 
 
 
 
X4 
 
 
 
 
 
 
 
 
 
CT chest/abd.6 
X 
 
 
 
 
 
X 
 
 
X 
 
 
X 
 
 
X6 
X 
Brain MRI5,8 
X5 
 
 
 
 
 
X5 
 
 
 
 
 
 
 
 
X5 
X5 
NivolumabAA  
 
 
X 
 
X 
 
X 
 
X 
XAA 
 
X 
 
X 
 
X 
 
Ipilimumab  
 
 
X 
 
X 
 
X 
 
X 
 
 
 
 
 
 
 
 
Ad.p53-DCBB 
 
 
X 
X 
 
X 
 
 
 
XBB 
 
X 
 
X 
 
 
 
Immune 
response 
evaluation9 
X 
X10 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Image guided core 
biopsy11 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor Biomarkers 
(p53 IHC)12  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Life-expectancy >4 
months 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1 
Informed consent form (ICF) must be signed within 3 weeks of first leukopheresis (start of study) 


Protocol: 
Version 8.0. September 19, 2018 
Page | 36  
 
2 
Brief history and physical (H+P) to include vital signs (VS), weight (W), height (H) and performance status (PS) and AE evaluation on Mid-Level visits 
and Full H+P on MD visits. 
3 
Can also be performed by protocol assigned Mid-Level: Nurse Practitioner (NP) or Physician Assistant (PA) 
4 
Only need repeated if leukopheresis being performed more than 4 weeks since a prior test performed 
5 
Only required for patients with CNS symptoms suspicious of brain metastasis or for patients known to have untreated brain metastasis. Otherwise it is 
only required if clinically indicated per treating physician discretion 
6 
Starting with visit #13 and beyond, while only receiving maintenance nivolumab, patients will have restaging CT scans every 3 months 
7 
When the patient is seen by the MD, then only a clinical trials coordinator (CTC) visit will be required. For all other appointments, a Mid Level (Mid L) 
visit will be required 
8 
The type and site of any other imaging scan will only be performed when clinically indicated, at the discretion of the treating physician 
9 
Including MDSC determination 
10 
Not necessary if blood drawn at screening 
11 
Tumor biopsy is mandatory. Ideally, 4-6 core samples should be obtained. A lesser number of cores (1-3) will be acceptable in cases where patient 
safety so requires or if in the judgement of the physician performing the biopsy less number of cores should be performed.. Simultaneously, all efforts 
will be made to collect archival tumor tissue from previous biopsies, either in the form of a FFPE block or unstained slides (ideally 5-10, but any 
number will be acceptable depending on availability). 
12 
Tumor Biomarker Testing for p53 expression  at enrollment is required. Tumor p53 biomarker evaluations can be performed with either original or 
recurrent tumor although samples from recurrent disease are preferred. Additional biomarkers will also be performed depending on tissue availability as 
per section 5.11.4. 
13 
See Table 5, (T3, T4 and TSH) 
 
A 
First leukopheresis should occur within 2-3weeks of completing screening evaluation (date of the last screening test performed) 
B 
Second leukopheresis should occur within 2-3weeks of completing restaging evaluation 
C 
Visit #1 should be scheduled within 2week of leukopheresis #1 
D 
Visit #5 should be scheduled within 2 week of leukopheresis #2 
E 
 For clarity and consistency purposes, if visits #1 and/or #5 occur more than 2 weeks from leukopheresis, they will still be considered to occur on weeks 
1 and/or 10 respectively 
F 
patients will be seen on a monthly schedule after visit #13 
G 
The mandatory Safety Follow-Up Visit (End of trial, EOT) should be conducted approximately 30-45 days after the last dose of trial treatment or before 
the initiation of a new anti-cancer treatment, whichever comes first (End of trial, EOT).   
 
AA 
Nivolumab is administered at a fixed dose of 480 mg every 4 weeks during the maintenance period until PD 
BB 
First booster vaccine (vaccine #4) should be administered with the first cycle of maintenance immunotherapy (C5D1), in combination with single agent 
(maintenance) nivolumab. The subsequent second and third booster vaccines will be administered 4 weeks later, on C7D1 and C9D1, respectively with 
the corresponding dose of nivolumab. 
CC 
The study stopping criteria incorporated to the protocol are applicable (as described in …..) ONLY PRIORr to D1C3.  
 
NOTE: IN CASE THAT, DURING THE CONDUCTION OF THE TRIAL, A DISCREPANCY WAS NOTED BETWEEN THE PROTOCOL 
CONTENT AND THIS CALENDAR, THE INFORMATION OR REQUIREMENTS INCLUDED IN THE CALENDAR WILL BE FOLLOWED 


Protocol: 
Version 8.0. September 19, 2018 
Page | 37  
 
6.1 
TRIAL FLOW CHART: Second Course Phase (Retreatment Period) 
All laboratory studies, visits and procedures included in these Flow chart have a +/- 7 day window. This rule applies in addition to any 
existing window included for specific laboratory studies, visits or procedures at the discretion of the investigators. 
 
Screening 
Visit 
#1 
Visit 
#2 
Visit 
#3 
Visit 
#4 
Visit 
#5 
Visit 
#6 
Visit 
#7 
Visit 
#8,A + 
End 
of 
Study 
VisitB 
 
 
 
Induction Immunotherapy 
Maintenance Immunotherapy 
 
 
Wk  
-4 to 0 
Wk 1 
C1 D1 
Wk 4 
C2D1 
Wk 7 
C3D1 
Wk 10 
C4D1 
Wk 13 
C5D1 
Wk 17 
C6D1 
Wk 21 
C7D1 
Wk 25, +  
C8 +D1 
 
H+P14 
X 
X20 
X 
X 
X 
X 
X 
X 
X 
X 
MD15/Mid-
Level visit 
X 
X20 
X 
X 
X 
X 
X 
X 
X 
X 
CTC18 visit 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concurrent 
Medications 
X 
X …………………………………………………………………………………….… X 
X 
AE 
evaluation 
X 
X …………………………..…………………………………………………………… X 
X 
CBC, diff 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CMP 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy 
test 
X 
 
 
 
 
 
 
 
 
 
CT 
chest/abd.17 
X 
 
 
X 
 
X 
 
 
X17 
X 
Brain 
MRI16,19 
X16 
 
 
X16 
 
 
 
 
X16 
X16 
NivolumabAA  
 
X 
X 
X 
X 
XAA 
X 
X 
X 
 
Ipilimumab  
 
X 
X 
X 
X 
 
 
 
 
 
 
14 
Brief history and physical (H+P) to include vital signs (VS), weight (W), height (H) and performance status (PS) and AE evaluation on 
Mid-Level visits or MD visits. 


Protocol: 
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Page | 38  
 
15 
Can also be performed by protocol assigned Mid-Level: Nurse Practitioner (NP) or Physician Assistant (PA) 
16 
Only required for patients with CNS symptoms suspicious of brain metastasis or for patients known to have untreated brain metastasis. 
Otherwise it is only required if clinically indicated per treating physician discretion 
17 
At the time of visits #8 and beyond, while only receiving maintenance nivolumab, patients will have restaging CT scans every 3 months 
18 
When the patient is seen by the MD, then only a clinical trials coordinator (CTC) visit will be required. For all other appointments, a Mid 
Level (Mid L) visit will be required 
19 
The type and site of any other imaging scan will only be performed when clinically indicated, at the discretion of the treating physician 
20 
This visit is not necessary if screening visit performed within 4 weeks of D1C1 
 
 
A 
patients will be seen on a monthly schedule after visit #8 
B 
The mandatory Safety Follow-Up Visit (End of trial, EOT) should be conducted approximately 30-45 days after the last dose of trial 
treatment or before the initiation of a new anti-cancer treatment, whichever comes first (End of trial, EOT).   
 
AA 
Nivolumab is administered at a fixed dose of 480 mg every 4 weeks until PD 


Protocol: 
Version 8.0. September 19, 2018 
 
 
Page | 39  
 
7.0 TRIAL PROCEDURES 
 
7.1 
Trial Procedures 
The Trial Flow Chart - Section 6.0 summarizes the trial procedures to be performed at each 
visit.  Individual trial procedures are described in detail below.  It may be necessary to 
perform these procedures at unscheduled time points if deemed clinically necessary by the 
investigator. 
 
Furthermore, additional evaluations/testing may be deemed necessary by the Sponsor and/or 
BMS for reasons related to subject safety. In some cases, such evaluation/testing may be 
potentially sensitive in nature (e.g., HIV, Hepatitis C, etc.), and thus local regulations may 
require that additional informed consent be obtained from the subject.  In these cases, such 
evaluations/testing will be performed in accordance with those regulations. 
 
7.1.1 Administrative Procedures 
 
7.1.1.1 Informed Consent 
The Investigator must obtain documented consent from each potential subject prior to 
participating in a clinical trial. 
 
7.1.1.1.1  General Informed Consent 
Consent must be documented by the subject’s dated signature or by the subject’s legally 
acceptable representative’s dated signature on a consent form along with the dated signature 
of the person conducting the consent discussion.  
A copy of the signed and dated consent form should be given to the subject before 
participation in the trial. 
 
The initial informed consent form, any subsequent revised written informed consent form 
and any written information provided to the subject must receive the IRB/ERC’s 
approval/favorable opinion in advance of use.  The subject or his/her legally acceptable 
representative should be informed in a timely manner if new information becomes available 
that may be relevant to the subject’s willingness to continue participation in the trial.  The 
communication of this information will be provided and documented via a revised consent 
form or addendum to the original consent form that captures the subject’s dated signature or 
by the subject’s legally acceptable representative’s dated signature. 
 
Specifics about a trial and the trial population will be added to the consent form template at 
the protocol level.   
 
The informed consent will adhere to IRB/ERC requirements, applicable laws and regulations 
and Sponsor requirements. 
 
7.1.1.2 Inclusion/Exclusion Criteria 
All inclusion and exclusion criteria will be reviewed by the investigator or qualified designee 
to ensure that the subject qualifies for the trial.  


Protocol: 
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7.1.1.3 Medical History 
A medical history will be obtained by the investigator or qualified designee.  Medical history 
will include all active conditions, and any condition diagnosed within the prior 10 years that 
are considered to be clinically significant by the Investigator.  Details regarding the disease 
for which the subject has enrolled in this study will be recorded separately and not listed as 
medical history.   
 
7.1.1.4 Prior and Concomitant Medications Review 
 
7.1.1.4.1 Prior Medications 
The investigator or qualified designee will review prior medication use, including any 
protocol-specified washout requirement, and record prior medication taken by the subject 
within 28 days before starting the trial.  Treatment for the disease for which the subject has 
enrolled in this study will be recorded separately and not listed as a prior medication.  
 
7.1.1.4.2 Concomitant Medications 
The investigator or qualified designee will record medication, if any, taken by the subject 
during the trial.  All medications related to reportable SAEs and ECIs should be recorded as 
defined in Section 7.2. 
 
7.1.1.5 Disease Details and Treatments 
 
7.1.1.5.1 Disease Details 
The investigator or qualified designee will obtain prior and current details regarding disease 
status.  
 
7.1.1.5.2 Prior Treatment Details 
The investigator or qualified designee will review all prior cancer treatments including 
systemic treatments, radiation and surgeries. 
 
7.1.1.5.3 Subsequent Anti-Cancer Therapy Status 
The investigator or qualified designee will review all new anti-neoplastic therapy initiated 
after the last dose of trial treatment.  If a subject initiates a new anti-cancer therapy within 30 
days after the last dose of trial treatment, the 30 day Safety Follow-up visit must occur before 
the first dose of the new therapy.  Once new anti-cancer therapy has been initiated the subject 
will move into survival follow-up.  
 
7.1.1.6 Assignment of Screening Number 
Once a patient is enrolled in the study, he/she will be assigned a simple 3 digit number, with 
the first patient assigned to 001 and so on.  A separate spreadsheet with password protection 
will be maintained that contains the patient study number along with personally identifiable 
information.  Password protection will be maintained in order to keep patient information 
strictly confidential.  Upon signing the informed consent form, the patient will be assigned a 
subject number by the investigator or his/her designee. Once assigned to a patient, a subject 
number will not be reused. If the patient fails to be started on treatment for any reason, the 
reason will be entered on the Eligibility Tab in OnCore, and his/her demographic information 


Protocol: 
Version 8.0. September 19, 2018 
 
 
Page | 41  
 
will be entered on the Demography Tab in OnCore. All laboratory, radiologic, and pathologic 
data collected on trial participants will be assigned the unique treatment number and stored in 
the OnCore system database.  
 
7.1.1.7 Assignment of Randomization Number 
Not applicable 
 
7.1.1.8 Trial Compliance (Medication/Diet/Activity/Other) 
The Principal Investigator and the Clinical Research Coordinator assigned to the case will be 
primarily responsible for maintaining all study related documents including the clinical 
research forms.  Oncore is the password protected, web-based electronic secure, database of 
record for all CRF entries and will be verified with source documentation. The review of 
medical records within the EMR will be done in a manner to assure that patient 
confidentiality is maintained.   
 
7.1.2 Clinical Procedures/Assessments 
 
7.1.2.1 Adverse Event (AE) Monitoring 
AEs will be collected from time of C1D1. The investigator or qualified designee will assess 
each subject to evaluate for potential new or worsening AEs as specified in the Trial Flow 
Chart and more frequently if clinically indicated.  Adverse experiences will be graded and 
recorded throughout the study and during the follow-up period according to NCI CTCAE 
Version 4.0 (see Appendix 11.2).  Toxicities will be characterized in terms regarding 
seriousness, causality, toxicity grading, and action taken with regard to trial treatment.  
 
All AEs of unknown etiology associated with Ipi-Nivo or Nivo alone exposure should be 
evaluated to determine if it is possibly an event of clinical interest (ECI) of a potentially 
immunologic etiology (termed immune-related adverse events, or irAEs); see the separate 
ECI guidance document in Appendix 4 regarding the identification, evaluation and 
management of potential irAEs.   
 
Please refer to section 7.2 for detailed information regarding the assessment and recording of 
AEs.   
 
7.1.2.2 Full Physical Exam 
The investigator or qualified designee will perform a complete physical exam during the 
screening period.  Clinically significant abnormal findings should be recorded as medical 
history.  A full physical exam should be performed during screening,  
 
7.1.2.3 Directed Physical Exam 
For cycles that do not require a full physical exam per the Trial Flow Chart, the investigator 
or qualified designee will perform a directed physical exam as clinically indicated prior to 
trial treatment administration.   
 


Protocol: 
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7.1.2.4 Vital Signs 
The investigator or qualified designee will take vital signs at screening, prior to the 
administration of each dose of trial treatment and at treatment discontinuation as specified in 
the Trial Flow Chart (Section 6.0).  Vital signs should include temperature, pulse, respiratory 
rate, weight and blood pressure.  Height will be measured at screening only. 
 
7.1.2.5 Eastern Cooperative Oncology Group (ECOG) Performance Scale 
The investigator or qualified designee will assess ECOG status (see Appendix 11.1) at 
screening, prior to the administration of each dose of trial treatment and discontinuation of 
trial treatment as specified in the Trial Flow Chart.   
 
7.1.2.6 Tumor Imaging and Assessment of Disease 
Patients will undergo a CT Thorax and Abdomen at baseline, then every 2 cycles or the 
frequency indicated by the Trial Flow Chart (see section 6.0). Radiographic assessments will 
be based on Response Evaluation Criteria in Solid Tumors v1.1 (RECIST v1.1, Appendix 
11.3). Subjects with progressive disease by RECIST v1.1 but without rapid clinical 
deterioration may continue to be treated at the discretion of the investigator under the 
assumption that clinical benefit continues. 
 
7.1.2.7    Laboratory Procedures/Assessments 
Details regarding specific laboratory procedures/assessments to be performed in this trial are 
provided below. Laboratory Safety Evaluations (Hematology, Chemistry and Urinalysis) 
Laboratory tests for hematology, chemistry, urinalysis, and others are specified in Table 5.   
 
 


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Table 5  Laboratory Tests 
Hematology 
Chemistry 
Urinalysis 
Other 
Hematocrit 
Albumin 
Blood 
Serum β-human chorionic gonadotropin† 
Hemoglobin 
Alkaline phosphatase 
Glucose 
(β-hCG)† 
Platelet count 
Alanine aminotransferase (ALT) 
Protein 
PT (INR) 
WBC (total and differential) 
Aspartate aminotransferase (AST) 
Specific gravity  
aPTT 
Red Blood Cell Count 
Lactate dehydrogenase (LDH) 
Microscopic exam (If abnormal)  
Total thriiodothyronine (T3) 
Absolute Neutrophil Count 
Carbon Dioxide ‡ 
results are noted 
Free tyroxine (T4) 
Absolute Lymphocyte Count 
(CO2 or biocarbonate) 
Urine pregnancy test † 
Thyroid stimulating hormone (TSH) 
 
 
 
 
 
Calcium 
 
 
 
Chloride 
 
Blood for correlative studies 
 
Glucose 
 
  
 
 
 
  
 
Potassium   
 
  
 
Sodium 
 
  
 
Magnesium 
 
  
 
Total Bilirubin 
 
  
 
Direct Bilirubin (If total bilirubin is 
elevated above the upper limit of 
normal) 
 
 
 
Total protein 
 
 
 
Blood Urea Nitrogen 
 
 
† Perform on women of childbearing potential only. If urine pregnancy results cannot be confirmed as negative, a serum pregnancy test will be required.   
‡ If considered standard of care in your region. 
• 
Should be performed every 8 weeks or as indicated on study calendars (section 6.0 and 6.1) 
 
 
 


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Laboratory tests for screening or entry into the Second Course Phase should be performed 
within 10 days prior to the first dose of treatment.  After Cycle 1, pre-dose laboratory 
procedures can be conducted up to 72 hours prior to dosing.  Results must be reviewed by the 
investigator or qualified designee and found to be acceptable prior to each dose of trial 
treatment.  
 
7.1.2.8   Pharmacokinetic/Pharmacodynamic Evaluations 
This study does not include Pharmacokinetic analysis. For Pharmacodynamic analysis see 
section 7.1.5 
 
7.1.3 Other Procedures-Leukopheresis 
Mononuclear cell collection will be conducted by the Moffitt Cancer Center apheresis team.  
 
Patients presenting for apheresis must have been screened for soundness of health consistent 
with undergoing apheresis. Females of child-bearing potential must also have been tested for 
pregnancy within the same time frame, per requirements of the FDA and American 
Association of Blood Banks. Patients must also have been tested within the preceding 30 
days for infectious disease markers including HIV, Hepatitis, HTLV I/II (Human T 
Lymphotropic Virus), Hepatitis B, Hepatitis C and RPR (Rapid Plasma Reagin). At 
presentation for leukopheresis, patients will have their vital signs taken. Based on criteria that 
are outlined in standard operating procedures, patients are cleared to begin apheresis, or if 
failing the criteria, will be examined by qualified medical personnel. 
 
Patients will be connected to the apheresis instrument and associated disposables by bilateral 
venipuncture, generally in the median cephalic vein, using 18 gauge needles. Patients who do 
not have suitable veins to support apheresis will have to be assessed for placement of an 
indwelling catheter. 
 
Following initiation of apheresis, approximately 1 – 2 blood volumes will be processed using 
the mononuclear cell collection protocol. At the conclusion of apheresis, it is anticipated that 
approximately 50 - 200 mL of apheresis product will be retained, which should ideally 
contain at least 1010 nucleated cells and less than 15 - 25 mL of RBC volume. 
 
7.1.4 Withdrawal/Discontinuation 
When a subject discontinues/withdraws prior to trial completion, all activities scheduled for 
the final trial visit should be performed at the time of discontinuation.  Any AEs which are 
present at the time of discontinuation/withdrawal should be followed in accordance with the 
safety requirements outlined in Section 7.2 (Assessing and Recording AEs).   
 
Subjects who a) attain a CR or b) complete 12 months of treatment with Ipi-Nivo and Nivo 
may discontinue treatment with the option of restarting treatment if they meet the criteria 
specified in Section 7.1.5.5.   
After discontinuing treatment following assessment of CR, these subjects should return to the 
site for a Safety Follow-up Visit (described in Section 7.1.5.3.1) and then proceed to the 
Follow-Up Period of the study (described in Section 7.1.5.4). 
 


Pr ot oc ol:  
Versi o n 8 . 0. Se pte m ber 1 9 , 2 0 1 8 
 
 
Pa ge | 4 5  
 
7. 1. 5  T u m or Tiss ue C ollecti o n a n d C orrel ati ve St u dies Bl o o d S a m pli n g  
We will e val uate p 5 3 -s p ecific I R a n d M D S C le v els as well as ot her i m m u ne cells i n patie nts 
d uri n g  treat me nt .  T hese  para meters  will  be  c orrelate d  wit h  cli nical  o utc o mes.  Peri p heral 
bl o o d  will  be  c ollecte d  pri or  t o  t he  treat me nt  a n d  at  differe nt  ti me  p oi nts (see  cale n d ar 
secti o n  6. 0)  d uri n g  a n d  after  t he  treat me nt.  M o n on uclear  cells  will  be  is olate d  a n d  k e pt 
fr oze n  i n  ali q u ots  i n  li q ui d  nitr o ge n.  All  sa m ples  fr o m  o ne  p atie nt  will  be  teste d 
si m ulta ne o usl y t o a v oi d t he i m pact of i nter-e x peri me ntal variati o n.  
 
7. 1. 5. 1 E v al u ati o n of p 5 3- s pecific i m m u ne res p o nse a g ai nst T A As.   
 
7. 1. 5. 1. 1  A n al ysis of I F N - γ pr o d ucti o n b y P B M C.  
T he n u m ber of I F N -γ pr o d uci n g cells will be e val uate d usi n g E LI S P O T assa ys as des cri be d 
earlier 3 9.  Bri efl y,  2 x 1 0 5  m o n o n uclear  cells  o btai ne d  fr o m  t he  peri p heral  bl o o d  of  patie nts 
will  be  plate d  i n  q ua dr u plicates  i n  9 6 -well  m ultiscree n  H A  filtrati o n  plates  ( Milli p ore, 
Be df or d,  M A)  pre -c o ate d  wit h  m o use  a nti -h u m a n  I F N  m o n ocl o nal  a nti b o d y  ( M A B 2 8 5, 
R & D  S yste m,  Mi n nea p olis,  M N)  a n d  i nc u bate d  f or  3 6  hr  at  3 7 o C  wit h  A L V A C -p 5 3,  or 
A L V A C -c  a n d  2 n g/ ml  I L-2.  T otal  v ol u me  is 2 0 0 l.  After  i nc u bati o n,  t he  wells  will  be 
was he d  a n d  t he n  i nc u bate d  o ver ni g ht  at  4 o C  wit h  a  bi oti n ylate d  g oat  a nti -h u ma n  I F N -γ 
a nti b o d y ( B A F 2 8 5, R & D S yste m), f oll o we d b y i nc u bati o n wit h a vi di n -al kali ne p h os p hatase 
( Si g ma).  T he  wells  will  t he n  be  was he d  a n d  s p ots  will  be  vis ualize d  wit h  B CI P/ N B T 
s u bstrate  ( Si g ma).  T he  plates  will  be  air-drie d  a n d  t he  c ol ore d  s p ots  c o u nte d  usi n g  C. T. L. 
E LI S P O T rea der. T he n u m ber of s p ots will be cal c ulate d p er 1 0 6 cells. U ntreate d P B M C will 
re pres e nt a ne gati ve c o ntr ol a n d P B M C sti m ulate d wit h 1 0 g/ ml C o n A – p ositi ve c o ntr ol. 
 
7. 1. 5. 1. 2  A n al ysis of cell pr olif er ati o n a n d I L- 2 pr o d ucti o n.   
P B M C ( 4 x 1 0 5 per w ell  i n r o u n d -b ott o m 9 6 -well plates)  will be c ult ure d  i n tri plicate i n X -
VI V O  1 5  me di u m  s u p ple me nte d  wit h  a nti bi otics  a n d  5 0 M 2- mer ca pt o et ha n ol.  A L V A C -
p 5 3  or  A L V A C -c  will  be  use d  as  descri be d  a b o ve.  N o n -sti m ulate d  cells  will  be  use d  as  a 
ne gati ve  c o ntr ol.  F or  e v al uati o n  of  cell  pr oliferati o n,  1 Ci/ we ll  of  [ 3 H]t h y mi di ne  will  be 
a d de d  o n  d a y  4  a n d  cells  will  be  har veste d  o n  da y  5. T h y mi di ne  i n c or p orati o n  will  be 
meas ure d usi n g a s ci ntillati o n c o u nter.  
 
7. 1. 5. 2  De ter mi n ati o n of t he rel ati o ns hi p bet w ee n M D S C n u m bers a n d a nti-p 5 3 T cell 
res p o nses.  
Bl o o d ( 7 s o di u m he pari n vac utai ner t u bes, 1 0 ml eac h a n d 1 re d t o p t u be) will be o btai ne d 
fr o m  eac h  patie nt  o n  s e veral  differe nt  occasi o ns.  T he  P B M C  will  be  a nal yze d  b y  fl o w 
c yt o metr y  f or  t he  prese n ce  of  M D S Cs,  a n d  t he  a bs ol ute  n u m bers  as  well  as  rati os  will  be 
deter mi ne d. P B M C fr o m eac h sa m ple will be stai ne d i m me diatel y t o e v al uate t he pres e nce of 
M D S C.   
 
T he f oll o wi n g criteri a will be use d t o e val uate M D S C b y fl o w c yt o metr y:  
1. Li n ( C D 3, C D 1 4, C D 1 9, C D 5 6) ne gati ve, H L A- D R -, C D 3 3 +; 
2. M D S C: C D 1 1 b + C D 1 4- C D 3 3 +; 
3. P M N- M D S C: C D 1 1 b + C D 1 4- C D 3 3 + C D 1 5 +; 
4. M- M D S C: C D 1 1 b + C D 1 4- C D 3 3 + C D 1 5-; 
5. M- M D S C: C D 1 4 + H L A- D R -/l o; 


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7.1.5.3 Analysis of other Immune Cells 
Correlative analysis will be performed on the peripheral blood mononuclear cells (PBMC) of 
all the patients enrolled in the study.  This will include flow cytometry based assessment of 
presence of suppressive cell types such as myeloid-derived suppressor cells (MDSC) and 
Tregs. In addition, we will determine expression of activation and resistance markers in 
lymphocytic lineages, including T cells, by flow cytometry and gene expression studies. 
 
7.1.5.4 Immunohistochemical Stains 
Archival or fresh paraffin-embedded tissue blocks containing formalin-fixed tumor or needle 
aspirate slides will be obtained for evaluation of the expression of p53 and PD-L1 using IHC 
methods with commercial antibodies. Paraffin blocks may be processed according to 
standard institutional protocols. If blocks are unavailable, 15 unstained slides are acceptable 
alternatives. This IHC scores will be correlated with the clinical efficacy endpoints and the 
blood surrogate biomarkers. Approximately half of the patients are expected to contribute 
with an archival tumor biopsy. 
 
Sections of formalin-fixed, paraffin-embedded tissue from the SCLC will be cut and stained 
with the respective antibodies against PD-L1 (TBD) and p53 (DO7, DAKOcytomation, 
1:50). In brief, the slides will be immersed in citrate buffer solution for antigen retrieval and 
boiled in microwave for 10 min and washed in buffer solution (TBS). They will be incubated 
with primary antibody for 1 hr at room temperature and then washed in TBS. After 1 hr of 
incubation in the secondary antibody, the sections will be incubated with streptavidin-biotin-
complex (DAKOcytomation). Appropriate positive and negative controls will be used.  
 
Results of IHC staining will be evaluated in the following 2 ways: (1) For estimation of 
positive reaction, only the strongly stained nuclei are counted as a percentage of all tumor 
nuclei. Less than 5% are estimated as negative. Samples with greater than 5% of cells 
exhibiting strong nuclear staining would be considered positive. (2) protein staining is 
scored, taking into account percentage of positive cells (from 1 to 100%) and intensity of 
staining (from 1 to 3), as compared with the protein intensity level 3 of the background 
lymphocytes.  Total score is established by multiplying the percentage by intensity, giving 
scores of 0 to 300.  Final scores of 1, 2, and 3 are given for total scores of 10-50, 50-100, and 
100-300, respectively. 
 
7.1.6 Visit Requirements 
Visit requirements are outlined in Section 6.0 - Trial Flow Chart.   Specific procedure-related 
details are provided above in Section 7.1 - Trial Procedures. 
 
7.1.6.1 Screening 
Screening evaluation requirements are outlined in Section 6.0 - Trial Flow Chart.    
 
7.1.6.1.1 Screening Period 
Defined in Section 6.0 - Trial Flow Chart 
 
7.1.6.2 Treatment Period 
Defined in Section 6.0 - Trial Flow Chart 


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7.1.6.3 Post-Treatment Visits 
Defined in Section 6.0 - Trial Flow Chart 
 
7.1.6.3.1  Safety Follow-Up Visit 
The mandatory Safety Follow-Up Visit should be conducted approximately 30-45 days after 
the last dose of trial treatment or before the initiation of a new anti-cancer treatment, 
whichever comes first (End of trial, EOT).  All AEs that occur prior to the Safety Follow-Up 
Visit should be recorded.  Subjects with an AE of Grade > 1 will be followed until the 
resolution of the AE to Grade 0-1 or until the beginning of a new anti-neoplastic therapy, 
whichever occurs first.  SAEs that occur within 90 days of the end of treatment or before 
initiation of a new anti-cancer treatment should also be followed and recorded.  Subjects who 
are eligible for retreatment with Ipi-Nivo or Nivo (as described in Section 7.1.5.5) may have 
up to two safety follow-up visits, one after the Treatment Period and one after the Second 
Course Phase. 
 
7.1.6.4 Follow-up Visits 
Subjects who discontinue trial treatment for a reason other than disease progression will 
move into the Follow-Up Phase and should be assessed every 6 weeks (42 ± 7 days) by 
radiologic imaging to monitor disease status.  After 1 year, the imaging time point will occur 
every 9 weeks (± 7 days). Every effort should be made to collect information regarding 
disease status until the start of new anti-neoplastic therapy, disease progression, death, end of 
the study or if the subject begins retreatment with Ipi-Nivo or Nivo as detailed in Section 
7.1.5.5.  Information regarding post-study anti-neoplastic treatment will be collected if new 
treatment is initiated. 
 
Subjects who are eligible to receive retreatment with Ipi-Nivo or Nivo according to the 
criteria in Section 7.1.5.5 will move from the follow-up phase to the Second Course Phase 
when they experience disease progression.   
 
7.1.6.4.1 Survival Follow-up 
Once a subject experiences confirmed disease progression or starts a new anti-cancer 
therapy, the subject moves into the survival follow-up phase and should be contacted by 
telephone every 12 weeks to assess for survival status until death, withdrawal of consent, or 
the end of the study, whichever occurs first.  
 
7.1.6.5 Second Course Phase (Retreatment Period) 
Subjects who stop Ipi-Nivo or Nivo with SD or better may be eligible for up to one year of 
additional Ipi-Nivo or Nivo therapy if they progress after stopping study treatment.  This 
retreatment is termed the Second Course Phase of this study and is only available if the study 
remains open and the subject meets the following conditions: 
• Either  
o Stopped initial treatment with Ipi-Nivo or Nivo after attaining an investigator-
determined confirmed CR according to RECIST 1.1 
 
 
OR 
o Had SD, PR or CR and stopped Ipi-Nivo or Nivo treatment after 6-12 months of 
study therapy for reasons other than disease progression or intolerability 


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AND 
• Did not receive any anti-cancer treatment since the last dose of Ipi-Nivo or Nivo 
• Has a performance status of 0 or 1 on the ECOG Performance Scale 
• Demonstrates adequate organ function as detailed in Section 5.1.2 
• Female subject of childbearing potential should have a negative serum or urine 
pregnancy test within 72 hours prior to receiving retreatment with study medication.   
• Female subject of childbearing potential should be willing to use 2 methods of birth 
control or be surgically sterile, or abstain from heterosexual activity for the course of 
the study through 120 days after the last dose of study medication (Reference Section 
5.7.2).  Subjects of child bearing potential are those who have not been surgically 
sterilized or have been free from menses for > 1 year.  
• Male subject should agree to use an adequate method of contraception starting with 
the first dose of study therapy through 120 days after the last dose of study therapy.   
• Does not have a history or current evidence of any condition, therapy, or laboratory 
abnormality that might interfere with the subject’s participation for the full duration 
of the trial or is not in the best interest of the subject to participate, in the opinion of 
the treating investigator. 
 
Subjects who restart treatment will be retreated at the same dose and interval as per the 
original treatment schedule in section 5.2.2.   Treatment will be administered for up to one 
additional year. Visit requirements are outlined in Section 6.0 – Trial Flow Chart. 
 
7.2 
Assessing and Recording Adverse Events 
An adverse event is defined as any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and which does not necessarily 
have to have a causal relationship with this treatment. An adverse event can therefore be any 
unfavorable and unintended sign (including an abnormal laboratory finding, for example), 
symptom, or disease temporally associated with the use of a medicinal product or protocol-
specified procedure, whether or not considered related to the medicinal product or protocol-
specified procedure.  Any worsening (i.e., any clinically significant adverse change in 
frequency and/or intensity) of a preexisting condition that is temporally associated with the 
use of the investigational product, is also an adverse event. 
 
Changes resulting from normal growth and development that do not vary significantly in 
frequency or severity from expected levels are not to be considered adverse events.  
Examples of this may include, but are not limited to, teething, typical crying in infants and 
children and onset of menses or menopause occurring at a physiologically appropriate time. 
 
BMS product includes any pharmaceutical product, biological product, device, diagnostic 
agent or protocol-specified procedure, whether investigational (including placebo or active 
comparator medication) or marketed, manufactured by, licensed by, provided by or 
distributed by BMS for human use. 
 
Adverse events may occur during the course of the use of BMS product in clinical trials or 
within the follow-up period specified by the protocol, or prescribed in clinical practice, from 
overdose (whether accidental or intentional), from abuse and from withdrawal. 


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Adverse events may also occur in screened subjects during any pre-allocation baseline period 
as a result of a protocol-specified intervention, including washout or discontinuation of usual 
therapy, diet, placebo treatment or a procedure. 
 
Progression of the cancer under study is not considered an adverse event unless it is 
considered to be drug related by the investigator. 
 
All adverse events will be recorded from the time the consent form is signed through 30 days 
following cessation of treatment and at each examination on the Adverse Event case report 
forms/worksheets. The reporting timeframe for adverse events meeting any serious criteria is 
described in section 7.2.3.1 and section 11.7 BMS guidelines for Adverse Event Reporting. 
 
7.2.1 Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Sponsor and to BMS 
For purposes of this trial, an overdose of Ipi-Nivo or Nivo will be defined as any dose of 
2400 mg or greater (≥5 times the indicated dose).  No specific information is available on the 
treatment of overdose of IPI-NIVO OR NIVO. Appropriate supportive treatment should be 
provided if clinically indicated. In the event of overdose, the subject should be observed 
closely for signs of toxicity.  Appropriate supportive treatment should be provided if 
clinically indicated. 
 
If an adverse event(s) is associated with (“results from”) the overdose of a BMS product, the 
adverse event(s) is reported as a serious adverse event, even if no other seriousness criteria 
are met. 
 
If a dose of BMS’s product meeting the protocol definition of overdose is taken without any 
associated clinical symptoms or abnormal laboratory results, the overdose is reported as a 
non-serious Event of Clinical Interest (ECI), using the terminology “accidental or intentional 
overdose without adverse effect.” 
 
All reports of overdose with and without an adverse event must be reported within 24 hours 
to the Sponsor and within 2 working days hours to BMS 
 
7.2.2 Reporting of Pregnancy and Lactation to the Sponsor and to BMS 
Although pregnancy and lactation are not considered adverse events, it is the responsibility of 
investigators or their designees to report any pregnancy or lactation in a subject 
(spontaneously reported to them), including the pregnancy of a male subject's female partner 
that occurs during the trial or within 120 days of completing the trial completing the trial, or 
30 days following cessation of treatment if the subject initiates new anticancer therapy, 
whichever is earlier.   
 
All subjects and female partners of male subjects who become pregnant must be followed to 
the completion/termination of the pregnancy.  Pregnancy outcomes of spontaneous abortion, 
missed abortion, benign hydatidiform mole, blighted ovum, fetal death, intrauterine death, 


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miscarriage and stillbirth must be reported as serious events (Important Medical Events).  If 
the pregnancy continues to term, the outcome (health of infant) must also be reported. 
 
Such events must be reported within 24 hours to the Sponsor and within 2 working days to 
BMS (see section 11.7) 
 
7.2.3 Immediate Reporting of Adverse Events to the Sponsor and to BMS 
 
7.2.3.1 Serious Adverse Events 
A serious adverse event is any adverse event occurring at any dose or during any use of 
BMS’s product that: 
• Results in death; 
• Is life threatening; 
• Results in persistent or significant disability/incapacity; 
• Results in or prolongs an existing inpatient hospitalization; 
• Is a congenital anomaly/birth defect; 
• Is a new cancer (that is not a condition of the study); 
• Is associated with an overdose; 
• Is another important medical event  
 
Refer to Table 6 for additional details regarding each of the above criteria. 
 
Any serious adverse event, or follow up to a serious adverse event, including death due to 
any cause other than progression of the cancer under study that occurs to any subject from 
the time the consent is signed through 90 days following cessation of treatment, or the 
initiation of new anti-cancer therapy, whichever is earlier, whether or not related to BMS 
product, must be reported within 24 hours to the Sponsor and within 2 working days to BMS.  
 
Non-serious Events of Clinical Interest will be forwarded to BMS and will be handled in the 
same manner as SAEs.  
 
Additionally, any serious adverse event, considered by an investigator who is a qualified 
physician to be related to BMS product that is brought to the attention of the investigator at 
any time outside of the time period specified in the previous paragraph also must be reported 
immediately to the Sponsor and to BMS. 
 
SAE reports and any other relevant safety information are to be forwarded to the BMS 
 
A copy of all 15 Day Reports and Annual Progress Reports is submitted as required by FDA, 
European Union (EU), Pharmaceutical and Medical Devices agency (PMDA) or other local 
regulators. Investigators will cross reference this submission according to local regulations to 
the BMS Investigational Compound Number (IND, CSA, etc.) at the time of submission.  
Additionally investigators will submit a copy of these reports to BMS at the time of 
submission to FDA. 
 
All subjects with serious adverse events must be followed up for outcome. 


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7.2.3.2 Events of Clinical Interest 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest 
(ECI) and must be recorded as such on the Adverse Event case report forms/worksheets and 
reported within 24 hours to the Sponsor and within 2 working days to BMS (see section 11.7) 
Events of clinical interest for this trial include: 
1.  an overdose of BMS product, as defined in Section 7.2.1 - Definition of an Overdose for 
This Protocol and Reporting of Overdose to the Sponsor, that is not associated with clinical 
symptoms or abnormal laboratory results.  
2.  an elevated AST or ALT lab value that is greater than or equal to 3X the upper limit of 
normal and an elevated total bilirubin lab value that is greater than or equal to 2X the upper 
limit of normal and, at the same time, an alkaline phosphatase lab value that is less than 2X 
the upper limit of normal, as determined by way of protocol-specified laboratory testing or 
unscheduled laboratory testing.* 
*Note:  These criteria are based upon available regulatory guidance documents. The 
purpose of the criteria is to specify a threshold of abnormal hepatic tests that may require 
an additional evaluation for an underlying etiology.  The trial site guidance for 
assessment and follow up of these criteria can be found in the Investigator Trial File 
Binder (or equivalent). 
 
 
Subjects should be assessed for possible ECIs prior to each dose.  Lab results should be 
evaluated and subjects should be asked for signs and symptoms suggestive of an 
immune-related event.  Subjects who develop an ECI thought to be immune-related 
should have additional testing to rule out other etiologic causes.  If lab results or 
symptoms indicate a possible immune-related ECI, then additional testing should be 
performed to rule out other etiologic causes.  If no other cause is found, then it is 
assumed to be immune-related. 
 
7.2.4 Evaluating Adverse Events 
An investigator who is a qualified physician will evaluate all adverse events according to the 
NCI Common Terminology for Adverse Events (CTCAE), version 4.0. Any adverse event 
which changes CTCAE grade over the course of a given episode will have each change of 
grade recorded on the adverse event case report forms/worksheets. 
 
All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 
 
7.2.5 Sponsor Responsibility for Reporting Adverse Events 
All Adverse Events will be reported to regulatory authorities, IRB/IECs and investigators in 
accordance with all applicable global laws and regulations.  
 
7.3 
Safety Stopping Criteria 
The purpose of safety stopping criteria is to control the number of subjects put at risk, in the 
event that early experience uncovers important safety problems.  
 
The event I have chosen to utilize as our safety target or endpoint is: “grade 4 adverse events 
that are at least possibly related to the investigational treatment”. 
 


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Based on our SCLC historical control population treated with the ipilimumab-nivolumab 
combination86, grade 3-4 treatment related adverse events occurred in 30% of patients. 
Given that an additional investigational agent/treatment (vaccine) is being added, we are 
willing to accept similar to slightly higher frequency of adverse events. 
 
Thus, the protocol we will abide by the following study stopping criteria: 
7.3.1 We will first accrue 10 patients to the study.  
a. If at the end of the first 3 vaccine administrations, the event occurs in 4 or less 
patients, we will accept the safety profile of our combination to be comparable 
to that of our SCLC historical control86 and the regimen will be consider safe 
for further treatment and the study will open to accrual unrestricted, until 
study completion 
b. If at the end of the first 3 vaccines administrations, the event occurs in 5 or 6 
patients, we will accrue an additional 10 patients before the study opens to 
accrual unrestricted, until study completion.  
c. If at the end of the first 3 vaccine administrations, the event occurs in 7 or 
more patients, we will consider our treatment combination unsafe and the 
study will be closed. 
 
7.3.2 
In case that an additional 10 patients need to be accrued (see above item 1b) 
d. If at the end of the first 3 vaccine administrations, the event occurs in 4 or less 
patients, we will accept the safety profile of our combination to be comparable 
to that of our SCLC historical control86 and the regimen will be consider safe 
for further treatment and the study will open to accrual unrestricted, until 
study completion 
e. If at the end of the first 3 vaccine administrations, the event occurs in more 
than 4 patients, we will consider our treatment combination unsafe and the 
study will be closed. 
 
 
 


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Table 6  Evaluating Adverse Events 
An investigator who is a qualified physician, will evaluate all adverse events as to: 
V4.0 
CTCAE 
Grading 
Grade 1 
Mild; asymptomatic or mid symptoms; clinical or diagnostic observations only; intervention not indicated. 
 
Grade 2 
Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental ADL. 
 
Grade 3 
Severe or medically significant but not immediately life-threatening; hospitalization or prolongation or hospitalization indicated; 
disabling; limiting self-care ADL. 
 
Grade 4 
Life threatening consequences; urgent intervention indicated. 
 
Grade 5 
Death related to AE 
Seriousness 
A serious adverse event is any adverse event occurring at any dose or during any use of BMS product that: 
 
†Results in death; or 
 
†Is life threatening; or places the subject, in the view of the investigator, at immediate risk of death from the event as it occurred (Note: This does not include an 
adverse event that, had it occurred in a more severe form, might have caused death.); or 
 
†Results in a persistent or significant disability/incapacity (substantial disruption of one’s ability to conduct normal life functions); or 
 
†Results in or prolongs an existing inpatient hospitalization (hospitalization is defined as an inpatient admission, regardless of length of stay, even if the 
hospitalization is a precautionary measure for continued observation. (Note: Hospitalization [including hospitalization for an elective procedure] for a preexisting 
condition which has not worsened does not constitute a serious adverse event.); or 
 
†Is a congenital anomaly/birth defect (in offspring of subject taking the product regardless of time to diagnosis);or 
 
Is a new cancer; (that is not a condition of the study) or 
 
Is an overdose (whether accidental or intentional).  Any adverse event associated with an overdose is considered a serious adverse event. An overdose that is not 
associated with an adverse event is considered a non-serious event of clinical interest and must be reported within 24 hours. 
 
Other important medical events that may not result in death, not be life threatening, or not require hospitalization may be considered a serious adverse event when, 
based upon appropriate medical judgment, the event may jeopardize the subject and may require medical or surgical intervention to prevent one of the outcomes 
listed previously (designated above by a †). 
Duration 
Record the start and stop dates of the adverse event. If less than 1 day, indicate the appropriate length of time and units 
Action taken  
Did the adverse event cause the BMS product to be discontinued? 
Relationship to 
test drug  
Did the BMS product cause the adverse event? The determination of the likelihood that the BMS product caused the adverse event will be provided by an investigator 
who is a qualified physician. The investigator’s signed/dated initials on the source document or worksheet that supports the causality noted on the AE form, ensures 
that a medically qualified assessment of causality was done. This initialed document must be retained for the required regulatory time frame. The criteria below are 
intended as reference guidelines to assist the investigator in assessing the likelihood of a relationship between the test drug and the adverse event based upon the 
available information.  
The following components are to be used to assess the relationship between the BMS product and the AE; the greater the correlation with the components and 
their respective elements (in number and/or intensity), the more likely the BMS product caused the adverse event (AE): 
 
Exposure 
Is there evidence that the subject was actually exposed to the BMS product such as: reliable history, acceptable compliance assessment (pill 
count, diary, etc.), expected pharmacologic effect, or measurement of drug/metabolite in bodily specimen? 
 
Time Course 
Did the AE follow in a reasonable temporal sequence from administration of the BMS product?  
Is the time of onset of the AE compatible with a drug-induced effect (applies to trials with investigational medicinal product)? 
 
Likely Cause 
Is the AE not reasonably explained by another etiology such as underlying disease, other drug(s)/vaccine(s), or other host or environmental 
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Relationship 
The following components are to be used to assess the relationship between the test drug and the AE: (continued) 
to BMS 
product 
(continued)  
Dechallenge 
Was the BMS product discontinued or dose/exposure/frequency reduced? 
If yes, did the AE resolve or improve? 
If yes, this is a positive dechallenge. If no, this is a negative dechallenge. 
(Note: This criterion is not applicable if: (1) the AE resulted in death or permanent disability; (2) the AE resolved/improved despite continuation 
of the BMS product; or (3) the trial is a single-dose drug trial); or (4) BMS product(s) is/are only used one time.) 
 
Rechallenge 
Was the subject re-exposed to the BMS product in this study? 
If yes, did the AE recur or worsen? 
If yes, this is a positive rechallenge. If no, this is a negative rechallenge. 
(Note: This criterion is not applicable if: (1) the initial AE resulted in death or permanent disability, or (2) the trial is a single-dose drug trial); or 
(3) BMS product(s) is/are used only one time). 
NOTE: IF A RECHALLENGE IS PLANNED FOR AN ADVERSE EVENT WHICH WAS SERIOUS AND WHICH MAY HAVE BEEN 
CAUSED BY THE BMS PRODUCT, OR IF REEXPOSURE TO THE BMS PRODUCT POSES ADDITIONAL POTENTIAL SIGNIFICANT 
RISK TO THE SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE U.S. CLINICAL MONITOR AS 
PER DOSE MODIFICATION GUIDELINES IN THE PROTOCOL. 
 
Consistency 
with Trial 
Treatment 
Profile 
Is the clinical/pathological presentation of the AE consistent with previous knowledge regarding the BMS product or drug class pharmacology 
or toxicology? 
The assessment of relationship will be reported on the case report forms /worksheets by an investigator who is a qualified physician according to his/her best clinical judgment, including 
consideration of the above elements. 
Record one of the following 
Use the following scale of criteria as guidance (not all criteria must be present to be indicative of a BMS product relationship). 
Yes, there is a reasonable 
possibility of BMS product 
relationship. 
There is evidence of exposure to the BMS product.  The temporal sequence of the AE onset relative to the administration of the BMS product is 
reasonable.  The AE is more likely explained by the BMS product than by another cause. 
No, there is not a reasonable 
possibility BMS product 
relationship 
Subject did not receive the BMS product OR temporal sequence of the AE onset relative to administration of the BMS product is not reasonable 
OR there is another obvious cause of the AE.  (Also entered for a subject with overdose without an associated AE.) 


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8.0 STATISTICAL ANALYSIS PLAN 
 
8.1 
Statistical Analysis Plan Summary 
 
8.1.1 Study Design 
This is a single institution, phase II study. The primary endpoint is disease control rate 
(DCR). Secondary endpoints include response rate, progression-free survival (PFS), overall 
survival (OS). Biomarkers correlative studies are also included. 
 
8.2 
Statistical Analysis Plan 
 
8.2.1 Sample size 
A sample size of 39 achieves 91% power to detect a difference of 0.20 using a one-sided 
binomial test. The target significance level is 0.100. The actual significance level achieved by 
this test is also 0.100. These results assume that the population proportion under the null 
hypothesis is 0.50. 
 
8.2.2 Analysis of Primary and Secondary Endpoints 
The disease control (DCR=CR+PR+SD) rates, overall response rate (ORR=CR+PR) will be 
summarized using both point estimates and exact confidence intervals based on the binomial 
distribution by group. The PFS, defined as time from enrollment (eligible date) to date of 
progression/death, whichever happens first, or censor at last clinical follow-up date. The OS, 
defined as the time from study enrollment (eligible date) to death from any cause. Both PFS 
and OS will be summarized utilizing the K-M method.  
 
8.2.3 Safety Analysis - Toxicity 
Toxicity from this trial will be collected on all study drug treated patients. Simple descriptive 
statistics will be utilized to display the data on toxicity seen from both groups. Toxicities will 
be assessed using NCI CTCAE v.4.1. 
 
8.2.4 Laboratory Correlative Studies 
Results from the different correlative variables will be reported descriptively. Cox 
proportional hazards regression models will be employed to explore the association of 
various such variables with DCR, PFS and OS. The Fisher exact/Chi-square test and logistic 
regression will be considered to study the association between various disease or patient 
characteristics and FFPE archival tissue studies (protein expressions by IHC).  
 
In some cases, due to the small sample size, these analyses may have low sensitivity for the 
predictive impact of the biomarkers, and will be exploratory by necessity. 
 
 
 
 


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9.0 LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL 
SUPPLIES 
 
9.1 
Investigational Products  
The investigator shall take responsibility for and shall take all steps to maintain appropriate 
records and ensure appropriate supply, storage, handling, distribution and usage of 
investigational product in accordance with the protocol and any applicable laws and 
regulations. 
 
9.1.1 Clinical Supplies provided by BMS as summarized in Table 7. 
 
Table 7  Product Descriptions 
Product 
Description/Class 
and 
Dosage Form 
IP/Non-
IMP 
Potency 
Packaging/ 
Appearance 
Storage Conditions 
(per label) 
Nivolumab Solution for 
Injection 
IP 
100 mg (10 
mg/mL) 
10 mL/vial (5 
or 10 
vials/carton) 
Store at 2-8°C; 
protect from light 
and freezing 
Ipilimumab Solution for 
Injection 
IP 
200 mg (5 
mg/mL) 
40 mL/vial (4 
vials/carton) 
Store at 2-8°C; 
protect from light 
and freezing 
 
9.1.2 Clinical Supplies provided by Moffitt Cell Therapy Facility 
 
Adp53-DC (see Appendix 11.4) 
 
9.2 
Packaging and Labeling Information 
Clinical supplies will be affixed with a clinical label in accordance with regulatory 
requirements. 
 
9.3 
Clinical Supplies Disclosure 
This trial is open-label; therefore, the subject, the trial site personnel, the Sponsor and/or 
designee are not blinded to treatment. Drug identity (name, strength) is included in the label 
text; random code/disclosure envelopes or lists are not provided. 
 
9.4 
Storage and Handling Requirements 
The product storage manager should ensure that the study drug is stored in accordance with 
the environmental conditions (temperature, light, and humidity) as outlined in the 
investigator’s brochure.  If concerns regarding the quality or appearance of the study drug 
arise, the study drug should not be dispensed and contact the principal investigator and BMS 
immediately.  
Study drug not supplied by BMS will be stored in accordance with the package insert (in this 
case in accordance with Moffitt Cell Therapy Laboratory). Please refer to Section 10.2.2 for 
guidance on IP records and documentation. Infusion-related supplies (eg, IV bags, in-line 


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filters, 0.9% sodium chloride injection, 5% dextrose injection) will not be supplied by the 
sponsor and should be purchased locally if permitted by local regulations. 
Please refer to the current version of the Investigator Brochure (IB) and/or pharmacy 
reference sheets for complete storage, handling, dispensing, and infusion information for 
nivolumab and ipilimumab. The infusion duration of nivolumab is 30 minutes and for 
ipilimumab is 90 minutes. 
Clinical supplies must be stored in a secure, limited-access location under the storage 
conditions specified on the label.  Receipt/dispensing of trial medication must be recorded by 
authorized person at the trial site.  
 
Clinical supplies may not be used for any purpose other than that stated in the protocol. 
 
9.5 
Returns and Reconciliation 
The investigator is responsible for keeping accurate records of the clinical supplies received 
from BMS or designee, the amount dispensed to and returned by the subjects and the amount 
remaining at the conclusion of the trial.  
 
Upon completion or termination of the study, all unused and/or partially used 
investigational product will be destroyed at the site per institutional policy. It is the 
Investigator’s responsibility to arrange for disposal of all empty containers, provided that 
procedures for proper disposal have been established according to applicable federal, state, 
local and institutional guidelines and procedures, and provided that appropriate records of 
disposal are kept. 
 
10.0  DATA SA DATA SAFETY MONITORING PLAN 
 
10.1 
Risk to Subjects 
 
10.1.1 Human subject involvement and characteristics 
Human subjects who have the diagnosis of advanced NSCLC are eligible to participate in the 
clinical trial described in this proposal. The risk to subjects will be outlined clearly and in 
detail in the informed consent. Women who are pregnant are not eligible. 
 
10.2 
Recruitment and Informed Consent 
Patients who present to the Thoracic Oncology Program at the Moffitt Cancer Center or the 
OSU Thoracic Clinics who have advanced NSCLC are offered participation in the clinical 
trial described in this proposal. The trial is explained in detail to the patients by one of the 
investigators on the trial.  The patients are given the opportunity to read the informed consent 
document and are given a chance to ask questions.  If they wish to participate the patient will 
then sign the informed consent document in the presence of a witness. The study team 
member who participates in the informed consent process also documents, in a clinic note, 
the nature of the consent process that occurred.  
 


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10.3 
Protection Against Risk 
To protect participants from excess risk, the above-mentioned study procedures and dose-
escalation scheme were instituted. Additional protection is provided through the data safety 
and monitoring plan described below. The complete care of each patient, including the 
clinical management of all toxicities, is provided to the patient by physicians at the Moffitt 
Cancer Center. The clinical data are kept in the patient's individual electronic hospital record. 
Research study documentation charts are kept in a locked secure room with limited access 
and through Oncore (a Web-based, password-protected database), with privacy protected to 
the full extent of the law. Authorized research investigators, the Department of Health and 
Human Services, and the Institutional Review Board may inspect the records. Final protocol 
and ICF approvals will be obtained from the IRB. 
 
Additional protection is provided in the data safety and monitoring plan described below.  
 
10.4 
Importance of the Knowledge to be Gained 
The development of a well-tolerated and effective regimen in a disease could potentially at 
worst add to the armamentarium of available regimens and at best change standard of care. 
Specific strategies to improve the care of patients relapsing following chemotherapy for lung 
cancer are direly needed.  
 
10.5 
Data Safety and Monitoring Plan 
The Data Safety & Monitoring Plan (DSMP) will ensure that this trial is well designed, 
responsibly managed, appropriately reported, and that it protects the rights and welfare of 
patients.  The following internal and external review and monitoring processes provide 
oversight and active monitoring of this trial: 
• 
The Principal Investigators (PI) 
• 
The Clinical Trials Office (CTO) 
• 
The Scientific Review Committee (SRC) 
• 
The Protocol Monitoring Committee (PMC); 
• 
The Research Compliance Division (RCD) of the Cancer Center's Compliance Office; 
• 
Institutional Review Board (IRB). 
 
The protocol includes a section that specifies the following with respect to Adverse Event 
reporting: what constitutes an adverse event (versus what is a serious adverse event), the 
entities to which adverse events should be reported, the timing of this reporting, and the 
person or persons responsible for reporting.  This includes prompt (within one day of 
knowledge of the event) reporting to the IRB for unanticipated risks to subjects and reporting 
in writing within five working days to the IRB and sponsor.  
 
10.6 
Scientific Review Committee (SRC) 
The two Therapeutic boards of the SRC meet every other week one on the first Wednesday 
and the second one meets on the third Thursday of every month.  
 
Each SRC conducts a formal internal peer review of all clinical protocols and general 
scientific oversight of interventional clinical research. Protocols are reviewed for scientific 


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merit, adequate study design, safety, availability of targeted study population, and feasibility 
of timely completion of all proposed research projects to be conducted by its assigned 
programs at each Cancer Center.  The SRC is responsible for evaluating the risk/benefit 
assessment and corresponding data and safety monitoring plan as part of the scientific review 
and approval process.   
 
10.7 
PI Responsibility 
The PI of each study is ultimately responsible for every aspect of the design, conduct and 
actions of all members of the research team.  This includes the final analysis of the protocol.   
All protocols include a DSMP and procedures for its implementation commensurate with the 
risk and complexity of the study.  The DSMP must include a structured adverse event 
determination, monitoring and reporting system, including standardized forms and 
procedures for referring and/or treating subjects experiencing adverse events.  The plan must 
include data and safety-monitoring procedures for subjects enrolled who may be receiving a 
part of their protocol-required treatment at community sites. 
 
In all cases, the PI of the study will have primary responsibility for ensuring that the protocol 
is conducted as approved by the SRC and IRB.  The PI will ensure that the monitoring plan is 
followed, that all data required for oversight of monitoring are accurately reported to a 
DSMB and/or to the PMC and IRB as required, that all adverse events are reported according 
to protocol guidelines, and that any adverse actions reflecting patient safety concerns are 
appropriately reported. 
 
10.8 
The Protocol Monitoring Committee (PMC) 
The PMC meets once a month.  The PMC reviews and evaluates safety and/or efficacy data 
for all physician authored clinical intervention trials. The PMC ensures the safety of patients 
and the validity and integrity of data. PMC reviews SAEs, deviations, Interim analysis, 
interim and final reports from the external Data Monitoring Committee (DMC) as well as 
audits both internally and externally. The PMC can make the following determinations, 
Accepted, Acceptable with Corrective Action and Tabled.    
 
Investigators of studies, which are designated to be reviewed by the PMC for data and safety 
monitoring, shall provide an interim analysis report of the study’s progress and summary of 
adverse events and deviations based on the phase of the study and the associated risk of the 
study or more often if applicable.  The external DSMB (if applicable) shall forward its report 
for high-risk studies designated for external review at least annually or more often if 
applicable. 
 
10.9 
Suspension/Termination 
The PMC and/or the IRB may vote to suspend or terminate approval of a research study not 
being conducted in accordance with the IRB, the Cancer Center and/or regulatory 
requirements or that has been associated with unexpected problems or serious harm to 
subjects.  The PMC/IRB will notify the PI in writing of such suspension or terminations.  It is 
the responsibility of the PMC/IRB Chairperson to ensure prompt written notification of any 
suspensions or terminations of PMC/IRB approval to the relevant Federal Agencies, 


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including OHRP, FDA, the study sponsor/funding source and if applicable, the Affiliate 
Program. 
 
 
10.10 Monitoring of the Study and Regulatory Compliance 
The Principal Investigator and the Clinical Research Coordinator assigned to the case will be 
primarily responsible for maintaining all study related documents including the clinical 
research forms.  Oncore is the database of record for all CRF entries and will be verified with 
source documentation. The review of medical records within PowerChart will be done in a 
manner to assure that patient confidentiality is maintained. 
 
10.11 Internal Monitoring Plan 
Data will be captured in Oncore, Moffitt’s Clinical Trials Database.  
Regulatory documents and case report forms will be reviewed routinely by the MCC Clinical 
Research Monitoring Core for accuracy, completeness and source verification of data entry, 
validation of appropriate informed consent process, adherence to study procedures, and 
reporting of SAEs and protocol deviations according to MCC Monitoring Policies.  
 
10.12 Protocol Modifications 
No modifications will be made to the protocol without the agreement of the investigators. 
Changes that significantly affect the safety of the patients, the scope of the investigation, or 
the scientific quality of the study will require Scientific Review Committee and Institutional 
Review Board approval prior to implementation, except where the modification is necessary 
to eliminate apparent immediate hazard to human subjects.  Any departures from the protocol 
must be fully documented in the case report form and the source documentation. 
 
10.13 The Institutional Review Board (IRB) 
The trial will not be initiated without approval of the appropriate Institutional Review Board 
(IRB).  All administrative requirements of the governing body of the institution will be fully 
complied with.  This protocol, consent procedures, and any amendments must be approved 
by the IRB in compliance with current regulations of the Food and Drug Administration.  A 
letter of approval will be sent to the institution(s) funding the study prior to initiation of the 
study and when any subsequent modifications are made.  The IRB will be kept informed by 
the investigator as to the progress of the study as well as to any serious or unusual adverse 
events. 
 
10.14 Patient Privacy 
In order to maintain patient confidentiality, all case report forms, study reports and 
communications relating to the study will identify patients by initials and assigned patient 
numbers.  The US Food and Drug Administration (FDA) may also request access to all study 
records, including source documentation for inspection. 
 
10.15 Records Retention 
U.S. FDA regulations (21 CFR §312.62[c]) require that records and documents pertaining to 
the conduct of this study and the distribution of investigational drug, including CRFs, 


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consent forms, laboratory test results, and medication inventory records, must be retained by 
the Principal Investigator for 2 years after marketing application approval.  If no application 
is filed, these records must be kept 2 years after the study is discontinued and the U.S. FDA 
and the applicable national and local health authorities are notified. 
 
10.16 Compliance with Trial Registration and Results Posting Requirements 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and the 
Food and Drug Administration Amendments Act (FDAAA), the Sponsor of the trial is solely 
responsible for determining whether the trial and its results are subject to the requirements 
for submission to the Clinical Trials Data Bank, http://www.clinicaltrials.gov.  Information 
posted will allow subjects to identify potentially appropriate trials for their disease conditions 
and pursue participation by calling a central contact number for further information on 
appropriate trial locations and trial site contact information.     
 


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11.0 APPENDICES 
11.1 ECOG Performance Status 
Grade 
Description 
0 
Normal activity. Fully active, able to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous 
activity, but ambulatory and able to carry out work of a light or 
sedentary nature (e.g., light housework, office work). 
2 
In bed <50% of the time. Ambulatory and capable of all self-care, 
but unable to carry out any work activities. Up and about more than 
50% of waking hours. 
3 
In bed >50% of the time. Capable of only limited self-care, confined 
to bed or chair more than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-
care. Totally confined to bed or chair. 
5 
Dead. 
* As published in Am. J. Clin. Oncol.:  Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., 
McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative 
Oncology Group. Am J Clin Oncol 5:649-655, 1982. The Eastern Cooperative Oncology Group, 
Robert Comis M.D., Group Chair. 
 
11.2 Common Terminology Criteria for Adverse Events V4.0 (CTCAE) 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version 4.0 will be utilized for adverse event reporting. 
(http://ctep.cancer.gov/reporting/ctc.html) 
 
11.3 Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 Criteria for 
Evaluating Response in Solid Tumors 
RECIST version 1.1* will be used in this study for assessment of tumor response. While 
either CT or MRI may be utilized, as per RECIST 1.1, CT is the preferred imaging technique 
in this study. 
* As published in the European Journal of Cancer: 
 
E.A. Eisenhauer, P. Therasse, J. Bogaerts, L.H. Schwartz, D. Sargent, R. Ford, J. 
Dancey, S. Arbuck, S. Gwyther, M. Mooney, L. Rubinstein, L. Shankar, L. Dodd, R. Kaplan, 
D. Lacombe, J. Verweij. New response evaluation criteria in solid tumors: Revised RECIST 
guideline (version 1.1). Eur J Cancer. 2009 Jan;45(2):228-47. 
 
 
 
 


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11.4 Pharmaceutical Information for Ad.p53-DC Vaccine 
A. Generation of Ad.p53 DC vaccine 
Mononuclear cells for the production of dendritic cells (DC) will be obtained through a 
single apheresis procedure and stored in liquid nitrogen at the Moffitt Cancer Center . After 
collection through apheresis, the product will be enriched for mononuclear cells via density 
centrifugation using Ficoll. The enriched product will be cryopreserved in 3 – 4 fractions and 
stored in cryoprotectant in validated LN2 freezers. Approximately one week prior to each 
scheduled vaccination, one fraction of cells will be thawed by the Moffitt Cell Therapy 
Facility staff and placed in CellGenix DC Medium in tissue culture flasks at a concentration 
of 1.3 – 1.7x106 cells/cm2. After culturing for 1.5 – 2 hours in a 37 C, 5%CO2 incubator, 
non-adherent cells will be removed. Fresh DC Medium supplemented with 100 ng/ml GM-
CSF and 50 ng/ml IL-4 will be added. Cells will be cultured for approximately 5 days in a 37 
C, 5%CO2 incubator. At the completion of incubation, non-adherent and loosely adherent 
cells will be collected and transduced with Ad.p53 for 2 – 3 hours at a concentration of 
approximately 10x106 cells/ml. At the completion of the transduction, cells will be diluted 10 
fold with medium supplemented with 5 ng/ml GM-CSF and 5 ng/ml IL-4. Transduced cells 
will be cultured for approximately 40 hours in a 37 C, 5%CO2 incubator, then harvested, 
washed and analyzed prior to administration. Vaccines will not be released for patient use 
until release criteria are met.   
Release criteria for vaccine administration include: 
Test 
Criteria 
Mycoplasma  
Negative 
Gram Stain 
No Organisms Seen 
Endotoxin 
< 5 EU/kg 
Phenotype 
> 10% DC expressing p53 
Dose 
1 – 5x106 viable p53+ DC 
 
The vaccine cell suspension will be injected intra-dermally (or subcutaneously) into 4 
separate sites to include proximal upper and lower extremities (in the regions of the axillary 
and inguinal nodal basins.  The patients will be monitored in the Clinical Research Unit at 
the H. Lee Moffitt Cancer Center for acute toxicity for 1 hour after their injections. 
 
 


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11.5 
Management Algorithms 
These general guidelines constitute guidance to the Investigator and may be supplemented by 
discussions with the Medical Monitor representing the Sponsor. The guidance applies to all 
immuno-oncology agents and regimens. 
 
A general principle is that differential diagnoses should be diligently evaluated according to 
standard medical practice. Non-inflammatory etiologies should be considered and 
appropriately treated. 
 
Corticosteroids are a primary therapy for immuno-oncology drug-related adverse events. The 
oral equivalent of the recommended IV doses may be considered for ambulatory patients 
with low-grade toxicity. The lower bioavailability of oral corticosteroids should be taken into 
account when switching to the equivalent dose of oral corticosteroids. 
 
Consultation with a medical or surgical specialist, especially prior to an invasive diagnostic 
or therapeutic procedure, is recommended.  
 
The frequency and severity of the related adverse events covered by these algorithms will 
depend on the immuno-oncology agent or regimen being used. 
 
NOTE: 
In cases of an-expected or unforeseen discrepancy between the guidelines or 
instructions in Table 3 (below) and Section 11.6 Management Algorithms, the 
latter guidelines/instructions should prevail for the purposes of patient 
management on protocol. 
 
 


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11.6 
BMS Guidelines for Adverse Event Reporting 
 
• All Serious Adverse Events (SAEs) that occur following the subject’s written consent 
to participate in the study through 90 days of discontinuation of dosing must be 
reported to BMS Worldwide Safety. 
• If the BMS safety address is not included in the protocol document (e.g. multicenter 
studies where events are reported centrally), the procedure for safety reporting must 
be reviewed/approved by the BMS Protocol Manager.  Procedures for such reporting 
must be reviewed and approved by BMS prior to study activation. 
• The BMS SAE form should be used to report SAEs.  If the BMS form cannot be 
used, another acceptable form (i.e CIOMS or Medwatch) must be reviewed and 
approved by BMS.  The BMS protocol ID number must be included on whatever 
form is submitted by the Sponsor/Investigator. 
• Following the subject’s written consent to participate in the study, all SAEs, whether 
related or not related to study drug, are collected, including those thought to be 
associated with protocol-specified procedures. The investigator should report any 
SAE occurring after these time periods that is believed to be related to study drug or 
protocol-specified procedure.  
•  
• In accordance with local regulations, BMS will notify investigators of all reported 
SAEs that are suspected (related to the investigational product) and unexpected (i.e., 
not previously described in the IB). In the European Union (EU), an event meeting 
these criteria is termed a Suspected, Unexpected Serious Adverse Reaction (SUSAR). 
Investigator notification of these events will be in the form of an expedited safety 
report (ESR).  
o Other important findings which may be reported by the as an ESR include: 
increased frequency of a clinically significant expected SAE, an SAE 
considered associated with study procedures that could modify the conduct of 
the study, lack of efficacy that poses significant hazard to study subjects, 
clinically significant safety finding from a nonclinical (eg, animal) study, 
important safety recommendations from a study data monitoring committee, 
or sponsor decision to end or temporarily halt a clinical study for safety 
reasons. 
o Upon receiving an ESR from BMS, the investigator must review and retain 
the ESR with the IB. Where required by local regulations or when there is a 
central IRB/IEC for the study, the sponsor will submit the ESR to the 
appropriate IRB/IEC. The investigator and IRB/IEC will determine if the 


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informed consent requires revision. The investigator should also comply with 
the IRB/IEC procedures for reporting any other safety information.  
o In addition, suspected serious adverse reactions (whether expected or 
unexpected) shall be reported by BMS to the relevant competent health 
authorities in all concerned countries according to local regulations (either as 
expedited and/or in aggregate reports). 
Serious Adverse Event Collection and Reporting 
Following the subject’s written consent to participate in the study, all SAEs, whether related 
or not related to study drug, must be collected, including those thought to be associated with 
protocol-specified procedures. All SAEs must be collected that occur within 90 days of 
discontinuation of dosing.  
All SAEs must be collected that occur during the screening period. If applicable, SAEs must 
be collected that relate to any protocol-specified procedure (eg, a follow-up skin biopsy).  
The investigator should report any SAE that occurs after these time periods that is believed to 
be related to study drug or protocol-specified procedure.  
SAEs, whether related or not related to study drug, and pregnancies must be reported to BMS 
within 24 hours. SAEs must be recorded on BMS or an approved form; pregnancies on a 
Pregnancy Surveillance Form. 
SAE Email Address:  Worldwide.Safety@BMS.com 
SAE Facsimile Number:  609-818-3804 
If only limited information is initially available, follow-up reports are required. (Note: 
Follow-up SAE reports should include the same investigator term(s) initially reported.)  
If an ongoing SAE changes in its intensity or relationship to study drug or if new information 
becomes available, a follow-up SAE report should be sent within 24 hours to the BMS (or 
designee) using the same procedure used for transmitting the initial SAE report.  
All SAEs should be followed to resolution or stabilization. 
The Sponsor/Investigator will ensure that all SAEs in the clinical database are reported to 
BMS and any applicable health authority during the conduct of the study including periodic 
reconciliation.  
 
For studies conducted under an Investigator IND in the US include the following 
timelines or text: 
For studies conducted under an Investigator IND in the US, any event that is both serious and 
unexpected must be reported to the Food and Drug Administration (FDA) as soon as possible 
and no later than 7 days (for a death or life-threatening event) or 15 days (for all other SAEs) 
after the investigator’s or institution’s initial receipt of the information. BMS will be 
provided with a simultaneous copy of all adverse events filed with the FDA.  


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SAEs should be reported on MedWatch Form 3500A, which can be accessed at: 
http://www.accessdata.fda.gov/scripts/medwatch/. 
MedWatch SAE forms should be sent to the FDA at: 
MEDWATCH 
5600 Fishers Lane 
Rockville, MD 20852-9787 
Fax: 1-800-FDA-0178 (1-800-332-0178) 
http://www.accessdata.fda.gov/scripts/medwatch/ 
 
All SAEs should simultaneously be faxed or e-mailed to BMS at: 
Global Pharmacovigilance & Epidemiology 
Bristol-Myers Squibb Company 
Fax Number: 609-818-3804 
Email: Worldwide.safety@bms.com 
 
• An SAE report should be completed for any event where doubt exists regarding its 
seriousness.  
• For studies with long-term follow-up periods in which safety data are being reported, 
include the timing of SAE collection in the protocol. 
• If the investigator believes that an SAE is not related to study drug, but is potentially 
related to the conditions of the study (such as withdrawal of previous therapy or a 
complication of a study procedure), the relationship should be specified in the 
narrative section of the SAE Report Form. 
• If only limited information is initially available, follow-up reports are required. (Note: 
Follow-up SAE reports should include the same investigator term(s) initially 
reported.) 
• If an ongoing SAE changes in its intensity or relationship to study drug or if new 
information becomes available, a follow-up SAE report should be sent within 24 
hours to BMS using the same procedure used for transmitting the initial SAE report. 
All SAEs should be followed to resolution or stabilization.  All SAEs should be 
followed to resolution or stabilization. 
 
DEFINITIONS 
The protocol must include a definition for Serious Adverse Events (SAE)  
SERIOUS ADVERSE EVENTS 


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A Serious Adverse Event (SAE) is any untoward medical occurrence that at any dose:  
• results in death 
• is life-threatening (defined as an event in which the subject was at risk of death at the 
time of the event; it does not refer to an event which hypothetically might have 
caused death if it were more severe) 
• requires inpatient hospitalization or causes prolongation of existing hospitalization 
(see NOTE below) 
• results in persistent or significant disability/incapacity 
• is a congenital anomaly/birth defect  
• is an important medical event (defined as a medical event(s) that may not be 
immediately life-threatening or result in death or hospitalization but, based upon 
appropriate medical and scientific judgment, may jeopardize the subject or may 
require intervention [eg, medical, surgical] to prevent one of the other serious 
outcomes listed in the definition above.) Examples of such events include, but are not 
limited to, intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization.)  
• Potential drug induced liver injury (DILI) is also considered an important medical 
event.  
• Suspected transmission of an infectious agent (eg, pathogenic or nonpathogenic) via 
the study drug is an SAE.  
• Although pregnancy, overdose, and cancer are not always serious by regulatory 
definition, these events must be handled as SAEs. 
NOTE: (PI- determines if this information should be included. This is provided as 
supplemental information that is included in BMS-sponsored trials) 
The following hospitalizations are not considered SAEs in BMS clinical studies:  
− a visit to the emergency room or other hospital department < 24 hours, that does 
not result in admission (unless considered an important medical or life-threatening 
event) 
− elective surgery, planned prior to signing consent 
− admissions as per protocol for a planned medical/surgical procedure 
− routine health assessment requiring admission for baseline/trending of health 
status (eg, routine colonoscopy) 
− Medical/surgical admission other than to remedy ill health and planned prior to 
entry into the study. Appropriate documentation is required in these cases 
− Admission encountered for another life circumstance that carries no bearing on 
health status and requires no medical/surgical intervention (eg, lack of housing, 


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economic inadequacy, caregiver respite, family circumstances, administrative 
reason). 
Potential Drug Induced Liver Injury (DILI) 
Wherever possible, timely confirmation of initial liver-related laboratory abnormalities 
should occur prior to the reporting of a potential DILI event.  All occurrences of potential 
DILIs, meeting the defined criteria, must be reported as SAEs  Potential drug induced liver 
injury is defined as: 
1) ALT or AST elevation > 3 times upper limit of normal (ULN)  
AND 
2) Total bilirubin > 2 times ULN, without initial findings of cholestasis (elevated 
serum alkaline phosphatase) 
AND 
3) No other immediately apparent possible causes of AST/ALT elevation and 
hyperbilirubinemia, including, but not limited to, viral hepatitis, pre-existing 
chronic or acute liver disease, or the administration of other drug(s) known to be 
hepatotoxic. 
 
ADVERSE EVENTS 
An Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of 
a preexisting medical condition in a clinical investigation subject administered an 
investigational (medicinal) product and that does not necessarily have a causal relationship 
with this treatment. An AE can therefore be any unfavorable and unintended sign (such as an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of 
investigational product, whether or not considered related to the investigational product. 
The causal relationship to study drug is determined by a physician and should be used to 
assess all adverse events (AE). The casual relationship can be one of the following: 
Related: There is a reasonable causal relationship between study drug administration and the 
AE. 
Not related: There is not a reasonable causal relationship between study drug administration 
and the AE.  
The term "reasonable causal relationship" means there is evidence to suggest a causal 
relationship.  
Adverse events can be spontaneously reported or elicited during open-ended questioning, 
examination, or evaluation of a subject. (In order to prevent reporting bias, subjects should 
not be questioned regarding the specific occurrence of one or more AEs.) 
NONSERIOUS ADVERSE EVENT 


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• Nonserious Adverse Events are to be provided to BMS in aggregate via interim or 
final study reports as specified in the agreement or, if a regulatory requirement [e.g. 
IND US trial] as part of an annual reporting requirement.  
• Nonserious AE information should also be collected from the start of a placebo lead-
in period or other observational period intended to establish a baseline status for the 
subjects.  
A nonserious adverse event is an AE not classified as serious.  
Nonserious Adverse Event Collection and Reporting 
The collection of nonserious AE information should begin at initiation of study drug. All 
nonserious adverse events (not only those deemed to be treatment-related) should be 
collected continuously during the treatment period and for a minimum of 100 days following 
the last dose of study treatment.  
Nonserious AEs should be followed to resolution or stabilization, or reported as SAEs if they 
become serious. Follow-up is also required for nonserious AEs that cause interruption or 
discontinuation of study drug and for those present at the end of study treatment as 
appropriate.  
 
Laboratory Test Abnormalities 
All laboratory test results captured as part of the study should be recorded following 
institutional procedures. Test results that constitute SAEs should be documented and reported 
as such. 
The following laboratory abnormalities should be documented and reported appropriately: 
• any laboratory test result that is clinically significant or meets the definition of an 
SAE 
• any laboratory abnormality that required the subject to have study drug discontinued 
or interrupted 
• any laboratory abnormality that required the subject to receive specific corrective 
therapy.  
 
Pregnancy 
If, following initiation of the investigational product, it is subsequently discovered that a 
study subject is pregnant or may have been pregnant at the time of investigational product 
exposure, including during at least 6 half lives after product administration, the 
investigational product will be permanently discontinued in an appropriate manner (eg, dose 
tapering if necessary for subject safety).  


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The investigator must immediately notify Worldwide Safety @BMS of this event via the 
Pregnancy Surveillance Form in accordance with SAE reporting procedures.  
Follow-up information regarding the course of the pregnancy, including perinatal and 
neonatal outcome and, where applicable, offspring information must be reported on the 
Pregnancy Surveillance Form [provided upon request from BMS] 
Any pregnancy that occurs in a female partner of a male study participant should be reported 
to BMS. Information on this pregnancy will be collected on the Pregnancy Surveillance 
Form. 
Overdose 
An overdose is defined as the accidental or intentional administration of any dose of a 
product that is considered both excessive and medically important. All occurrences of 
overdose must be reported as an SAE. 
Other Safety Considerations 
Any significant worsening noted during interim or final physical examinations, 
electrocardiograms, x-rays, and any other potential safety assessments, whether or not these 
procedures are required by the protocol, should also be recorded as a nonserious or serious 
AE, as appropriate, and reported accordingly. 
NOTE: 
In cases of an anexpected or unforeseen discrepancy regarding procedures for 
the reporting of adverse events between the content of the protocol (section 
7.2) and the BMS guidelines outlined in section 11.7, it is the latter 
guidelines/instructions that should prevail for the purposes of patient 
management on protocol. 
 
 
 


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12.0 
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