Conditions: Bladder Cancer
Keywords: Muscle-Invasive Cisplatin-Ineligible Nivolumab Lirilumab
Allocation: NON_RANDOMIZED | Intervention model: SEQUENTIAL
Enrollment: 43
Healthy volunteers: no

Brief summary:
Patients with muscle-invasive bladder cancer (MIBC) who can not receive cisplatin or refuse cisplatin therapy will receive nivolumab or nivolumab/lirilumab before a planned surgical procedure called a radical cystectomy (RC) to remove the bladder.

Nivolumab works by attaching to and blocking a molecule called Programmed Death-1 (PD-1). Lirilumab attaches to and blocks a group of molecules called Killer Cell Immunoglobulin-Like Receptor (KIR). PD-1 and KIR are proteins present mainly on immune system cells, and each controls part of the immune system by shutting it down. It is hoped that by binding to and inactivating these proteins, these drugs can enhance the body's ability to detect, attack and destroy cancer cells.

The purpose of this research study is to see whether nivolumab alone or combination of nivolumab and lirilumab given before surgery is effective in treating people who have bladder cancer, and to examine the side effects, good and bad, associated with nivolumab and lirilumab.

Detailed description:
Bladder cancer (BC) is the 6th most common malignancy in the United States with an estimated 79,030 new cases and 16,870 deaths in 2017. It is the 4th most common cancer in men and there are presently \>500,000 BC patients alive in the US. It accounts for about 5% of all new cancers in the US. It is also the most expensive cancer to treat from diagnosis to death. Almost a third of BC patients present with MIBC.

This is a Phase Ib open-label clinical trial for patients that are either cisplatin-ineligible or refuse cisplatin-based chemotherapy and have MIBC (T2-T4a, N0-N1, M0).Neoadjuvant treatment must start within 10 weeks of transurethral resection of the most recent transurethral resection of bladder tumor (TURBT) that showed muscularis propria invasion.

Patients must have sufficient baseline tumor tissue. Tumor tissue content for CD8+ T-cell density assessment must be qualified as sufficient (≥ 20% tumor content in the specimen) for analysis and must be documented by the local pathologist prior to registration.

The first 12 patients will be enrolled into Cohort 1 and treated with nivolumab before a planned RC (Completed November 20, 2019).

In the absence of the occurrence of high rate of treatment related Adverse Events (AEs) with nivolumab, the study will proceed with enrollment into Cohort 2 with the combination of nivolumab/lirilumab before a planned RC.

Each group will receive a total of 2 doses (week 0 and 4) of nivolumab (Cohort 1) or nivolumab/lirilumab (Cohort 2) therapy followed by RC with bilateral (standard or extended) pelvic lymph node dissection (PLND).

Mandatory tumor tissue at Screening (archived tumor tissue from Transurethral Resection of Bladder Tumor \[TURBT\] may be used) and at time of RC. Peripheral blood and urine samples are also required.

Arms:
arm 1: Nivolumab 480 mg IV on week 0 and week 4 arm 2: Nivolumab 480 mg IV and Lirilumab 240 mg on week 0 and week 4

Interventions: intervention 1: Nivolumab intervention 2: Nivolumab/Lirilumab
Intervention descriptions: intervention 1: Nivolumab 480 mg intravenously (IV) over approximately 30 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) followed by RC with bilateral (standard or extended) PLND as soon as possible but within 6 weeks after the last neoadjuvant infusion. intervention 2: Nivolumab 480 mg IV over approximately 60 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) with at least a 30 minute rest between infusions followed by lirilumab 240 mg IV over approximately 60 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) followed by RC with bilateral (standard or extended) PLND as soon as possible but within 6 weeks after the last neoadjuvant infusion.

Protocol document:
Prot_000.pdf: 
PrECOG Protocol Number: PrE0807 
Date: 12/10/2019 
 
1 
 
 
PrECOG Protocol Number: PrE0807 
Phase Ib Feasibility Trial of Neoadjuvant Nivolumab/Lirilumab 
in Cisplatin-Ineligible Muscle-Invasive Bladder Cancer 
 
NCT#: 
NCT03532451 
IND #: 
139580 
Protocol Version Number: 
3.0 
Version Date: 
12/10/2019 
 




PrECOG Protocol Number: PrE0807 
IND Number: 139580 
Confidential 
Date: 12/10/2019 
 
2 
Table of Contents 
List of Abbreviations ....................................................................................................................................8 
1. 
Introduction- Background and Rationale ........................................................................................ 12 
1.1 
Bladder Cancer – Disease Overview ......................................................................................... 12 
1.2 
Background ................................................................................................................................ 12 
1.3 
Rationale for Immunotherapy .................................................................................................... 12 
1.4 
Rationale for Nivolumab Therapy in MIBC Patients .................................................................. 13 
1.5 
Lirilumab and the Rationale for NK-cells as a Target in MIBC .................................................. 13 
1.5.1 
Preclinical Data ............................................................................................................ 13 
1.5.2 
Clinical Data................................................................................................................. 14 
1.6 
Rationale for Dual Immunotherapy in UC .................................................................................. 15 
1.7 
Background and Rationale of Key Secondary Endpoint ............................................................ 15 
1.8 
Rationale for Phase Ib Trial of Nivolumab/Lirilumab Combination vs Nivolumab Alone as 
Neoadjuvant Therapy in Cisplatin-Ineligible Patients with MIBC or those Refusing Cisplatin-
Based Chemotherapy ................................................................................................................ 16 
2. 
Study Objectives ................................................................................................................................ 17 
2.1 
Primary Objective ....................................................................................................................... 17 
2.2 
Secondary Objectives ................................................................................................................ 17 
2.3 
Exploratory Objectives ............................................................................................................... 17 
3. 
Selection of Patients .......................................................................................................................... 19 
4. 
Registration Procedures .................................................................................................................... 23 
4.1 
Ethics ......................................................................................................................................... 23 
4.2 
Regulatory Requirements .......................................................................................................... 23 
4.3 
Phase Ib Patient Registration .................................................................................................... 23 
4.4 
Research Tissue, Blood, and Urine Samples ............................................................................ 24 
5. 
Study Design ...................................................................................................................................... 25 
5.1 
Number of Patients .................................................................................................................... 25 
5.2 
Replacement of Patients ............................................................................................................ 25 
5.3 
Expected Duration of Treatment and Patient Participation ........................................................ 25 
5.4 
Interim Safety Analysis .............................................................................................................. 25 
6. 
Treatment Plan ................................................................................................................................... 27 
6.1 
Overview .................................................................................................................................... 27 
6.1.1 
Nivolumab Administration ............................................................................................ 27 
6.1.2 
Lirilumab Administration .............................................................................................. 27 
6.1.3 
Name of Other Modality or Procedures ....................................................................... 28 
7. 
Dose Delays ........................................................................................................................................ 29 
7.1 
Dose Delays for Treatment Related Hematological Toxicity ..................................................... 29 
7.1.1 
Grade 1 and Grade 2 Toxicities................................................................................... 29 
7.1.2 
Grade 3 Toxicities ........................................................................................................ 29 
7.1.3 
Grade 4 Toxicities ........................................................................................................ 29 
7.2 
Dose Delays for Treatment Related Non-Hematological Toxicity ............................................. 29 
7.2.1 
Grade 1 and Grade 2 Toxicities................................................................................... 29 
7.2.2 
Grade 3 Toxicities ........................................................................................................ 30 
7.2.3 
Grade 4 Toxicities ........................................................................................................ 30 


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7.3 
Infusion Reaction Guidelines ..................................................................................................... 31 
7.4 
Concurrent Therapies ................................................................................................................ 32 
7.4.1 
Required and/or Permitted .......................................................................................... 32 
7.4.2 
Prohibited and/or Restricted Treatments ..................................................................... 32 
7.4.3 
Other Restrictions and Precautions ............................................................................. 32 
8. 
Study Duration and Discontinuation of Therapy ............................................................................ 33 
8.1 
Study Duration ........................................................................................................................... 33 
8.2 
Duration of Follow-Up ................................................................................................................ 33 
8.3 
Criteria for Removal from Study Treatment ............................................................................... 33 
9. 
Adverse Event Reporting .................................................................................................................. 35 
9.1 
Collection of Safety Information ................................................................................................. 35 
9.2 
Handling of Serious Adverse Events (SAEs) ............................................................................. 36 
9.2.1 
SAE Definitions ............................................................................................................ 36 
9.3 
SAE Reporting Requirements .................................................................................................... 36 
9.4 
Potential Drug-Induced Liver Injury ........................................................................................... 37 
9.5 
Reporting of Other Second Primary Cancers ............................................................................ 38 
9.6 
Procedures in Case of Pregnancy ............................................................................................. 38 
9.7 
Reporting Guidelines in the Case of Overdose ......................................................................... 38 
10. Measurement of Effect ....................................................................................................................... 39 
10.1 Evaluable Population Definitions ............................................................................................... 39 
10.2 CD8+ T-Cell Density .................................................................................................................. 39 
10.3 %CD8+ Tumor-Infiltrating T-Cells .............................................................................................. 39 
10.4 Methods for Evaluation of Pathological Response .................................................................... 39 
10.5 Pathologic Tumor Response Definitions .................................................................................... 39 
10.5.1 
Pathologic Response ................................................................................................... 39 
10.5.2 
Pathologic Complete Response .................................................................................. 39 
10.5.3 
Pathologic Non-Response ........................................................................................... 40 
10.6 Tumor IHC Staining Intensity Definitions ................................................................................... 40 
10.7 Recurrence-Free Survival (RFS) as per RECIST 1.1 ................................................................ 40 
10.8 Overall Survival (OS) ................................................................................................................. 40 
11. Study Parameters ............................................................................................................................... 41 
12. Drug Formulation and Procurement ................................................................................................ 45 
12.1 Nivolumab30 ............................................................................................................................... 45 
12.1.1 
Other Names ............................................................................................................... 45 
12.1.2 
Classification................................................................................................................ 45 
12.1.3 
Mode of Action ............................................................................................................. 45 
12.1.4 
Description ................................................................................................................... 45 
12.1.5 
Preparation and Administration ................................................................................... 45 
12.1.6 
Storage and Stability ................................................................................................... 45 
12.1.7 
Drug Interactions ......................................................................................................... 46 
12.1.8 
Agent Availability ......................................................................................................... 46 
12.1.9 
Agent Ordering ............................................................................................................ 46 
12.1.10 Agent Accountability .................................................................................................... 46 
12.1.11 Side Effects.................................................................................................................. 46 


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12.2 Lirilumab37 .................................................................................................................................. 47 
12.2.1 
Other Names ............................................................................................................... 47 
12.2.2 
Mode of Action ............................................................................................................. 47 
12.2.3 
Description ................................................................................................................... 47 
12.2.4 
Preparation and Administration ................................................................................... 47 
12.2.5 
Storage and Stability ................................................................................................... 47 
12.2.6 
Drug Interactions ......................................................................................................... 48 
12.2.7 
Agent Availability ......................................................................................................... 48 
12.2.8 
Agent Ordering ............................................................................................................ 48 
12.2.9 
Agent Accountability .................................................................................................... 48 
12.2.10 Side Effects.................................................................................................................. 48 
13. Statistical Considerations ................................................................................................................. 49 
13.1 Study Design & Sample Size Considerations ............................................................................ 49 
13.1.1 
Interim Safety Analysis (Primary Endpoint) ................................................................. 49 
13.2 Statistical Analysis ..................................................................................................................... 49 
13.2.1 
Primary Objective ........................................................................................................ 49 
13.2.2 
Key Secondary Objective ............................................................................................ 50 
13.2.3 
Additional Secondary Objectives ................................................................................. 50 
13.2.4 
Exploratory Objectives ................................................................................................. 51 
14. Laboratory and Pathology Correlative Studies ............................................................................... 53 
14.1 Correlative Studies: Mandatory Tumor Samples and Analysis ................................................. 53 
14.1.1 
Tumoral Assessments ................................................................................................. 53 
14.1.2 
Tumor Infiltrating CD8+ T-Cell Density........................................................................ 53 
14.1.3 
Percentage CD8+ Tumor Infiltrating T-Cell ................................................................. 54 
14.1.4 
PD-1 and PD-L1 IHC ................................................................................................... 54 
14.1.5 
Banking for Future Research: Additional Analysis ...................................................... 54 
14.2 Correlative Studies: Mandatory Peripheral Blood Samples and Analysis ................................. 55 
14.2.1 
Peripheral Blood Assessments.................................................................................... 55 
14.2.2 
Peripheral Blood Lymphocyte Subsets ....................................................................... 55 
14.2.3 
Natural Killer Cell (NK-cell) Activation ......................................................................... 55 
14.2.4 
ctDNA Analysis ............................................................................................................ 55 
14.2.5 
Cytokine Analysis ........................................................................................................ 56 
14.3 Correlative Studies: Mandatory Urine Samples and Analysis ................................................... 56 
14.3.1 
Urine Assessment and Sample Collection .................................................................. 56 
14.3.2 
Banking for Future Research: Urine Marker Analysis ................................................. 56 
14.4 Research Samples Processing and Shipment .......................................................................... 56 
14.4.1 
FFPE Tissue Block or Slide Samples .......................................................................... 56 
14.4.2 
Peripheral Blood Samples ........................................................................................... 56 
14.4.3 
Urine Sample Processing ............................................................................................ 58 
15. Administrative .................................................................................................................................... 59 
15.1 Protocol Compliance .................................................................................................................. 59 
15.2 Institutional Review Board (IRB) ................................................................................................ 59 
15.3 Informed Consent Procedures ................................................................................................... 59 
15.4 Safety Communication ............................................................................................................... 60 
15.5 Monitoring .................................................................................................................................. 60 


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15.6 Study Records ........................................................................................................................... 60 
15.7 Electronic Case Report Form (eCRF) Information .................................................................... 61 
15.8 Records Retention ..................................................................................................................... 61 
16. References .......................................................................................................................................... 62 
Appendix I 
ECOG Performance Status ....................................................................................... 65 
Appendix II: 
Cockcroft-Gault Formula .......................................................................................... 66 
Appendix III: 
Management 
Algorithms 
for 
Endocrinopathy, 
Gastrointestinal, 
Hepatic, 
Neurological, Pulmonary, Renal, and Skin Adverse Events .......................................................... 67 
Appendix IV: 
RECIST Version 1.1 ................................................................................................... 74 
Appendix V: 
Bladder Cancer TNM Staging ................................................................................... 79 
Appendix VI: 
Investigator’s Statement ........................................................................................... 80 
 
 
 






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8 
List of Abbreviations 
Abbreviation 
Term 
ADL 
Activities of Daily Living 
AE 
Adverse Event 
AJCC 
American Joint Commission on Cancer 
ALT 
Alanine Aminotransferase 
AML 
Acute Myeloid Leukemia 
ANC 
Absolute Neutrophil Count 
ASCO 
American Society of Clinical Oncology 
AST 
Aspartate Aminotransferase 
BC 
Bladder Cancer 
BCG 
Bacilllus Calmette Guerin 
BID 
Twice Daily 
BMS 
Bristol-Myers Squibb 
BSA 
Body Surface Area 
BUN 
Blood Urea Nitrogen 
C 
Celsius 
CABG 
Coronary Artery Bypass Graft 
CBC 
Complete Blood Count 
CBPF 
Central Biorepository Pathology Facility 
cc 
Cubic Centimeter 
CFR 
Code of Federal Regulations 
CHF 
Congestive Heart Failure 
CR 
Complete Response 
CrCl 
Creatinine Clearance 
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
ctDNA 
Circulating Tumor Deoxyribonucleic Acid 
CTLA-4 
Cytotoxic T Lymphocyte Antigen-4 
CVA 
Cerebrovascular Accident 
DAB 
Diamiobenzidine 
DBP 
Diastolic Blood Pressure 
DEHP 
Non-Di-2-Ethylhexyl Phthalate 
dL 
Deciliter 


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Abbreviation 
Term 
DNA 
Deoxyribonucleic Acid 
DSMB 
Data Safety Monitoring Board 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic Case Report Form 
eDC 
Electronic Data Capture 
FDA 
Food and Drug Administration 
F 
Fahrenheit 
FFPE 
Formalin-Fixed Paraffin-Embedded 
FT3 
Free-Triiodothyronine 
FT4 
Free-Thyroxine 
GCP 
Good Clinical Practice 
g 
Gram 
G-CSF 
Granulocyte-Colony Stimulating Factor 
GI 
Gastrointestinal 
HBsAg 
Hepatitis B Surface Antigen 
HBV 
Hepatitis B Virus 
HCV 
Hepatitis C Virus 
HIPAA 
Health Information Portability and Accountability Act 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 
HPF 
High Powered Field 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
ID 
Infectious Disease 
IF 
Immunofluorescence 
Ig 
Immunoglobulin 
IHC 
Immunohistochemistry 
IL-2 
Interleukin-2 
IND 
Investigational New Drug 
I-O 
Immuno-Oncology 
IRB 
Institutional Review Board 


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Abbreviation 
Term 
IV 
Intravenous; Intravenously 
IVIG 
Intravenous Immunoglobulin 
KIRs 
Killer Cell Immunoglobulin-Like Receptors 
kg 
Kilogram 
LFT 
Liver Function Tests 
LLN 
Lower Limit of Normal 
LN 
Lymph Node 
mAb 
Monoclonal antibody 
mg 
Milligram 
MHC 
Major Histocompatibility Complex 
MI 
Myocardial Infarction 
MIBC 
Muscle-Invasive Bladder Cancer 
min 
Minute 
mL 
Milliliter 
mm 
Millimeter 
MRI 
Magnetic Resonance Imaging 
MTD 
Maximum Tolerated Dose 
NA 
Not Applicable 
NCI 
National Cancer Institute 
NCDB 
National Cancer Database 
NCI CTCAE 
National Cancer Institute Common Terminology Criteria for Adverse 
Events 
NK-Cells 
Natural Killer Cells 
NKG2D 
Natural Killer Group 2, Member D 
NMIBC 
Non-Muscle-Invasive Bladder Cancer 
NS 
Normal Saline 
NSAID 
Nonsteroidal Anti-Inflammatory Drug 
NYHA 
New York Heart Association 
OS 
Overall Survival 
PBMC 
Peripheral Blood Mononuclear Cell 
PBS 
Phosphate-Buffered Saline 
PD 
Progressive Disease (disease progression) 
PD-1 
Programmed Death-1 
PD-L1 
Programmed Death-Ligand 1 


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Abbreviation 
Term 
PET 
Positron Emission Tomography 
PK 
Pharmacokinetic(s) 
PLND 
Pelvic Lymph Node Dissection 
PO 
Orally; By Mouth 
PR 
Partial Response 
PS 
Performance Status 
Q2W 
Every 2 Weeks 
Q4W 
Every 4 Weeks 
RC 
Radical Cystectomy 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RFS 
Recurrence-Free Survival 
RNA 
Ribonucleic Acid 
RPM 
Revolutions Per Minute 
SAE 
Serious Adverse Event 
SBP 
Systolic Blood Pressure 
SD 
Stable Disease 
SITC 
Society for Immunotherapy Cancer 
SRM 
Study Reference Manual 
T. Bili 
Total Bilirubin 
TCGA 
The Cancer Genome Atlas 
TIA 
Transient Ischemic Attack 
TIL 
Tumor-Infiltrating Lymphocytes 
TMA 
Tissue Microarray 
TSH 
Thyroid Stimulating Hormone 
TURBT 
Transurethral Resection of Bladder Tumor 
UC 
Urothelial Carcinoma 
ULN 
Upper Limit of the Normal Range 
US 
United States 
vs 
Versus 
WBC 
White Blood Cell 
WOCBP 
Women of Childbearing Potential 
 


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1. 
Introduction- Background and Rationale 
1.1 
Bladder Cancer – Disease Overview 
Bladder cancer (BC) is the 6th most common malignancy in the United States (US) with an 
estimated 79,030 new cases and 16,870 deaths in 2017.1 It is the 4th most common cancer 
in men and there are presently >500,000 BC patients alive in the US. It accounts for about 
5% of all new cancers in the US. It is also the most expensive cancer to treat from diagnosis 
to death. Almost a third of BC patients present with muscle-invasive bladder cancer (MIBC). 
Moreover, among the ~65% of BC patients presenting with non-muscle-invasive bladder 
cancer (NMIBC), up to 15-20% may progress to MIBC every year. Altogether, approximately 
35,000 patients are diagnosed with MIBC in the US annually.2 Urothelial carcinoma (UC) is 
the most common BC histology and can affect the entire urinary tract (e.g. renal pelvis, 
ureter, proximal urethra). Radical cystectomy (RC) is the standard of care for MIBC, 
however it results in a 5-year recurrence-free survival rate of 68% (only 35% for those with 
lymph node involvement). This is most probably due to micro-metastases present at the 
time of surgery considering the high rate of distant recurrence.3,4 Systemic cisplatin-based 
combination chemotherapy prior to RC results in high pathologic complete response rates 
and modest but clinically meaningful increase in overall survival compared to local therapy 
alone, and has become the standard of care for cisplatin-eligible patients with MIBC.5-7 
1.2 
Background 
Patients with UC often have multiple medical comorbidities which preclude cisplatin use.8 A 
reported consensus definition of cisplatin ineligibility for patients with metastatic UC includes 
any of the following clinical characteristics: ECOG performance status ≥ 2, creatinine 
clearance <60 mL/min, grade ≥ 2 hearing loss, grade ≥ 2 neuropathy, and/or New York 
Heart Association (NYHA) Class ≥ III heart failure. The proportion of patients ineligible for 
cisplatin based on renal function alone has been reported up to 50%, and if other factors 
are also considered the proportion is probably even higher.9 Furthermore, among patients 
with MIBC who do not receive cisplatin-based chemotherapy, a recent analysis from the 
National Cancer Database (NCDB) recorded patient refusal of cisplatin-based 
chemotherapy in 58% of patients as the reason for its omission.10 Several non-cisplatin-
based chemotherapy regimens and targeted agents have been evaluated in cisplatin-
ineligible patients with UC, but none has demonstrated adequate efficacy to warrant wide 
adoption or regulatory approval. Before the recent Food and Drug Administration (FDA) 
approval of atezolizumab and nivolumab, there had been no advances in the systemic 
therapy of UC for almost three decades, resulting in considerable attention and prioritization 
from regulatory agencies. Therefore, cisplatin-ineligible patients represent a large 
population “in need” of effective therapies. In addition, due to the very high number of 
cisplatin-ineligible patients and the opportunity to examine both pre- and post-therapy tumor 
tissue and blood for pharmacodynamics and biomarker assessment, the neoadjuvant (pre-
RC) setting presents an ideal opportunity to evaluate novel therapeutic agents that can be 
applied in other cancer types and settings. 
1.3 
Rationale for Immunotherapy 
The role of immunotherapy in UC is very well established. Intra-vesical administration of 
Bacillus Calmette-Guerin (BCG), a bovine mycoplasma-derived agent that lowers bladder 
tumor recurrence by inciting a robust immunologic reaction in the bladder 
microenvironment, is standard of care for high grade NMIBC. The evident clinical benefit 
with intra-vesical BCG immunotherapy supports the potential benefit from systemic 
immunotherapies in UC. The presence of CD8 tumor-infiltrating lymphocytes (TILs) has 
been associated with longer disease-free and overall survival in UC.11,12 Aberrant 
expression of the immune checkpoint programmed death-ligand 1 (PD-L1) has been shown 
in UC, implying that tumor-associated PD-L1 can play a regulatory role in anti-tumor 
immunity and be a relevant therapeutic target.13 PD-L1 expression was associated with high 


PrECOG Protocol Number: PrE0807 
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13 
tumor grade, tumor infiltration by mononuclear cells, stage progression and attenuated 
response to BCG immunotherapy by neutralizing T cells.14 In NMIBC, PD-L1 expression 
was observed in 69% of post-BCG relapsed tumors compared to 19% of BCG-naïve tumors 
from the same patients implicating programmed death-1 (PD-1)/PD-L1 pathway as a 
possible resistance mechanism to BCG therapy.14 Furthermore, the number of TILs and 
CD8+ peripheral blood lymphocytes have been found to be reversely correlated with each 
other; while each has been associated with recurrence in UC.15,16 Therefore, 
immunotherapy via inhibition of PD-1/PD-L1 mediated pathway can be an important tool to 
improve outcomes in UC. 
1.4 
Rationale for Nivolumab Therapy in MIBC Patients 
Breakthrough clinical data have been noted with agents targeting cytotoxic T-programmed 
death-1 (PD-1) and PD-L1.17,18 PD-1 expression in TILs has been observed in almost all 
MIBC patients undergoing cystectomy with nearly all TILs expressing CD8; 76% of patients 
with PD-L1 positive tumors had moderate or marked TILs PD-1 expression. PD-L1 
expression in bladder tumors and TILs PD-1 expression were significantly associated with 
advanced pathologic stage, and PD-L1 expression independently predicted all-cause 
mortality after cystectomy.19 In a Phase I expanded cohort of post-platinum advanced UC, 
anti-PD-L1 single agent therapy induced up to 67% objective response rate in tumors with 
high PD-L1 immunostaining, including rapid and durable responses with an excellent safety 
profile.20,21 A Phase II trial with single agent anti-PDL1 confirmed durable activity and good 
tolerability in this patient population; the level of PD-L1 expression on immune cells, The 
Cancer Genome Atlas (TCGA) subtype and mutational load correlated with response.22 
Significant anti-tumor activity and favorable tolerability was also noted with the anti-PD1 
agents, pembrolizumab and nivolumab in post-platinum advanced UC.18,23-25 Similar data 
have been noted with two other anti-PD-L1 agents, durvalumab and avelumab.26,27 
Pembrolizumab demonstrated overall survival benefit over chemotherapy in a large Phase 
III trial of post-platinum metastatic & locally-advanced UC.24 Pembrolizumab and 
atezolizumab have also shown significant efficacy as frontline therapy in cisplatin-ineligible 
patients with advanced UC with a good safety profile.28,29 Atezolizumab, nivolumab, 
durvalumab 
and 
avelumab 
have 
been 
FDA-approved 
for 
platinum-treated 
advanced/metastatic UC. 
A flat dose of nivolumab 240 mg Q2W is identical to a dose of 3 mg/kg for subjects 
weighing 80 kg, the observed median body weight in nivolumab treated cancer patients.30 
The FDA has approved nivolumab for metastatic urothelial carcinoma at a dose of 240 mg 
every 2 weeks. 
However, Nivolumab 480 mg Q4W allows flexibility of dosing with less frequent visits.30 
Population pharmacokinetics (PKs) and exposure response analysis have been performed 
and support the use of 480 mg Q4W.30 Nivolumab has been shown to be safe and well 
tolerated up to a dose level of 10 mg/kg, and the relationship between nivolumab 
exposure produced by 3 mg/kg and efficacy and safety has been found to be relatively 
flat.30 
Two neoadjuvant doses of nivolumab 480 mg Q4W for 2 doses (week 0 and 4) should show 
efficacy as well as provide immunologic effects and allow radical cystectomy completion 
within 6 weeks of last dose of neoadjuvant therapy. 
Refer to the current Nivolumab Investigator’s Brochure (IB) for details regarding nivolumab. 
1.5 
Lirilumab and the Rationale for NK-cells as a Target in MIBC 
1.5.1 
Preclinical Data 
Natural killer cells (NK-cells) are a critical component of innate human immunity due 
to their ability to cause cell lysis and apoptosis in the absence of major 




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Lirilumab dose and schedule was based on a Bristol-Myers Squibb (BMS) Phase I 
safety study. Two neoadjuvant doses of lirilumab (week 0 and 4) should show 
efficacy as well as provide immunologic effects and allow radical cystectomy 
completion within 6 weeks of last dose of neoadjuvant therapy. 
Refer to the Lirilumab IB for details regarding lirilumab. 
1.6 
Rationale for Dual Immunotherapy in UC 
Despite very promising, rapid and durable anti-tumor responses with single agent immune 
checkpoint inhibitor therapy, the overall response rates with anti-PD-1/PD-L1 agents alone 
is low, especially in tumors with low PD-L1 protein expression. To augment the efficacy of 
immune checkpoint inhibitors, various immunotherapy combination strategies are being 
investigated. Phase I trial of combination nivolumab and lirilumab in solid tumors has been 
conducted.38 An interim analysis from a Phase I/II trial of nivolumab/lirilumab combination 
in advanced platinum refractory squamous cell head and neck carcinoma was presented 
recently.39 Among 29 evaluable patients, the objective response rate was 24%. Five patients 
had deep responses with reductions in tumor burden >80%. Early signal of enhanced 
clinical benefit was noted in PD-L1-positive tumors, with an objective response rate of 41% 
in patients with >1% PD-L1 expression. The safety profile of the combination was generally 
consistent with that observed with nivolumab alone. The overall treatment-related adverse 
event rate was 72% (114/159) and the grade 3-4 treatment-related adverse event rate was 
15% (24/159). Discontinuations due to treatment-related adverse events occurred in 8% of 
patients (12/159). In a recent press release on 11/22/2017, the combination of nivolumab 
and lirilumab did not show any apparent benefit in an expanded cohort of patients with 
squamous cell head and neck carcinoma; however, this tumor type is different than UC 
while there was no new toxicity concern.40 The combination regimen of anti-PD-1 and anti-
KIR agents are feasible and very attractive based on their complementary and non-
overlapping roles in regulating both adaptive and innate immune response as well as 
impacting both CD8+ T-cells and NK-cells. Data suggests that T and NK cell activation in 
bladder cancer models requires the collaboration of various immune cells, suggesting that 
combination immunotherapies may have at least additive value.41,42 Moreover, regulation of 
T cell responses by innate lymphoid cells is clearly documented. Direct and indirect 
crosstalk between innate cells and T cells during and after T cell activation can impact their 
differentiation, polarization, and survival; this synergistic activity may translate to improved 
outcomes.43,44 The neoadjuvant setting provides an optimal platform to evaluate the safety 
and efficacy of this combination, leveraging the ability to evaluate tissue, urine and blood-
based biomarkers before, during and after combination therapy. Of particular interest is the 
density of CD8+ TILs following treatment, which can be used as a surrogate for better 
survival and prognosis in UC. Data from this neoadjuvant trial can inform further 
development of this combination in many UC settings as well as in other cancer types. 
1.7 
Background and Rationale of Key Secondary Endpoint 
Density of CD8+ TILs has been found to correlate with survival outcomes in UC. An older 
study assessed the prognostic value of TILs in a cohort of 512 patients with UC over a 
period of 9 years.11 In advanced stage tumors (T3-T4) increased TIL density was related to 
less aggressive behavior whereas in a multivariate analysis, dense TILs were a highly 
significant factor of favorable prognosis and allowed to separate UC into prognostic groups 
based on TIL density.11 A study by Sharma et al. in 2007 included a cohort of 69 patients 
with UC who underwent cystectomy. Patients were separated into those with high vs low 
density of TILs in cystectomy samples. Patients with advanced UC (pT2, pT3 and pT4) who 
had increased density of TILs were shown to have better disease-free survival and overall 
survival, compared to patients at the same stage who had lower density of TILs.12 A study 
by Faraj et al. also looked at 56 tissue microarrays from cystectomy samples in a single 
institution. Patient samples were divided into high and low CD8+ T cell density categories. 


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High CD8+ T cell density was associated with longer overall and disease-specific survival 
even when adjusted for demographic and clinicopathologic parameters.42 Another study 
showed that CD8+ to Treg TIL density in the pre-treatment tissues predicted response to 
neoadjuvant chemotherapy.45 Altogether, data suggests that CD8+ TIL density is associated 
with improved outcomes in advanced stage MIBC and can be utilized as a surrogate marker 
of clinical benefit. This data needs to be verified prospectively and this can be done as part 
of a feasibility trial suggested here. 
1.8 
Rationale for Phase Ib Trial of Nivolumab/Lirilumab Combination vs Nivolumab Alone as 
Neoadjuvant Therapy in Cisplatin-Ineligible Patients with MIBC or those Refusing Cisplatin-
Based Chemotherapy 
As detailed above, a strong rationale exists to study both nivolumab and lirilumab in 
cisplatin-ineligible MIBC in the neoadjuvant setting based upon the following: 
1. Cisplatin-ineligible or cisplatin-refusing patients with MIBC represents a common, 
sizeable population. 
2. Expression of PD-1/PD-L1 is frequent in MIBC. 
3. NK-cell function and number have been associated with improved outcomes in NMIBC 
and MIBC. 
4. Cisplatin-ineligible or cisplatin-refusing patients with MIBC represents a potential 
nivolumab/lirilumab FDA-registration pathway population with few competing regimens 
in this space. 
The Phase Ib design in the neoadjuvant setting provides several additional advantages 
including: 
1. Assessment of safety and feasibility of nivolumab alone and nivolumab/lirilumab in a 
curative disease setting (neoadjuvant). 
2. An ideal platform for biomarker discovery and validation efforts due to the ability to 
analyze pre- and post-treatment bio-specimens. 
3. Preliminary assessment of whether single-agent immunotherapy (nivolumab alone) and 
combination immunotherapy (nivolumab/lirilumab) have efficacy in the neoadjuvant 
setting. 
As such, the cisplatin-ineligible MIBC population presents a unique opportunity to assess 
pre- and post-treatment pharmacodynamic effects and gain preliminary safety and efficacy 
data to inform further development strategy decisions for both nivolumab without or with 
lirilumab in the neoadjuvant setting in muscle-invasive bladder cancer. 


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2. 
Study Objectives 
2.1 
Primary Objective 
To assess safety of treatment according to Common Terminology Criteria for Adverse 
Events version 5.0 (CTCAE v5.0) manifested as the rate of Grade 3 or higher treatment 
related adverse events in patients treated with nivolumab (Cohort 1) or combination of 
nivolumab/lirilumab (Cohort 2). 
2.2 
Secondary Objectives 
• 
To assess the change in CD8+ TIL density from pre-treatment Transurethral Resection 
of Bladder Tumor (TURBT) to post-treatment Radical Cystectomy (RC) tissues 
separately in patients treated with nivolumab or combination of nivolumab/lirilumab. 
• 
To assess percentage (%) change in CD8+ TIL density from pre-treatment TURBT to 
post-treatment RC tissues separately in patients treated with nivolumab and 
combination of nivolumab/lirilumab. 
• 
To describe the rate of patients in each cohort who do not get RC within 6 weeks after 
completion of neoadjuvant treatment specifically and directly related to treatment-
related adverse events (AEs). 
• 
To assess the antitumor efficacy of nivolumab and combination of nivolumab/lirilumab 
as measured by pathologic complete (pT0N0) and partial (<pT2N0) response rate in 
the two cohorts. 
• 
To assess the rate of recurrence-free survival (RFS) at the two-year time point from the 
time of registration in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 
2.3 
Exploratory Objectives 
• 
To assess the prognostic and predictive value of the expression of baseline 
immunohistochemistry (IHC) markers of interest (e.g. PD-1, PD-L1, PD-L2, NKG2D, 
KIR2DL1/2/3), and change in expression, for pathologic partial and complete tumor 
response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, respectively), 
in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive value of peripheral blood mononuclear cell 
(PBMC) T-cell subset status (%CD4+ T-cells, %CD8+ T-cells, %Treg T-cells, %Myeloid 
Derived Suppressor Cells, %Natural Killer cells, etc.) and change in status, as assessed 
by flow cytometry analysis, for pathologic partial and complete tumor response (defined 
by cystectomy pathologic staging < pT2N0 and pT0N0, respectively), in patients treated 
with nivolumab and combination of nivolumab/lirilumab. 
• 
To compare CD8+ TIL density in post-treatment RC tissues in patients treated with 
nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive relationship between pre- and post- treatment 
TIL and NK-cell level and activation and pathologic partial and complete response 
(defined by cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as 
two-year 
RFS, 
in 
patients 
treated 
with 
nivolumab 
and 
combination 
of 
nivolumab/lirilumab. 
• 
To assess impact of prior BCG exposure on rates of pathologic partial and complete 
response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, respectively) 
as well as two-year RFS, in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 


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• 
To assess the prognostic and predictive relationship of tumor mutational load, neo-
epitope burden, intrinsic molecular subtypes (basal vs. luminal), and T-cell clonality with 
pathologic partial and complete response (defined by cystectomy pathologic staging 
<pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with 
nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive relationship of pre- and post-treatment 
peripheral blood T-cell subsets, CD4+/CD8+ and CD4+/FOXP3+ ratios and plasma 
cytokine multiplex panels with pathologic partial and complete response (defined by 
cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year 
RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive relationship between pre- and post-
neoadjuvant treatment levels in plasma cytokine biomarkers of interest (e.g. IFN-α, 
TGF-β, IL-10, IL-4, IL-5, IL-13, IFN-γ, etc.) and pathologic partial and complete 
response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, respectively) 
as well as two-year RFS, in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 
• 
To assess prognostic and predictive associations between baseline tumor and/or tumor 
infiltrating lymphocyte tissue and ctDNA genomic alterations, gene expression, and 
methylation signatures for pathologic partial and complete response (defined by 
cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year 
RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess prognostic and predictive value of serum circulating antibody profiles on 
pathologic partial and complete response (defined by cystectomy pathologic staging 
<pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with 
nivolumab and combination of nivolumab/lirilumab. 
• 
To assess CD8+ TIL density by central pathology review using image analysis in both 
cohorts. 


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3. 
Selection of Patients 
Each of the criteria in the checklist that follows must be met in order for a patient to be considered 
eligible for this study. Use the checklist to confirm a patient’s eligibility. For each patient, this 
checklist must be photocopied, completed and maintained in the patient’s chart. 
In calculating days of tests and measurements, the day a test or measurement is done is 
considered Day 0. Therefore, if a test is done on a Monday, the Monday four weeks later 
would be considered Day 28. 
PrECOG Patient No. 
 
 
Patient’s Initials ( F, M, L) 
 
 
Physician Signature and Date 
 
NOTE: PrECOG does not allow waivers to any protocol specified criteria. All eligibility criteria listed 
in Section 3 must be met, without exception. The registration of individuals who do not meet 
all criteria listed in Section 3 can result in the participant being censored from the analysis 
of the study, and a major protocol violation. All questions regarding clarification of eligibility 
criteria must be directed to the Medical Monitor or PrECOG Study Contact. 
NOTE: Institutions may use the eligibility checklist as source documentation if it has been reviewed, 
signed, and dated prior to registration by the treating physician. 
3.1 
Patients must have histologically confirmed MIBC (T2-T4a, N0-N1, M0 per American Joint 
Commission on Cancer [AJCC]) pure or mixed histology urothelial carcinoma [urothelial 
carcinoma should be the dominant histology]. Clinical node-positive (N1) patients are 
eligible provided the lymph nodes (LNs) are confined to the true pelvis and are within the 
planned surgical LN dissection template. 
Staging: _______________ 
3.2 
The most recent TURBT that showed muscularis propria invasion should be within 10 weeks 
prior to beginning study therapy. Patients must have sufficient baseline tumor tissue from 
either initial or repeat TURBTs. The local site pathologist will be asked to estimate and 
record the rough approximate percentage of viable tumor in the TURBT sample (initial 
or repeat TURBT with highest tumor content) to document at least 20% viable tumor 
content prior to registration. This is to ensure adequate tissue is available to perform 
tumor infiltrating CD8+ T-cell assessment. (The actual CD8+ T-analysis will be done by a 
Central Laboratory and will not be done prior to registration.) 
3.3 
Patients must be ineligible for cisplatin-based chemotherapy due to any of the following 
below OR refused cisplatin-based chemotherapy: 
• 
Creatinine clearance(CrCl) <60 mL/min (with ECOG Performance Status (PS) 0-1 
[Appendix I]) 
CrCl _____ mL/min  
ECOG PS _____ 
NA  
• 
Creatinine clearance(CrCl) ≥ 60 mL/min with ECOG PS 2 (if patient fit for RC) 
CrCl _____ mL/min  
ECOG PS _____ 
NA  
• 
Hearing impaired ≥ Grade 2 by CTCAE criteria 
Yes  
No  
• 
Neuropathy ≥ Grade 2 by CTCAE criteria 
Yes  
No  
Patient refused cisplatin-based chemotherapy? 
Yes  
N/A  (see above) 
_____
_____
_____


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3.4 
Patients must be medically fit for TURBT and radical cystectomy (RC). 
3.5 
Age ≥ 18 years. 
3.6 
Ability to understand and willingness to sign IRB-approved informed consent. 
3.7 
Willing to provide tumor tissue, blood, and urine samples for research (Section 14). 
3.8 
Adequate organ function as measured by the following criteria, obtained ≤ 4 weeks prior to 
registration: 
• 
Absolute Neutrophil Count (ANC) ≥ 1000/mm3 (stable off growth factor within 4 weeks 
of first study drug administration) 
ANC: __________________ 
Date of Test: ____________ 
• 
Platelets ≥ 100,000/mm3 
Platelets: _______________ 
Date of Test: ____________ 
• 
Hemoglobin ≥ 8 g/dL 
Hemoglobin: _______________ 
Date of Test: ____________ 
• 
Serum Creatinine Clearance ≥ 30 mL/min using the Cockcroft-Gault formula (Appendix 
II) 
CrCL: ________ 
Date of Test: ___________ 
• 
ALT and AST ≤ 2.5x ULN 
ALT: _________ Institution ULN: ________ Date of Test: __________ 
AST: _________ Institution ULN: ________ Date of Test: __________ 
• 
Total Bilirubin ≤ 1.5x ULN (in the absence of previously diagnosed Gilbert’s disease) 
Total Bilirubin: ___________ 
ULN: ________ 
Date of Test: ___________ 
3.9 
Women must not be pregnant or breastfeeding since we do not know the effects of 
nivolumab and lirilumab on the fetus or breastfeeding child. All sexually active females of 
childbearing potential (not surgically sterilized and between menarche and 1 year post 
menopause) must have a blood test to rule out pregnancy within 4 weeks prior to 
registration. 
Is the patient a woman of childbearing potential? _____________________ (yes/no) 
If yes, Date of Test: _______________ Results: ____________________________ 
3.10 
Sexually active women of child-bearing potential with a non-sterilized male partner and 
sexually active men must agree to use 2 methods of adequate contraception (hormonal plus 
barrier or 2 barrier forms) OR abstinence prior to study entry, for the duration of study 
participation, and for 5 months for women and 7 months for men following last dose of study 
drugs. Method of contraception must be documented. 
NOTE: Should a woman become pregnant or suspect she is pregnant while participating in 
this study, she should inform her treating physician immediately. 
3.11 
Patients may not have active or prior documented autoimmune disease within the past 2 
years prior to Screening or other immunosuppressive agent within 14 days of study 
treatment. 
NOTE: Patients with well controlled type 1 diabetes mellitus, vitiligo, Graves disease, 
Hashimoto’s disease, eczema, lichen simplex chronicus, or psoriasis not requiring systemic 
treatment (within the past 2 years prior to Screening) are not excluded. 
_____
_____
_____
_____
_____ 
_____ 
_____ 
_____ 


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3.12 
Patients may not have locally advanced unresectable or metastatic urothelial carcinoma as 
assessed on baseline radiographic imaging obtained within 28 days prior to study 
registration. The required radiographic imaging includes: Chest/Abdomen/Pelvis CT with or 
without contrast. CT with contrast is the preferred method unless otherwise contraindicated 
due to allergy, impaired renal function, etc. (MRI is allowed as alternative). 
3.13 
Patients may not have concurrent upper urinary tract (i.e. ureter, renal pelvis) invasive 
urothelial carcinoma. Patients with history of non-invasive (Ta, Tis) upper tract urothelial 
carcinoma that has been definitively treated with at least one post-treatment disease 
assessment (i.e. cytology, biopsy, imaging) that demonstrates no evidence of residual 
disease are eligible. 
3.14 
Patients may not have another malignancy that could interfere with the evaluation of safety 
or efficacy of the study drugs. Patients with a prior malignancy will be allowed without study 
chair approval in the following circumstances: 
a. Not currently active and diagnosed at least 3 years prior to the date of registration. 
b. Non-invasive diseases such as low risk cervical cancer or any cancer in situ. 
c. Localized (early stage) cancer treated with curative intent (without evidence of 
recurrence and intent for further therapy), and in which no systemic chemotherapy was 
indicated (e.g. low/intermediate risk prostate cancer, etc.). Patients with other 
malignancies not meeting these criteria must be discussed with PrECOG prior to 
registration. 
3.15 
Patients may not have received any prior immune checkpoint inhibitor (i.e. anti-KIR, anti-
PD-1, anti-PD-L1, or other). 
3.16 
Patients may not have undergone major surgery (e.g. intra-thoracic, intra-abdominal or 
intra-pelvic), open biopsy or significant traumatic injury or specific anti-cancer treatment ≤ 4 
weeks prior to starting study drug, or patients who have had percutaneous biopsies or 
placement of vascular access device ≤ 1 week prior to starting study drug, or who have not 
recovered from side effects of such procedure or injury. 
3.17 
Patients must not have clinically significant cardiac diseases, including any of the following: 
a. History or presence of serious uncontrolled ventricular arrhythmias. 
b. Clinically significant resting bradycardia. 
c. Any of the following within 3 months prior to starting study drug: myocardial infarction 
(MI), severe/unstable angina, Coronary Artery Bypass Graft (CABG), Congestive Heart 
Failure (CHF), Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA). 
d. Uncontrolled hypertension defined by a SBP ≥ 160 mm Hg and/or DBP ≥ 100 mm Hg, 
with or without anti-hypertensive medication(s). 
3.18 
Patients may not have chronic active liver disease or evidence of acute or chronic Hepatitis 
B Virus (HBV) or Hepatitis C (HCV). 
3.19 
Patients may not have known diagnosis of human immunodeficiency virus (HIV) infection. 
Testing is not required in absence of clinical suspicion. 
3.20 
Patients may not have known diagnosis of any condition (e.g. post-hematopoietic or solid 
visceral organ transplant, pneumonitis, inflammatory bowel disease, etc.) that requires 
chronic immunosuppressive therapy. Usage of non-steroidal anti-inflammatory medications 
(NSAIDS) for the treatment of osteoarthritis and uric acid synthesis inhibitors for the 
treatment of gout are permitted. For questions, please consult PrECOG. 
 
 
_____ 
_____ 
_____ 
_____ 
_____ 
_____ 
_____ 
_____ 
_____ 


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3.21 
Patients with any serious and/or uncontrolled concurrent medical conditions (e.g. active or 
uncontrolled infection, uncontrolled diabetes) or psychiatric illness that could, in the 
investigator’s opinion, cause unacceptable safety risks or potentially interfere with the 
completion of the treatment according to the protocol are not eligible. 
3.22 
Patients may not have any live viral vaccine used for prevention of infectious diseases within 
4 weeks prior to study drug(s). 
3.23 
Patients unwilling or unable to comply with the protocol. 
3.24 
Patients with a known allergy to any of the study medications, their analogues, or excipients 
in the various formulations of any agent are not eligible. 
3.25 
Patients may not participate in any other therapeutic clinical trials, including those with other 
investigational agents not included in this trial throughout the duration of this study. 
_____ 
_____ 
_____ 
_____ 
_____ 


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4. 
Registration Procedures 
4.1 
Ethics 
This study will be conducted in accordance with the ethical principles that have their origin 
in the current Declaration of Helsinki and will be consistent with applicable US regulatory 
requirements and International Conference on Harmonization/Good Clinical Practice 
(ICH/GCP). 
The study will be conducted in compliance with the protocol. The protocol and any 
amendments and the patient informed consent will receive Institutional Review Board (IRB) 
approval prior to initiation of the study. 
Freely given written informed consent must be obtained from every patient or their legally 
authorized representative prior to clinical trial participation, including informed consent for 
any screening procedures conducted to establish patient eligibility for the trial. 
Study personnel involved in conducting this trial will be qualified by education, training, and 
experience to perform their respective task(s). This trial will not use the services of 
investigators or study personnel where sanctions have been invoked or where there has 
been scientific misconduct or fraud (e.g., loss of medical licensure, debarment). 
Investigators are responsible for the conduct of the study at their study site. 
4.2 
Regulatory Requirements 
Before a site may enter patients, protocol-specific regulatory and other documents must be 
submitted to PrECOG as noted in study materials. Detailed information regarding document 
submission and control is provided to each site in separate study materials. 
Once required documents are received, reviewed, and approved by PrECOG or their 
representative, a Study Reference Manual (SRM) will be forwarded to the site. Any changes 
to site regulatory documents must be submitted by the investigator to the responsible party 
in a timely manner. Initial study drug shipment will not occur until the regulatory packet is 
complete. No patients will begin protocol therapy without formal registration as per the 
process below. 
4.3 
Phase Ib Patient Registration 
Patients must not start protocol treatment prior to registration. 
Patients must meet all of the eligibility requirements listed in Section 3 prior to registration. 
An eligibility checklist is included in Section 3. A confirmation of eligibility assessment by 
the investigator and/or site will be performed during the registration process. 
Upon determination that a subject meets eligibility criteria, the subject will be registered in 
the study by site personnel via an electronic data capture (eDC) system. 
NOTE: The local site pathologist will be asked to estimate and record the rough 
approximate percentage of viable tumor in the TURBT sample (initial or repeat TURBT 
with highest tumor content) to document at least 20% viable tumor content prior to 
registration. This is to ensure adequate tissue is available to perform tumor 
infiltrating CD8+ T-cell assessment. (The actual CD8+ T-analysis will be done by a 
Central Laboratory and will not be done prior to registration.) 
Neoadjuvant treatment should begin ≤ 10 working days from date of registration. Please 
note neoadjuvant treatment must also start within 10 weeks of the most recent TURBT that 
showed muscularis propria invasion. 
Full information regarding registration procedures and guidelines can be found in the SRM 
provided to your site. Correspondence regarding patient registration must be kept in the 
study records. 


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4.4 
Research Tissue, Blood, and Urine Samples 
Mandatory tumor tissue samples are required at baseline and from radical cystectomy. 
Mandatory peripheral blood and urine samples will also be collected. 
Time points for tissue, blood, and urine samples are outlined in the study parameters 
(Section 11) and specific requirements are outlined in the correlative section of this protocol 
(Section 14) and the lab manual. 


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5. 
Study Design 
This is a Phase Ib open-label clinical trial for patients that are either cisplatin-ineligible or refuse 
cisplatin-based chemotherapy and have MIBC (T2-T4a, N0-N1, M0). Patients will be sequentially 
enrolled first into Cohort 1 treated with nivolumab alone (N=12). In the absence of the occurrence 
of high rate of treatment related AEs as defined in Section 5.4 and 13.1.1 with neoadjuvant 
nivolumab treatment, the study will proceed with enrollment into Cohort 2 of neoadjuvant treatment 
with combination nivolumab/lirilumab. (In both cohorts, neoadjuvant treatment must start within 10 
weeks of transurethral resection of the most recent TURBT that showed muscularis propria 
invasion). Each group will receive a total of 4 weeks (week 0 and 4) of neoadjuvant therapy followed 
by radical cystectomy (RC) with bilateral (standard or extended) pelvic lymph node dissection 
(PLND). 
The RC with bilateral (standard or extended) PLND will occur as soon as possible but within 6 weeks 
after the last neoadjuvant dose in either cohort. 
5.1 
Number of Patients 
The study will aim to screen 43 eligible patients in order to enroll 36 patients in the trial 
(assuming about 20% tumor tissue assessment screen failure rate). Estimate at least 2-3 
patients per month at approximately 8 sites. The estimated time for accrual completion will 
be approximately 18 months. 
5.2 
Replacement of Patients 
A patient will be replaced if following TURBT and registration into the study, they do not 
meet any of the following criteria: 
• 
Begin neoadjuvant therapy within 10 weeks of the most recent TURBT that showed 
muscularis propria invasion 
• 
Receive at least one study treatment dose (nivolumab alone or nivolumab and 
lirilumab) 
• 
Adequate (at least 20%) viable tumor content in any TURBT 
5.3 
Expected Duration of Treatment and Patient Participation 
Following registration, patients in each group will receive a total of 4 weeks of neoadjuvant 
therapy followed by RC with bilateral (standard or extended) PLND as soon as possible but 
within 6 weeks of the completion of neoadjuvant therapy. 
Off treatment visit will occur approximately 30 days following cystectomy (if cystectomy is 
not performed, Off Treatment visit should be performed at next scheduled appointment or 
treating physician discretion, as clinically indicated) and patients will be followed for 100 
days after neoadjuvant treatment for AEs. Adverse events may be reviewed at the next visit 
≥ 100 days after last dose of neoadjuvant therapy or phone follow-up may be done to review 
adverse events. 
Patients will be followed clinically and radiographically for at least 2 years post-cystectomy 
or when study-wide follow-up ends per standard of care. Date of diagnosis for progression, 
first subsequent therapy and survival shall be reported. Phone follow-up may also be done 
for patients unable or unwilling to return for follow-up evaluations. 
5.4 
Interim Safety Analysis 
After 6 and 12 patients on Cohort 1 and 6 patients on Cohort 2 complete surgery, the study 
will be monitored for nivolumab or nivolumab/lirilumab treatment-related toxicities as noted 
below. 
• 
Any Grade hypophysitis, meningitis, or immune-related neurologic AEs 


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• 
Grade 2 or higher myocarditis 
• 
Persistent Grade 2 immunologic AEs (such as colitis, pneumonitis, and nephritis) that 
do not recover to Grade 1 or resolve within 6 weeks after the last dose of study drug 
(Exceptions: rash, fatigue, amylase/lipase elevations, other electrolyte abnormalities). 
• 
Grade 3 or higher immunologic AEs such as uveitis, pericarditis, hepatitis, 
colitis/diarrhea, nephritis, pancreatitis, myositis, endocrine, rash, etc., except Grade 3 
hypothyroidism or Grade 3 infusion reaction. 
• 
Grade 4 non immunologic AEs, as well as Grade 4 hypothyroidism or Grade 4 infusion 
reaction. 
There will be no suspension to accrual after the first 6 patients in each cohort. Also, accrual 
will start on Cohort 2 once accrual to Cohort 1 is complete (unless needed based on toxicity 
noted). 
If 3 or more of these 6 patients on a single cohort experience nivolumab or nivolumab/ 
lirilumab treatment-related adverse events as noted above, the study will be suspended for 
a safety review. 


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6. 
Treatment Plan 
6.1 
Overview 
No investigational or commercial agents or therapies other than those described below may 
be administered with the intent to treat the subject's malignancy. 
Neoadjuvant treatment must start within 10 weeks of transurethral resection of the most 
recent bladder tumor (TURBT) that showed muscularis propria invasion. 
Patients enrolled in the trial will be administered one of two of the following treatment 
regimens: 
Cohort 1: Nivolumab 480 mg IV over approximately 30 minutes every 4 weeks for 2 neo-
adjuvant doses (week 0 and 4) followed by radical cystectomy (RC) with bilateral (standard 
or extended) pelvic lymph node dissection (PLND) as soon as possible but within 6 weeks 
after the last neoadjuvant infusion. 
Cohort 2: Nivolumab 480 mg intravenously (IV) over approximately 60 minutes every 4 
weeks for 2 neo-adjuvant doses (week 0 and 4) with at least a 30 minute rest between 
infusions followed by lirilumab 240 mg IV over approximately 60 minutes every 4 weeks for 
2 neo-adjuvant doses (week 0 and 4) followed by RC with bilateral (standard or extended) 
PLND as soon as possible but within 6 weeks after the last neoadjuvant infusion. 
NOTE: A few mild infusion reactions occurred on Cohort 2 with the nivolumab infusion, 
requiring only steroids and resuming dose at 50%. Infusion time increased to 60 minutes 
per package insert guidelines. 
6.1.1 
Nivolumab Administration 
Cohort 1 
Neoadjuvant Dose: Subjects will receive nivolumab 480 mg IV over approximately 
30 minutes for a total of 2 doses on week 0 and 4. 
Nivolumab is to be administered as an approximately 30 minute IV infusion, using 
a volumetric pump with a 0.2/0.22 micron in-line filter. It is not to be administered 
as an IV push or bolus injection. Nivolumab infusion will be followed by at least a 
30 minute rest before lirilumab infusion is given. 
Cohort 2 
Neoadjuvant Dose: Subjects will receive nivolumab 480 mg IV over approximately 
60 minutes for a total of 2 doses on week 0 and 4. 
Nivolumab is to be administered as an approximately 60 minute IV infusion, using 
a volumetric pump with a 0.2/0.22 micron in-line filter. It is not to be administered 
as an IV push or bolus injection. Nivolumab infusion will be followed by at least a 
30 minute rest before lirilumab infusion is given. 
Refer to Section 12 for further handling and stability information. 
6.1.2 
Lirilumab Administration 
Cohort 1 
Subjects will not receive lirilumab. 
Cohort 2 
Neoadjuvant Dose: Subjects will receive lirilumab 240mg IV over 60 approximately 
minutes for a total of 2 doses on week 0 and 4. 


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Lirilumab is to be administered as an approximately 60 minute IV infusion, using a 
volumetric pump through a non-di-2-ethylhexyl phthalate (DEHP) or DEHP IV 
infusion set with a 0.2-micron polyethersulfone in-line filter. It is not to be 
administered as an IV push or bolus injection. 
Refer to Section 12 for further handling and stability information. 
6.1.3 
Name of Other Modality or Procedures 
All patients enrolled in this trial will undergo a RC with bilateral (standard or 
extended) PLND as soon as possible but within 6 weeks of the last dose of 
neoadjuvant therapy as outlined above. 


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7. 
Dose Delays 
All toxicities should be graded according to the National Cancer Institute (NCI) Common 
Terminology Criteria for Adverse Events Version 5.0 (CTCAE V5.0). A copy of the CTCAE 
V5.0 can be downloaded from the CTEP website (http://www.ctep.cancer.gov). 
A +/-3 day window is allowed for scheduled therapy, required tests and/or visits except as otherwise 
noted. Delays due to holidays, weekends, bad weather or other unforeseen circumstances will be 
permitted. 
Dose delays are not required for adverse events not deemed to be related to study treatment (i.e. 
events due to underlying disease) or for laboratory abnormalities not deemed to be clinically 
significant. Treat accordingly per institutional standards. 
Any patient who cannot receive study therapy within 6 weeks from the previous dose in either cohort, 
will be permanently discontinued, except as noted below. 
NO dose modifications will be allowed. 
7.1 
Dose Delays for Treatment Related Hematological Toxicity 
7.1.1 
Grade 1 and Grade 2 Toxicities 
No dose interruptions will be performed for Grade 1 or 2 hematologic toxicities. 
7.1.2 
Grade 3 Toxicities 
Study therapy will be permanently discontinued for Grade 3 drug-related 
thrombocytopenia >7 days or associated with bleeding. 
If the patient experiences other Grade 3 treatment related hematologic toxicity in 
either study cohort, all study therapy must be withheld until the toxicity has resolved 
to ≤ Grade 1. If the Grade 3 toxicity does not resolve to ≤ Grade 1 within 21 days, 
all study therapy will be permanently discontinued. 
7.1.3 
Grade 4 Toxicities 
If the patient experiences Grade 4 treatment related hematologic toxicity in either 
study cohort, all study therapy must be permanently discontinued regardless of 
the time to resolution ≤ Grade 1. 
7.2 
Dose Delays for Treatment Related Non-Hematological Toxicity 
See Appendix III for Management Algorithms for Endocrinopathy, Gastrointestinal, 
Hepatic, Neurological, Pulmonary, Renal, and Skin Adverse Events. 
7.2.1 
Grade 1 and Grade 2 Toxicities 
No dose interruptions will be performed for Grade 1 or 2 non-hematologic toxicities, 
except for: 
• 
Any grade hypophysitis, meningitis, immune-related neurological AEs 
• 
Any Grade 2 drug-related uveitis, eye pain, or blurred vision that does not 
respond to topical therapy and does not improve to Grade 1 severity within the 
retreatment period OR requires systemic treatment will require permanent 
discontinuation. 
• 
Colitis (Grade 2) 
• 
AST, ALT, bilirubin (Grade 2) 
• 
Pneumonitis (Grade 2) 
• 
Nephritis (Grade 2) 


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• 
Infusion reaction that does not resolve within an hour of stopping infusion 
(Section 7.3 for Infusion Reaction Guidelines), or 
• 
Other intolerable or persistent Grade 2 drug-related AE, as per physician 
discretion. 
Discontinue treatment for persistent Grade 2 immunologic AEs (such as colitis, 
pneumonitis, and nephritis) that do not recover to Grade 1 or resolve within 6 weeks 
after the last dose of study drug (Exceptions: rash, fatigue, amylase/lipase 
elevations, other electrolyte abnormalities). 
In addition, discontinue treatment for persistent Grade 2 ALT, AST, or bilirubin that 
do not recover to Grade 1 or resolve within 6 weeks after the last dose of study 
drug. A thorough investigation of the cause of the ALT, AST, or total bilirubin 
elevation is recommended including the exclusion of other causes – e.g. concurrent 
medications, infection, injury, hypo-perfusion, and alcohol consumption. Close 
monitoring of hepatic labs at least weekly and consideration of imaging such as 
ultrasound of the liver is suggested. 
7.2.2 
Grade 3 Toxicities 
Subjects will be required to permanently discontinue all study drugs for the following 
AEs: 
• 
Any Grade 3 non-skin, drug-related AE lasting >7 days or recurs, with the 
following clarifications: 
o 
Grade 3 drug-related uveitis, pneumonitis, myocarditis, bronchospasm, 
hypersensitivity reaction, or infusion reaction of any duration requires 
discontinuation. 
o 
Grade 3 drug-related endocrinopathies, adequately controlled with only 
physiologic hormone replacement, do not require discontinuation. Adrenal 
insufficiency requires discontinuation regardless of control with hormone 
replacement. 
o 
Grade 3 drug-related laboratory abnormalities do not require treatment 
discontinuation except: 
 
Grade ≥ 3 drug-related AST, ALT, or total bilirubin 
 
Concurrent AST or ALT >3x ULN and total bilirubin >2x ULN 
For any other Grade 3 treatment related non-hematologic toxicities, if the Grade 3 
toxicity does not resolve to ≤ Grade 1 within 21 days, all study therapy will be 
permanently discontinued. 
7.2.3 
Grade 4 Toxicities 
If the patient experiences Grade 4 treatment related non-hematologic toxicity in 
either study cohort, all study therapy must be permanently discontinued 
regardless of the time to resolution ≤ Grade 1 with the exception of the following 
instances: 
• 
Grade 4 nausea or emesis which resolves to ≤ Grade 1 within 7 days of optimal 
anti-emetic therapy. 
• 
Grade 4 endocrinopathies that can be mitigated with endocrine replacement 
with resolution to ≤ Grade 1 within 7 days of initiating endocrine replacement 
therapy (i.e. hypothyroid, etc.). 


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7.3 
Infusion Reaction Guidelines 
Since nivolumab and lirilumab contain only human immunoglobulin protein sequences, each 
is unlikely to be immunogenic and induce an infusion or hypersensitivity reaction. However, 
if such a reaction were to occur, it might manifest with fever, chills, rigors, headache, rash, 
pruritus, arthralgias, hypo- or hypertension, bronchospasm, or other symptoms. All Grade 3 
or 4 infusion reactions should be reported within 24 hours to PrECOG and reported as a 
serious adverse event (SAE) if criteria are met. Infusion reactions should be graded 
according to NCI CTCAE (Version 5.0) guidelines. Treatment recommendations are 
provided below and may be modified based on local treatment standards and guidelines as 
appropriate: 
• 
For Grade 1 symptoms (Mild reaction; infusion interruption not indicated; intervention 
not indicated): 
Remain at bedside and monitor subject until recovery from symptoms. The following 
prophylactic pre-medications are recommended for future infusions: diphenhydramine 
50 mg (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen) at least 30 
minutes before additional nivolumab or lirilumab administrations. 
• 
For Grade 2 symptoms (Moderate reaction requires therapy or infusion interruption but 
responds promptly to symptomatic treatment [e.g., antihistamines, non-steroidal anti-
inflammatory drugs, narcotics, corticosteroids, bronchodilators, IV fluids]; prophylactic 
medications indicated for ≤ 24 hours): 
Stop the nivolumab or lirilumab infusion, begin an IV infusion of normal saline (NS), and 
treat the subject with diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 
to 1000 mg (acetaminophen); remain at bedside and monitor subject until resolution of 
symptoms. Corticosteroid or bronchodilator therapy may also be administered as 
appropriate. If the infusion is interrupted, restart the infusion at 50% of the original 
infusion rate when symptoms resolve; if no further complications ensue after 30 
minutes, the rate may be increased to 100% of the original infusion rate. Monitor subject 
closely. If symptoms recur then no further nivolumab or lirilumab will be administered at 
that visit. Administer diphenhydramine 50 mg IV, and remain at bedside and monitor 
the subject until resolution of symptoms. The amount of study drug infused must be 
recorded on the electronic case report form (eCRF). The following prophylactic pre-
medications are recommended for future infusions: diphenhydramine 50 mg (or 
equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen) should be 
administered at least 30 minutes before additional nivolumab or lirilumab 
administrations. If necessary, corticosteroids (recommended dose: up to 25 mg of IV 
hydrocortisone or equivalent) may be used. 
• 
For Grade 3 or Grade 4 symptoms (Severe reaction, 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 ventilator support indicated): 
Immediately discontinue infusion of nivolumab or lirilumab. Begin an IV infusion of NS, 
and treat the subject as follows. Recommend bronchodilators, epinephrine 0.2 to 1 mg 
of a 1:1,000 solution for subcutaneous administration or 0.1 to 0.25 mg of a 1:10,000 
solution injected slowly for IV administration, and/or diphenhydramine 50 mg IV with 
methylprednisolone 100 mg IV (or equivalent), as needed. Subject should be monitored 
until the investigator is comfortable that the symptoms will not recur. Nivolumab or 
lirilumab will be permanently discontinued. Investigators should follow their institutional 
guidelines for the treatment of anaphylaxis. Remain at bedside and monitor subject until 
recovery from symptoms. In the case of late-occurring hypersensitivity symptoms (e.g., 


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appearance of a localized or generalized pruritus within 1 week after treatment), 
symptomatic treatment may be given (e.g., oral antihistamine, or corticosteroids). 
7.4 
Concurrent Therapies 
7.4.1 
Required and/or Permitted 
The following medications and procedures are permitted during the study: 
• 
Anti-emetic medications (with the exception of dexamethasone and/or other 
steroids) are permitted at the treating physician’s discretion. 
• 
Subjects are permitted the use of topical, ocular/auricular, intra-articular, 
intranasal, inhalational steroids, also systemic steroid dose of oral prednisone 
≤10 mg daily or equivalent, as well as any adrenal replacement steroid dose all 
in the absence of active autoimmune disease. 
• 
Colony 
stimulating 
growth 
factors 
(i.e. 
erythropoietin, 
darbepoetin, 
pegfilgrastim) are permitted at the treating physician’s discretion. Their use 
should follow American Society of Clinical Oncology (ASCO) guidelines and/or 
label indications/institutional practice. 
• 
Patients should be transfused with red cells and platelets as clinically indicated 
and according to institutional guidelines. However, transfusions may not be 
used to satisfy inclusion criteria for study entry. 
• 
Treatment with full-dose anticoagulation therapy (i.e. warfarin, enoxaparin, 
rivaroxaban, etc.) are permitted at the treating physician’s discretion. 
• 
Supportive measures consistent with optimal patient care may be given 
throughout the study. 
7.4.2 
Prohibited and/or Restricted Treatments 
• 
Immunosuppressive agents are prohibited during the study, unless they are 
utilized to treat an adverse event or as outlined in Section 7.4.1. NSAIDs for 
treatment of osteoarthritis and allopurinol to prevent gout flares is allowed. 
• 
Concurrent administration of any anti-cancer therapies (investigational or 
approved) are also prohibited with the exception of subjects in the follow-up 
period of the study. 
• 
Any medicinal herbal preparation unless prescribed by the treating physician. 
All concomitant medications including prescribed medicinal herbal preparations 
must be documented. 
• 
G-CSF (granulocyte-colony stimulating factor) will be permitted. However, the 
use 
of 
these 
agents 
is 
allowed 
as 
per 
their 
respective 
label 
indications/institutional guidelines to treat neutropenia that occurs on study. G-
CSF must not be used for the treatment of cancer or for any primary prophylaxis 
while on study. 
7.4.3 
Other Restrictions and Precautions 
• 
Any non-oncology live viral vaccine therapies used for the prevention of 
infectious diseases within 4 weeks prior to study drug is prohibited. The use of 
the killed/inactivated vaccines, e.g. seasonal influenza vaccine will be permitted 
on study without restriction. 
• 
Alcohol consumption while on study is strongly discouraged due to the potential 
to confound interpretation of hepatotoxic events. 
 


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8. 
Study Duration and Discontinuation of Therapy 
8.1 
Study Duration 
Patients will receive protocol therapy unless: 
1. Disease progression per RECIST Version 1.1 criteria or clinical progression. 
2. Toxicities considered unacceptable by either the patient or the investigator, despite 
optimal supportive care and dose delays. 
3. Any requirement to discontinue based on dose delay guidelines in Section 7.1, Section 
7.2, infusion reaction guidelines in Section 7.3 and Appendix III. 
4. Development of an inter-current illness that prevents further administration of study 
treatment. 
5. Extraordinary Medical Circumstances: If at any time the constraints of this protocol are 
detrimental to the patient's health, protocol treatment should be discontinued. 
6. Patient withdraws consent or is unable to comply with study procedures. 
8.2 
Duration of Follow-Up 
Patients will be followed for adverse events for 100 days after their last dose of neoadjuvant 
treatment. Adverse events may be reviewed at the next visit ≥ 100 days after last dose of 
neoadjuvant therapy or phone follow-up may be done to review adverse events. However, 
if a patient experiences an adverse event >100 days after their last dose of study medication 
that is felt to be, in the opinion of the investigator, possibly, probably or definitely related to 
study therapy, the adverse event should be reported. 
Patients will be followed clinically and radiographically per standard of care (3 -6 months) at 
the discretion of the treating physician for at least 2 years post-cystectomy or when study-
wide follow-up ends. Date of diagnosis for progression, first subsequent therapy and survival 
shall be reported. Phone follow-up may also be done for patients unable or unwilling to 
return for follow-up evaluations. 
If a patient is removed from treatment for reason(s) other than progression, follow with 
regular tumor assessments per standard of care until progression or start of new treatment. 
For patients who are registered but do not receive any protocol therapy, baseline and follow-
up information per Section 11 will be collected. 
8.3 
Criteria for Removal from Study Treatment 
A genuine effort will be made to determine the reason(s) why a patient fails to return for the 
necessary visits or is discontinued from the trial, should this occur. It will be documented 
whether or not each patient completed the clinical study. If for any patient study treatment 
or observations were discontinued, the reason will be recorded on the appropriate eCRF. 
Reasons that a patient may discontinue treatment in a clinical study are considered to 
constitute one of the following: 
1. Completion of all study therapy and follow-up. 
2. Recurrence of disease or documented progression of disease. 
3. Intercurrent illness that prevents further administration of treatment per investigator 
discretion. 
4. Unacceptable adverse events. 
5. Investigator and/or patient discontinue study therapy. 
6. Pregnancy. 


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7. Develops a second malignancy (except low risk cervical cancer or cancer in-situ) that 
requires treatment, which would interfere with this study. 
8. The patient may choose to withdraw from the study at any time for any reason. 
9. General or specific changes in the patient's condition that render the patient 
unacceptable for further treatment in the judgment of the investigator. 
10. Severe non-compliance to protocol as judged by the investigator. 
11. Lost to follow-up. 
12. Death. 
13. Closure of study by PrECOG. 
Any patient who receives at least one dose of nivolumab or lirilumab will be included in the 
safety analysis. Patients who discontinue study treatment early should be followed for 
response assessments, if possible. Follow-up will continue per Section 11, as applicable. 


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9. 
Adverse Event Reporting 
9.1 
Collection of Safety Information 
Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of 
a pre-existing medical condition in a patient administered a medicinal product in a clinical 
investigation and which does not necessarily have a causal relationship with this treatment. 
An AE can therefore be any unfavorable and unintended sign (e.g., including an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of a product 
(investigational or marketed), whether or not considered related to the product 
(investigational or marketed). 
After informed consent, but prior to initiation of study treatment (nivolumab and lirilumab), 
only AEs/SAEs caused by a protocol-mandated intervention will be collected (e.g., SAEs 
related to invasive procedures such as biopsies). After the initiation of study treatment, all 
identified AEs and SAEs must be recorded and described on the appropriate page of the 
electronic Case Report Form (eCRF). If known, the diagnosis of the underlying illness or 
disorder should be recorded, rather than individual symptoms. The following information 
should be documented for all AEs: date of onset and resolution, severity of the event; the 
investigator’s opinion of the relationship to investigational product (see definitions below); 
treatment required for the AE treatment required for the AE; cause of the event (if known); 
and information regarding resolution/outcome. 
Only clinically significant laboratory abnormalities that require active management will be 
recorded as AEs or SAEs on the eCRF (e.g., abnormalities that require study drug dose 
delay, discontinuation of study treatment, more-frequent follow-up assessments, further 
diagnostic investigation, etc.). 
If the clinically significant laboratory abnormality is a sign of a disease or syndrome (e.g., 
alkaline phosphatase and bilirubin 5x the ULN associated with cholecystitis), only the 
diagnosis (e.g., cholecystitis) needs to be recorded on the Adverse Event eCRF. 
If the clinically significant laboratory abnormality is not a sign of a disease or syndrome, the 
abnormality itself should be recorded as an AE or SAE on the eCRF. If the laboratory 
abnormality can be characterized by a precise clinical term, the clinical term should be 
recorded as the AE or SAE. For example, an elevated serum potassium level of 7.0 mEq/L 
should be recorded as “hyperkalemia”. 
Observations of the same clinically significant laboratory abnormality from visit to visit 
should not be repeatedly recorded as AEs or SAEs on the eCRF unless their severity, 
seriousness, or etiology changes. 
Severity 
The categories and definitions of severity used for clinical trials AEs are defined in the NCI’s 
Common Terminology Criteria (CTCAE) V5.0 (http://www.ctep.cancer.gov). 
Attribution 
The following categories and definitions of causal relationship or attribution to study drug 
should be used to assess Adverse Events: 
• Definite: There is a reasonable causal relationship between the study drug and the event. 
The event response to withdrawal of study drug (dechallenge) and recurs with 
rechallenge, if clinically feasible. 
• Probable: There is a reasonable causal relationship between the study drug and the 
event. The event responds to dechallenge. Rechallenge is not required. 
• Possible: There is a reasonable causal relationship between the study drug and the 
event. Dechallenge information is lacking or unclear. 


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• Unlikely: There is doubtful causal relationship between the study drug and the event. 
• Unrelated: There is clearly not a causal relationship between the study drug and the 
event or there is a causal relationship between another drug, concurrent disease, or 
circumstances and the event. 
Categories ‘definite’, ‘probable’ and ‘possible’ are considered study drug related. Categories 
‘unlikely’ and ‘unrelated’ are considered not study drug-related. 
The development of a new cancer should be regarded as an AE. New cancers are those 
that are not the primary reason for administration of study treatment and have been 
identified after inclusion of the patient into the clinical study. 
AEs related to nivolumab and lirilumab should be followed for 100 days after last 
dose of study therapy until ≤ grade 1 or stabilization, and reported as SAEs if they 
become serious. Any AE’s (serious or not) that occur more than 100 days after the 
last dose of study therapy but that are deemed to be at least possibly related to study 
therapy shall be reported. 
9.2 
Handling of Serious Adverse Events (SAEs) 
9.2.1 
SAE Definitions 
A serious AE is any untoward medical occurrence occurring after initiation of study 
treatment or that at any dose: 
• 
results in death 
• 
is life-threatening (defined as an event in which the study patient 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 
• 
results in persistent or significant disability/incapacity 
• 
is a congenital anomaly/birth defect 
• 
is suspected transmission of an infectious agent (e.g., pathogenic or 
nonpathogenic) via the study drug 
• 
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 patient or may 
require intervention (e.g., 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. 
9.3 
SAE Reporting Requirements 
Serious adverse events (SAE) are defined above. The investigator should inform PrECOG 
of any SAE within 24 hours of being aware of the event. The date of awareness should be 
noted on the report. This must be documented on the PrECOG SAE form. This form must 
be completed and supplied to PrECOG within 24 hours/1 business day at the latest on the 
following working day. The initial report must be as complete as possible, including details 
of the current illness and (serious) adverse event, and an assessment of the causal 
relationship between the event and the investigational product(s). Information not available 
at the time of the initial report (e.g., an end date for the adverse event or laboratory values 
received after the report) must be documented on a follow-up PrECOG SAE report form. A 
final report to document resolution of the SAE is required. The investigator is responsible 


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for following all SAEs until resolution, until the subject returns to baseline status, or until the 
condition has stabilized with the expectation that it will remain chronic, even if this extends 
beyond study participation. A copy of the transmission confirmation of the SAE report to 
PrECOG should be attached to the SAE and retained with the patient records. 
SAEs should be scanned and emailed to PrE0807SAE@qdservices.com as per the 
instructions found in study materials provided to the investigator site. 
 
Medical Monitor 
During normal business hours  
(8:30 am-5:00 pm EST): 
Phone: 610-354-0404 
After normal business hours: 
Phone: 484-574-2367 
Email: 
 
Manager, Clinical Safety 
During normal business hours  
(8:30 am-5:00 pm EST): 
Phone: 610-354-0404 
After normal business hours: 
Cell: 484-574-2367 
PrECOG will notify BMS or designee of all SAE’s within 24 hours of PrECOG’s & 
Investigator’s Awareness Date as discussed above. Relevant follow-up information will be 
provided to BMS as soon as it becomes available. In addition, every 3 months PrECOG will 
send BMS a listing of all non-serious events (only adverse events not previously submitted). 
Investigators should also report event(s) to their IRB as required. 
Collection of complete information concerning SAEs is extremely important. Full 
descriptions of each event will be followed. Thus, follow-up information which becomes 
available as the SAE evolves, as well as supporting documentation (e.g., hospital discharge 
summaries and autopsy reports), should be collected subsequently, if not available at the 
time of the initial report, and immediately sent using the same procedure as the initial SAE 
report. 
All SAEs, regardless of causality, must be collected which occur within 100 days of last dose 
of study treatment. This includes all deaths within 100 days of last dose of nivolumab and/or 
lirilumab regardless of attribution. In addition, the Investigator should notify PrECOG or 
designee of any SAE that may occur after this time period which they believe to be definitely, 
probably or possibly related to investigational product. 
NOTE: After study closure, study-drug related SAEs should be reported voluntarily by the 
treating physician to the manufacturer. 
Serious adverse event reporting to regulatory authorities and all participating investigators 
will be conducted by PrECOG (or designee) in accordance with 21CFR312.32, local 
requirements and international regulations, as appropriate. FDA reporting requirement 
timelines will be followed. PrECOG will also concurrently forward any such reports to BMS. 
9.4 
Potential Drug-Induced Liver Injury 
All occurrences of potential drug-induced liver injury, meeting the defined criteria below, 
must be reported as SAEs. 
• 
ALT or AST elevation >3 times upper limit of normal (ULN) 
AND 
• 
Total bilirubin >2 times ULN, without initial findings of cholestasis (elevated serum 
alkaline phosphatase) 
AND 
• 
No other immediately apparent possible causes of ALT or AST 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. 


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9.5 
Reporting of Other Second Primary Cancers 
New cancers are those that are not the primary reason for administration of study treatment 
and have been identified after inclusion of the patient into the clinical study. 
All cases of new primary cancers that occur during or after protocol treatment must be 
reported to PrECOG on a Second Primary Cancer form within 30 days of diagnosis, 
regardless of relationship to protocol treatment. Secondary primary malignancies should 
also be reported as a SAE. The SAE form is not for use for reporting recurrence or 
development of metastatic disease. A copy of the pathology report, if applicable, should be 
sent, if available. 
NOTE: Once data regarding survival and remission status are no longer required by the 
protocol, no follow-up data should be submitted. 
9.6 
Procedures in Case of Pregnancy 
Prior to study registration, women of childbearing potential (WOCBP) and male patients with 
a female partner of childbearing potential must be advised of the importance of avoiding 
pregnancy during trial participation and the potential risk factors for an unintentional 
pregnancy, documented in the informed consent. In addition, all WOCBP should be 
instructed to contact the Investigator immediately if they suspect they might be pregnant 
(e.g., missed or late menstrual period) at any time during study participation. 
Pregnancy of a female patient or the female partner of a male patient occurring while the 
patient is receiving study drug or within 5 months after a female patient’s last dose of study 
drug or 7 months for the female partner of a male patient’s last dose of study drug will be 
reported to PrECOG on a SAE Form within 24 hours of the investigator’s knowledge of the 
pregnancy. 
All reports of congenital abnormalities/birth defects and spontaneous miscarriages should 
also be reported and handled as SAEs. Elective abortions without complications should not 
be handled as AEs. 
The outcome of all pregnancies (spontaneous miscarriage, elective termination, normal 
birth including health of the newborn or congenital abnormality) must be followed and 
documented on the Pregnancy Form even if the subject was discontinued from the study 
treatment. Should pregnancy occur during a subject’s participation, the subject will 
immediately be discontinued from the treatment and followed per protocol. 
The SAE Form can be found in the Study Reference Manual. A study specific Pregnancy 
Form will also be completed. 
9.7 
Reporting Guidelines in the Case of Overdose 
Any overdose of a study subject with nivolumab and/or lirilumab, with or without associated 
AEs/SAEs, is required to be reported within 24 hours of knowledge of the event to PrECOG. 
If the overdose results in an AE, the AE must also be recorded as an AE. Overdose does 
not automatically make an AE serious, but if the consequences of the overdose are serious, 
for example death or hospitalization, the event is serious and must be recorded and reported 
as an SAE. There is currently no specific treatment in the event of an overdose of nivolumab 
and/or lirilumab. 


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10. 
Measurement of Effect 
Patients should be evaluated for pathologic tumor response at post-treatment radical cystectomy 
time point. Progression will be evaluated in this study using the new international criteria proposed 
by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline Version 1.1 
(Appendix IV).46 RECIST response assessments will be performed locally for the trial. 
10.1 
Evaluable Population Definitions 
Evaluable for Toxicity: All patients will be evaluable for toxicity from the time of their first 
treatment with nivolumab and/or lirilumab. 
Evaluable for Tumor Response: Only those patients who have received at least one dose 
of therapy, and undergo radical cystectomy will be considered evaluable for tumor response. 
These patients will have their tumor response classified according to the definitions stated 
below. (NOTE: Patients who exhibit objective disease progression prior to the end of 
treatment will also be considered evaluable.) 
10.2 
CD8+ T-Cell Density 
The CD8+ T-cell density is defined as the number of CD8+ tumor-infiltrating T-cells per 100 
tumor cells within a 400x high power field (HPF). The CD8+ T-cell density will be calculated 
as: 
Tumor Infiltrating CD8+ T-cell density (CD8+ T-cells per 100 tumor cells) = 
(Total # of CD8+ TILS)/ (Total # of tumor cells per HPF) x 100 
Five representative tumor fields with the greatest gross tumor infiltrating lymphocyte fields 
(minimum 100 tumor cells per representative field) will be chosen for measurement by 
microscope analysis by the pathologist with the final CD8+ T-cell density determined as the 
mean of the CD8+ T-cell density across the five fields. 
10.3 
%CD8+ Tumor-Infiltrating T-Cells 
The %CD8+ tumor-infiltrating T-cells will be quantified by immunohistochemistry (IHC) 
analysis of tissue. Using semi-automated image analysis, a staining percentage determined 
by dividing the area of brown 3,3'-Diaminobenzidine (DAB) staining by the area of epithelial 
cells will be obtained. 
Five representative tumor fields with the greatest gross tumor infiltrating lymphocyte fields 
will be chosen for measurement by the pathologist with the final %CD8+ tumor-infiltrating 
T-cells determined as the mean of the %CD8+ tumor-infiltrating T-cells across the five fields. 
10.4 
Methods for Evaluation of Pathological Response 
The post-treatment pathologic tumor stage will be determined from each patient’s 
cystectomy pathology report according to American Joint Commission on Cancer (AJCC) 
Staging system T, N, M categories for bladder cancer (Appendix V). 
10.5 
Pathologic Tumor Response Definitions 
10.5.1 Pathologic Response 
Pathologic response (<ypT2N0M0) is defined by post-treatment radical cystectomy 
tumor stages with N0 and M0 status with the following T-stages: T0, Ta, Tis, T1. 
10.5.2 Pathologic Complete Response 
Pathologic response (ypCR) is defined by post-treatment radical cystectomy tumor 
stages with N0 and M0 status with the following T-stages: T0. 








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3 
Patients will have Temperature, Pulse and Blood Pressure taken at each visit. In addition, patients will have their blood pressure and pulse measured before, 
during and after the infusions at the following times: 
• 
At the beginning of the infusion 
• 
After nivolumab infusion and before lirilumab infusion for patients receiving lirilumab 
• 
At the end of the infusion 
4 
CBC with differential and platelet count which includes WBC, ANC, Platelets, Hemoglobin, and Hematocrit required prior to each dose of study therapy. 
Results known prior to treatment administration. 
5 
Albumin, BUN/creatinine, uric acid, sodium, potassium, chloride, glucose, calcium, alkaline phosphatase, AST, ALT, total bilirubin, and total protein. 
6 
Hepatitis B surface antigen (HBsAg), and Hepatitis C (HCV) testing within 4 weeks of registration. These tests may be repeated during the course of the study, 
if clinically indicated. 
7 
TSH, FT3, FT4. Please note this is Free T3 and Free T4. 
8 
Required for sexually active females of child-bearing potential. Infusion 1 and Infusion 2: Must be within 24 hours prior to treatment with nivolumab. 
9 
Chest/ Abdomen/Pelvic CT with or without contrast. CT with contrast is the preferred method unless otherwise contraindicated due to allergy, impaired renal 
function, etc. MRI exams of the chest and/or abdomen/pelvis may be performed, if CT of chest and/or abdomen/pelvis cannot be obtained. Preferably, use 
the same modality (CT or MRI) that was initially used during the study course, if possible. 
10 Research blood and urine samples shall be obtained at time points noted below. Refer to Section 14 for details. NOTE: Blood draw order is specified in 
the PrE0807 Lab Manual. 
Screening 
One 10 mL Streck DNA tube (for germline) 
Before First and Second Neoadjuvant Dose 
Peripheral Blood: One 10 mL red top tube, two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
Pre-Radical Cystectomy 
Peripheral Blood: One 10 mL red top tube, two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
Off Treatment Visit (approximately 30 days after Cystectomy) 
Peripheral Blood: One 10 mL red top tube and two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
At Time of Recurrence, if feasible 
Peripheral Blood: One 10 mL red top tube, two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
 
 


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11 Research tumor tissue samples shall be obtained at time points noted below. Refer to Section 14 for details. 
Screening/Study Entry 
FFPE: Up to 3 blocks preferred or 1 H&E slide plus minimum of 20 unstained slides (30 preferred) 
Radical Cystectomy 
FFPE: Up to 3 blocks preferred or 1 H&E slide plus minimum of 20 unstained slides (30 preferred) 
At Time of Recurrence, if feasible 
FFPE: Up to 3 blocks preferred or 1 H&E slide plus minimum of 20 unstained slides (30 preferred) 
12 See Section 6 for Treatment Plan and Section 7 for Dose Delays. 
Cohort 1: 
Nivolumab 480 mg IV over approximately 30 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) followed by radical cystectomy 
with bilateral (standard or extended) pelvic lymph node dissection as soon as possible but within 6 weeks after the last neoadjuvant infusion. 
Cohort 2: 
Nivolumab 480 mg IV over approximately 60 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) with at least a 30 minute rest 
between infusions followed by lirilumab 240 mg IV over approximately 60 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) 
followed by radical cystectomy with bilateral (standard or extended) pelvic lymph node dissection as soon as possible but within 6 weeks after 
the last neo-adjuvant infusion. 
13 Record oxygen saturation by pulse oximetry at rest and after exertion at each on-study visit prior to dosing. 
14 Radical cystectomy with bilateral (standard or extended) pelvic lymph node dissection to be performed as soon as possible but within 6 weeks after the last 
neoadjuvant infusion. 
15 Obtain CTs (or MRI as noted above) after second dose of nivolumab +/- lirilumab and before surgery. 
16 Thirty (30) days +/- 7 days after cystectomy. If patient is removed from treatment for reason(s) other than progression, follow with regular tumor assessments 
per standard of care until progression or start of new treatment. Once a patient has initiated a new therapy, no further imaging assessments for this study are 
required. 
NOTE: 
If cystectomy is not performed, Off Treatment visit should be performed at next scheduled appointment or treating physician discretion, as clinically 
indicated. 
17 Patients will be followed for adverse events for 100 days after their last dose of neoadjuvant therapy. Adverse events may be reviewed at the next visit ≥ 100 
days after last dose of neoadjuvant therapy or phone follow-up may be done to review adverse events. However, an adverse event occurring at any time after 
discontinuation of study therapy that is felt to be at least possibly related to study therapy should be recorded. 
18 Patients will be followed clinically and radiographically per standard of care (every 3-6 months) at the discretion of the treating physician for at least 2 years 
post-cystectomy or when study-wide follow-up ends. Date of diagnosis for progression, first subsequent therapy and survival shall be reported. Phone follow-
up may also be done for patients unable or unwilling to return for follow-up evaluations. 
 




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The administration of nivolumab infusion must be completed within 24 hours of 
preparation. If not used immediately, the infusion solution may be stored under 
refrigeration conditions (2°-8°C, 36°-46°F) for up to 24 hours, and a maximum of 8 
hours of the total 24 hours can be at room temperature (20°-25°C, 68°-77°F) and room 
light. The maximum 8-hour period under room temperature and room light conditions 
includes the product administration period. 
12.1.7 Drug Interactions 
No formal pharmacokinetic drug-drug interaction studies have been conducted with 
nivolumab. 
Nivolumab is not expected to have any effect on cytochrome P450 or other drug 
metabolizing enzymes in terms of inhibition or induction, and is, therefore, not 
expected to induce these types of PK-based drug interactions. 
12.1.8 Agent Availability 
Nivolumab will be supplied by BMS. 
The initial supply of nivolumab will be sent directly to the site upon site activation. As 
needed, nivolumab may be requested by the principal investigator (or their authorized 
designees) at each participating institution. The investigator, or a responsible party 
designated by the investigator, must maintain a careful record of the receipt, 
disposition, and return/destruction (site’s drug destruction policy must be reviewed and 
approved by PrECOG before any study drug can be destroyed at a site) of nivolumab. 
12.1.9 Agent Ordering 
PrECOG will be responsible for ordering drug for re-supply to the site. Requests for 
shipments of nivolumab will be coordinated between PrECOG and BMS. 
12.1.10 Agent Accountability 
Nivolumab will be stored in a secure location. Only authorized pharmacy and study 
staff will have access to this agent. Drug accountability will be performed by PrECOG. 
12.1.11 Side Effects 
The overall safety experience with nivolumab is based on approximately 1500 subjects 
as either a monotherapy or in combination with other therapeutics. In general for 
monotherapy, the safety profile is similar across tumor types. The one exception is 
pulmonary inflammation AEs which may be numerically greater in subjects with Non-
Small Cell Lung Cancer possibly because in some cases it can be difficult to 
distinguish between nivolumab-related and unrelated causes of pulmonary symptoms 
and radiographic changes. The most frequently reported treatment related AE is 
fatigue which is almost always low grade. 
Most related AEs are thought to be due to the effects of inflammatory cells on specific 
tissues. The most common treatment-related adverse events seen in clinical trials of 
nivolumab included rash, pruritus, cough, peripheral edema, fatigue, arthralgias, upper 
respiratory tract infections, diarrhea and liver function test abnormalities. Additionally 
a number of patients experienced more severe autoimmune effects including immune-
mediated pneumonitis, immune-mediated colitis, immune-mediated hepatitis, 
immune-mediated nephritis, immune-mediated encephalitis and immune-mediated 
endocrinopathies, such as adrenal insufficiency, hypothyroidism/hyperthyroidism and 
Type I Diabetes Mellitus. Less than 1% of patients in clinical trials experienced severe 
infusion reactions. 
Nivolumab is a Pregnancy Category D drug. 






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13. 
Statistical Considerations 
13.1 
Study Design & Sample Size Considerations 
This is a Phase Ib study evaluating whether the addition of lirilumab to nivolumab is feasible 
and safe in patients that are either cisplatin-ineligible or refuse cisplatin-based chemotherapy 
and have muscle-invasive urothelial carcinoma of the bladder in the neoadjuvant therapy 
setting. Eligible patients will be assigned sequentially to either nivolumab monotherapy in 
Cohort 1, and if there is no negative safety signal (see next paragraph) after the first 12 
patients, subsequent patients will be assigned to Cohort 2 treated with nivolumab/lirilumab. 
13.1.1 Interim Safety Analysis (Primary Endpoint) 
Treatment-related 
toxicities 
as 
noted 
below 
related 
to 
nivolumab 
or 
nivolumab/lirilumab will be monitored in each cohort of the study separately after 6 and 
12 patients in Cohort 1 and 6 patients in Cohort 2 have completed surgery. There will 
be no suspension to accrual. 
• 
Any Grade hypophysitis, meningitis, or immune-related neurologic AEs 
• 
Grade 2 or higher myocarditis 
• 
Persistent Grade 2 immunologic AEs (such as colitis, pneumonitis, and nephritis) 
that do not recover to Grade 1 or resolve within 6 weeks after the last dose of 
study drug (Exceptions: rash, fatigue, amylase/lipase elevations, other electrolyte 
abnormalities). 
• 
Grade 3 or higher immunologic AEs such as uveitis, pericarditis, hepatitis, 
colitis/diarrhea, nephritis, pancreatitis, myositis, endocrine, rash, etc., except for 
Grade 3 hypothyroidism, Grade 3 pruritus or Grade 3 infusion reaction. 
• 
Grade 4 non immunologic AEs, as well as Grade 4 hypothyroidism or Grade 4 
infusion reaction. 
If 3 or more of these 6 patients on a single cohort experience treatment-related 
adverse events as noted above related to nivolumab or nivolumab/lirilumab, the study 
will be suspended for a safety review. The following table gives the probabilities of 
stopping given various probabilities of toxicity. 
True but unknown probability of 
immunologic toxicity 
0.17 
0.25 
0.33 
0.42 
0.5 
Probability of suspension 
0.06 
0.17 
0.32 
0.49 
0.66 
13.2 
Statistical Analysis 
13.2.1 Primary Objective 
The primary endpoint of this study is the rate of Grade 3 or higher adverse events 
during neoadjuvant treatment. 
13.2.1.1 
Analytic Plan for Primary Objective 
The rates of Grade 3 or higher adverse events during neoadjuvant 
treatment will be reported along with 90% exact binomial confidence 
intervals. In Cohort 1 the maximum width of the confidence interval is 0.51 
while in Cohort 2 it is 0.36. 


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13.2.2 Key Secondary Objective 
The key secondary endpoint of this study is the change in tumor-infiltrating CD8+ T-
cell density from TURBT to radical cystectomy in each arm. CD8+ TIL density is 
defined as the number of CD8+ tumor infiltrating T-cells per 100 tumor cells within a 
400x HPF. All biopsies will be reviewed centrally by a pathologist. Final CD8+ T-cell 
density for each patient will be the mean of five representative tumor fields in a 
cystectomy sample with the greatest gross percentage of tumor infiltrating 
lymphocytes (minimum 100 tumor cells per representative field), as selected by the 
pathologist. The mean change in CD8+ TIL density of each cohort will be calculated 
by averaging the change in TIL densities of all patients in the cohort. (Additionally, the 
TIL density at radical cystectomy will be compared between the two cohorts as one of 
the exploratory objectives). 
13.2.2.1 
Analytic Plan for Key Secondary Objective 
The estimate of the standard deviation of tumor-infiltrating CD8+ T-cell 
density in urothelial carcinoma (defined as CD8+ TILs/ 100 tumor cells in 
high power field [HPF]) is derived from a prior study published by Sharma 
et al. In that cohort of 69 patients who underwent cystectomy, the standard 
deviation of TIL density was 3.9.12 Our hypothesis is that the change in 
TIL density between TURBT and radical cystectomy will be approximately 
3.0 CD8+ TILs per 100 tumor cells within HPF. Up to 43 patients will be 
enrolled for 36 eligible, treated patients (12 on nivolumab monotherapy 
and 24 patients on the combination). In each cohort a one-sample 
Wilcoxon signed-rank test will be used to test whether the mean change 
in TIL density differs significantly from zero. In the monotherapy cohort 
there will be 81% power to detect the hypothesized difference with a one-
sided type I error rate of 0.05. In the combination cohort there will be 98% 
power to detect the hypothesized difference with a one-sided type I error 
rate of 0.05. Additionally, the TIL density at radical cystectomy will be 
compared between the two cohorts using a Wilcoxon rank sum test. With 
this design there is 82% power to detect a difference of 0.80 standard 
deviations, which translates to a difference of about 3.0 TILs per 100 
tumor cells, between the two cohorts with a one-sided type I error rate of 
0.1. This comparison will be exploratory in nature. 
13.2.3 Additional Secondary Objectives 
1. The average percentage (%) change in the CD8+ TIL density from TURBT to RC 
in each of the two cohorts. Each individual patient’s percent change will be defined 
as [(Cystectomy TIL Density) – (TURBT TIL Density)] / (TURBT TIL Density). 
2. Proportion of patients in each cohort who do not get a radical cystectomy 
specifically and directly related to treatment related AEs within 6 weeks of the last 
dose of neoadjuvant treatment. 
3. Proportion of patients with pathologic complete (pT0N0) and partial (<pT2N0) 
response in the two cohorts. 
4. Proportion of patients who are alive and free of disease in each cohort at 2 years 
from registration. 
13.2.3.1 
Analytic Plan for Additional Secondary Objectives 
1. The mean percent change of CD8+ TIL density from pre-treatment 
(TURBT) to post-treatment (radical cystectomy) samples in all 12 
patients in Cohort 1 and all 24 patients in Cohort 2 will be calculated 


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and compared between the two cohorts using a Wilcoxon rank sum 
test. 
2. The proportion of patients in each treatment cohort who do not get 
radical cystectomy specifically and directly related to treatment 
related AEs within 6 weeks of the completion of neoadjuvant 
treatment, will be reported along with exact binomial 90% confidence 
intervals for each cohort and compared between the two cohorts 
using Fisher’s exact test. 
3. The proportion of patients in each treatment cohort with pathologic 
complete response (CR) and pathologic partial response (PR) will be 
reported along with exact binomial 90% confidence intervals for each 
cohort. 
4. Recurrence-free survival (defined as patients who are alive and 
without evidence of disease recurrence) from the time of registration 
will be estimated using Kaplan-Meier method for each treatment 
cohort and compared between the two cohorts using a log-rank test. 
One-year and two-year disease-free survival estimates and 
confidence intervals will be provided for each cohort. 
13.2.4 Exploratory Objectives 
1. The relationship between the expression of baseline IHC markers of interest (e.g. 
PD-1, PD-L1, PD-L2, NKG2D, KIR2DL1/2/3), and change in expression, for 
pathologic partial and complete tumor response (defined by cystectomy pathologic 
staging <pT2N0 and pT0N0, respectively), in patients treated with nivolumab and 
combination of nivolumab/lirilumab. To also compare the association of study 
cohort and pathologic response stratified by levels of expression of these 
biomarkers of interest. 
2. The relationship between peripheral blood mononuclear cell (PBMC) T-cell subset 
status (%CD4+ T-cells, %CD8+ T-cells, %Treg T-cells, %Myeloid Derived 
Suppressor Cells, %Natural Killer cells, etc.) and change in status, as assessed 
by flow cytometry analysis, for pathologic partial and complete tumor response 
(defined by cystectomy pathologic staging < pT2N0 and pT0N0, respectively), in 
patients treated with nivolumab and combination of nivolumab/lirilumab. 
3. To compare the CD8+ TIL density at radical cystectomy between the patients 
treated with nivolumab and combination of nivolumab/lirilumab. 
4. The prognostic and predictive relationship between pre- and post- treatment TIL 
and NK-cell level and activation and pathologic partial and complete response 
(defined by cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as 
well as two-year RFS, in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 
5. To assess impact of prior BCG exposure on rates of pathologic partial and 
complete response (defined by cystectomy pathologic staging <pT2N0 and 
pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab 
and combination of nivolumab/lirilumab. 
6. To assess the prognostic and predictive relationship of tumor mutational load, neo-
epitope burden, intrinsic molecular subtypes (basal vs. luminal), and T-cell 
clonality with pathologic partial and complete response (defined by cystectomy 
pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in 
patients treated with nivolumab and combination of nivolumab/lirilumab 


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7. To assess the prognostic and predictive relationship of pre- and post-treatment T-
cell subsets, CD4+/CD8+ and CD4+/FOXP3+ ratios and plasma cytokine 
multiplex panels with pathologic partial and complete response (defined by 
cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as two-
year 
RFS, 
in 
patients 
treated 
with 
nivolumab 
and 
combination 
of 
nivolumab/lirilumab. 
8. To assess the prognostic and predictive relationship between pre- and post-
neoadjuvant treatment levels in plasma cytokine biomarkers of interest (e.g. IFN-
α, TGF-β, IL-10, IL-4, IL-5, IL-13, IFN-γ, etc.) and pathologic partial and complete 
response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, 
respectively) as well as two-year RFS, in patients treated with nivolumab and 
combination of nivolumab/lirilumab. 
9. To assess prognostic and predictive associations between baseline tumor and/or 
tumor infiltrating lymphocyte tissue and ctDNA genomic alterations, gene 
expression, and methylation signatures for pathologic partial and complete 
response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, 
respectively) as well as two-year RFS, in patients treated with nivolumab and 
combination of nivolumab/lirilumab. 
10. To assess prognostic and predictive value of serum circulating antibody profiles 
on pathologic partial and complete response (defined by cystectomy pathologic 
staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients 
treated with nivolumab and combination of nivolumab/lirilumab 
11. To assess CD8+ TIL density by central pathology review using image analysis in 
TURBT and radical cystectomy in each arm. 
13.2.4.1 
Analytic Plan for Exploratory Objectives 
As a general strategy, marker levels in responders vs. non-responders will 
be compared by a t-test or Wilcoxon rank sum test as appropriate. In 
addition to evaluating expression on a continuous scale we will explore 
quantile values for each marker as potential thresholds to discretize the 
marker levels. The two-year RFS will then be compared between marker 
groups with a Fisher’s exact test as well as via time-to-even analyses 
using standard methods for survival analysis. Changes in biomarker 
levels will be computed and compared between groups using a Wilcoxon 
rank sum test. Analyses of the predictive ability of markers will be 
accomplished via standard tests of treatment-by-marker interaction using 
the appropriate model for the endpoint of interest (logistic regression or 
proportional hazards regression). Pearson’s correlation and the Wilcoxon 
signed rank test will be used to characterize the relationship between 
CD8+ TIL densities produced by various methods of assessment. The 
study is not powered for these analyses, however, so conclusions 
regarding the predictive ability of any given marker will be limited. 


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14. 
Laboratory and Pathology Correlative Studies 
14.1 
Correlative Studies: Mandatory Tumor Samples and Analysis 
Kits will be supplied for research samples. Instructions and shipping address will be provided. 
14.1.1 Tumoral Assessments 
• 
Pre-treatment TURBT (archived tissue may be used) 
- 
Up to 3 formalin-fixed paraffin-embedded (FFPE) blocks OR a minimum of 20 
(30 preferred) unstained (5 micron thickness) sections on unbaked, charged 
slides plus 1 H&E slide with highest volume of representative tumor histology. 
• 
Radical Cystectomy 
- 
Up to 3 formalin-fixed paraffin-embedded (FFPE) blocks OR a minimum of 20 
(30 preferred) unstained (5 micron thickness) sections on unbaked, charged 
slides plus 1 H&E slide with highest volume of representative tumor histology. 
• 
At the time of recurrence, if feasible 
- 
Up to 3 formalin-fixed paraffin-embedded (FFPE) blocks OR a minimum of 20 
(30 preferred) unstained (5 micron thickness) sections on unbaked, charged 
slides plus 1 H&E slide with highest volume of representative tumor histology. 
14.1.2 Tumor Infiltrating CD8+ T-Cell Density 
Post-treatment tumor infiltrating CD8+ T-cell density is the secondary endpoint of the 
trial. In pre- and post-treatment tumor tissue specimens CD8+ T-cell density will be 
examined by IHC performed on whole tissue histology sections. The CD8+ T-cell 
density is defined as the number of CD8+ tumor-infiltrating T-cells per 100 tumor cells 
within a 400x HPF.12,45 Five representative tumor fields with the greatest gross tumor 
infiltrating lymphocyte fields (minimum 100 tumor cells per representative field) will be 
chosen for measurement by microscope analysis by the pathologist with the final 
CD8+ T-cell density determined as the mean of the CD8+ T-cell density across the 
five fields. CD8 IHC on both the pre- and post-treatment will be performed by a central 
pathology lab. Pre- and post-treatment CD8+ staining cells intermixed within 
surrounding tumor cells will be considered tumor infiltrating CD8+ T-cells. These cells 
will be counted as will the number of tumor cells within the chosen 400x HPF. The 
CD8+ T-cell density will be calculated as: 
Tumor Infiltrating CD8+ T-cell density (CD8+ T-cells per 100 tumor cells) = 
(Total # of CD8+ TILS)/ (Total # of tumor cells per HPF) x 100 
In addition, CD8+ TIL density will be assessed by central pathology review using 
image analysis of five 1-mm-sq areas using image analysis (Aperio, Leica Biosystem). 
Additionally, eight areas of highest inflammatory infiltrate (“hot-spots”) will be reviewed 
by image analysis to document focal or diffuse process of inflammation. This 
methodology will be utilized to determine both the pre- and post-treatment tumor 
infiltrating CD8+ T-cell densities. 
For additional analysis, tissue microarrays (TMAs) of pre- and post-treatment tumor 
tissue biopsies will be constructed using available tumor FFPE blocks. The TMAs will 
be constructed using three 1.0 mm diameter tumor core tissues containing at least 100 
malignant cells. Also, a minimum of 20 (30 preferred) unstained 5 micron thick sections 
from both the pre- and post-treatment tumor samples will be cut into slides for 
additional correlative investigations. In the event that a patient’s post-treatment TMA 
section is not suitable for averaging three representative tumor infiltrating lymphocyte 
regions, the post-treatment slides may be used for the CD8+ T-cell density analyses. 


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14.1.3 Percentage CD8+ Tumor Infiltrating T-Cell 
Utilizing tissue slides described above in Section 14.1.2, the %CD8+ tumor infiltrating 
cells pre- and post-treatment will be quantified by semi-automated image analysis. 
CD8+ tumor infiltrating IHC percentage will be determined by dividing the area of 
brown 3,3'-Diaminobenzidine (DAB) staining by the area of epithelial cells within HPF. 
The final %CD8+ tumor infiltrating T-cell measurement will be determined by an 
average of five representative tumor fields with the greatest gross tumor infiltrating 
lymphocytes. 
14.1.4 PD-1 and PD-L1 IHC 
PD-1 and PD-L1 IHC staining will be performed on the TMAs constructed from the 
pre- and post-treatment archived tumor specimens. TMA tumor sections will be 
stained for PD-1 and for PD-L1. All IHC staining will be performed per manufacturer’s 
instructions. 
14.1.5 Banking for Future Research: Additional Analysis 
Other analysis that may be performed depending on resources, tissue quality and 
availability may include the following: 
KIR2DL1, KIR2DL2, and KIR2DL3 IHC 
IHC staining for KIR2DL1, KIR2DL2, and KIR2DL3 on the TMAs constructed from the 
pre-treatment archived tumor specimens. TMA tumor sections will be stained for 
KIR2DL1, KIR2DL2, and KIR2DL3. All IHC staining will be performed per 
manufacturer’s instructions. 
Additional IHC Analyses 
As tissue availability permits, additional IHC and immunofluorescence (IF) staining is 
planned to further characterize functional immune phenotypes and targets of interest 
for future drug development. Utilizing the TMAs constructed from the pre- and post-
treatment archived tumor specimens, additional IHC/IF stains planned, but not limited 
to the following: CD4, FOXP3, Ki-67, CTLA-4, Hsp27, PTEN, OX40, LAG3, TIM-3, 
KIR2DL, CSF1R, 4-1BB, IDO, GITR, TIGIT, CD27, CD73, CD40L, CD163, pSTAT1, 
RBP-J, CMAF, LGR4, LGR5, LGR6, SLAMF7, etc. Exact list of IHC markers may be 
modified according to new target identification and emerging translational science. 
Immunoscore and immune reports may be evaluated. 
Immune Gene Expression Analysis 
Baseline and post-treatment tumor cells will be isolated and enriched from patient 
baseline tumor slides by macro-dissection. RNA will be extracted and assessed for 
quality control utilizing standard manufacturer RNA extraction kits and per 
manufacturer instructions and per standard methods. Extracted RNA from each 
sample will be analyzed for the expression of immune mediating genes. Additional 
RNA based investigations on tumor RNA may be performed as tumor RNA availability 
and emerging analysis platforms permit. 
T-Cell Receptor Repertoire Analysis 
Baseline and post-treatment tumor cells will be isolated and enriched from patient pre- 
and post-treatment tumor slides by macro-dissection. DNA will be extracted and 
assessed for quality control utilizing standard manufacturer DNA extraction kits and 
per manufacturer instructions and per standard methods. Extracted DNA from each 
sample will be analyzed for T-cell and B-cell receptor mutations by next generation 
sequencing platform, statistical and bioinformatics analysis. 
 


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Next Generation Sequencing, Whole Genome Methylation Analysis, and 
Mutation Load Analysis 
Baseline and post-treatment tumor cells will be isolated and DNA will be extracted 
from patient tumor slides. Extracted DNA from each sample will be analyzed for gene 
methylation, genomic alterations and mutational load estimate; statistical and 
bioinformatics analysis. Additional DNA based investigations on tumor DNA may be 
performed as tumor DNA availability and emerging analysis platforms permit. 
14.2 
Correlative Studies: Mandatory Peripheral Blood Samples and Analysis 
Kits will be supplied for research samples. Instructions and shipping address will be provided. 
14.2.1 Peripheral Blood Assessments 
• 
Screening 
- 
One 10 mL Streck DNA tube (for germline testing) 
• 
Before First Neoadjuvant Dose 
- 
One 10 mL red top tube 
- 
Two 10 mL green top tubes 
- 
One 10 mL Streck DNA tube and one 10 mL Streck RNA tube 
• 
Before 2nd Neoadjuvant Dose 
- 
One 10 mL red top tube 
- 
Two 10 mL green top tubes 
- 
One 10 mL Streck DNA tube and one 10 mL Streck RNA tube 
• 
Pre-Radical Cystectomy 
- 
One 10 mL red top tube 
- 
Two 10 mL green top tubes 
- 
One 10 mL Streck DNA tube and one 10 mL Streck RNA tube 
• 
Off Treatment Visit (approximately 30 days after Cystectomy) 
- 
One 10 mL red top tube 
- 
Two 10 mL green top tubes 
- 
One 10 mL Streck DNA tube and one 10 mL Streck RNA tube 
• 
At time of recurrence, if feasible 
- 
One 10 mL red top tube 
- 
Two 10 mL green top tubes 
- 
One 10 mL Streck DNA tube and one 10 mL Streck RNA tube 
14.2.2 Peripheral Blood Lymphocyte Subsets 
T-cell subset proportions (%CD4+ T-cells, %CD8+ T-cells, %Treg T-cells, %Myeloid 
Derived Suppressor Cells, %Natural Killer cells, etc.) will be determined by flow 
cytometry analysis. 
14.2.3 Natural Killer Cell (NK-cell) Activation 
After flow cytometry isolation of NK-cells (CD45+/CD3-/CD56 or CD16+), NK-cell 
activation will be analyzed by K562 co-culture lysis and CD107a degranulation assays. 
May be performed depending on resources and specimen availability. 
14.2.4 ctDNA Analysis 
ctDNA analysis will be performed on Streck DNA tube samples at time points indicated 
in Section 14.2.1. 


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14.2.5 Cytokine Analysis 
The pharmacodynamics functional effects of nivolumab and/or lirilumab will be 
analyzed by assessment of pre- and post-treatment plasma cytokine markers of 
interest (e.g. IFN-α, TGF-β, IL-10, IL-4, IL-5, IL-13, IFN-γ, etc.). The exact list of 
cytokines analyzed will be selected based on assay methodology optimization and 
validation testing. It is expected that a panel of a few markers will be analyzed to 
distinguish between major immune effector pathways. Additional exploratory analysis 
of the relationship between circulating free tumor DNA/RNA, micro-RNA, and other 
novel platforms will be pursued as resources and specimen availability permit. 
14.3 
Correlative Studies: Mandatory Urine Samples and Analysis 
Kits will be supplied for research samples. Instructions and shipping address will be provided. 
14.3.1 Urine Assessment and Sample Collection 
• 
Before 1st and 2nd Neoadjuvant Dose 
• 
Pre-Radical Cystectomy 
• 
Off Treatment Visit (approximately 30 days after Cystectomy) 
• 
At time of recurrence, if feasible 
Urine should be collected in a standard urinalysis cup and 30 mL aliquoted into two 15 
mL cryovials. 
14.3.2 Banking for Future Research: Urine Marker Analysis 
Initially, urine samples will be banked and stored. Future analyses of urinary cytokine 
changes, urine cell pellet profiles, T-cell receptor repertoire, gene methylation and 
mutation analysis are proposed as resources and specimen availability permit. The 
exact list of urine biomarkers may be modified according to new target identification 
and emerging translational science. 
14.4 
Research Samples Processing and Shipment 
Kits will be supplied for research samples. Instructions, shipping labels, supplies and address 
will be provided. 
All samples collected will be labeled with a unique numeric identifier that will be coded for 
patient privacy protection. 
14.4.1 FFPE Tissue Block or Slide Samples 
Sites should submit FFPE tumor tissue blocks or FFPE slides plus H&E slide from a 
tumor tissue block as noted in Section 14.1.1. Thickness of the sections should be at 
5 micron. Pre-treatment TURBT samples should be submitted within 1 month of 
patient registration. 
Radical cystectomy and recurrence (if applicable) samples should be submitted within 
2 months of procedure. 
A copy of the pathology report should be sent when the sample is shipped. Samples 
should be shipped Monday-Thursday. Samples will be shipped ambient via overnight 
courier to the Central Biorepository Pathology Facility (CBPF). 
14.4.2 Peripheral Blood Samples 
Sites should submit peripheral blood samples in as noted in Section 14.2.1. 
NOTE: Blood draw order is specified in the PrE0807 Lab Manual. 


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14.4.2.1 
Red Top Tube Processing 
Gently mix the blood sample by inversion 5 times (do not shake). Allow 
the sample to sit at room temperature for 30-60 minutes in vertical positon 
until a clot has formed. The sample should be centrifuged within 2 hours 
of collection. 
Once the clot has formed, the sample is ready for centrifugation. 
Centrifuge for 30 minutes at room temperature at 3500 RPM. Immediately 
aliquot and store the resulting serum into two (2) properly labeled 
polypropylene tubes. Be careful to not disturb the clot. Store the samples 
in the freezer at -70°C or colder until they are shipped for analysis. DO 
NOT ALLOW SAMPLES TO THAW. 
14.4.2.2 
Green Top Tubes Processing for Plasma and Buffy Coat 
**Process samples within 30 minutes of collection** 
• 
Gently mix each blood sample by inversion 10 times (do not shake). 
• 
Place tubes immediately on wet ice for 5 minutes. 
• 
Centrifuge at 1500 RPM for 15 minutes at 4°C. If a refrigerated 
centrifuge is not available, spin samples at room temperature (1500 
RPM for 15 minutes). Immediately place the tubes on wet ice after 
centrifugation. 
After centrifugation, the plasma layer will be at the top half of the tubes. 
The nucleated cells (WBC) will be in a whitish layer, called the “buffy coat”, 
just under the plasma and above the red blood cells. 
Plasma Preparation 
• 
Using a transfer pipette for each tube take the top two-thirds of the 
plasma and transfer plasma into a 15 mL conical centrifuge tube, be 
careful not to disturb the buffy coat layer in each green top tube 
(NOTE: see below for buffy coat processing instructions). Centrifuge 
the 15 mL conical tubes at 1500 RPM for 15 minutes at 4°C. If a 
refrigerated centrifuge is not available, spin samples at room 
temperature (1200 RPM for 15 minutes). Immediately place the 
conical tubes on wet ice after centrifugation. 
• 
Transfer equal amounts of plasma from each tube into two (2) 
properly labeled polypropylene tubes for cryopreservation being 
careful not to disturb the small PBMC/pellet. 
• 
Store the two aliquots of plasma samples from each tube in freezer at 
≤ -70°C or colder until they are shipped to central lab. DO NOT 
ALLOW SAMPLES TO THAW. 
Buffy Coat Preparation 
• 
From each green top tube remove and aliquot the “buffy coat”; be 
careful not to disturb the layer of red blood cells. 
• 
Store the aliquot of cells from each tube in one (1) properly labeled 
polypropylene tube for cryopreservation. 
• 
Store the samples in the freezer at ≤ -70°C or colder until it is shipped 
to central lab. DO NOT ALLOW SAMPLES TO THAW. 


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Serum, plasma and buffy coat samples should be batched together and 
shipped approximately every 4 months. Individual patients should only be 
included in the shipment if all of their samples have been completed 
through the Off Treatment Sample. Samples should be shipped Monday-
Thursday. Samples must be shipped on dry ice via overnight courier to 
the CBPF. 
14.4.2.3 
Streck Tube Processing 
Fill tube completely. IMMEDIATELY mix the blood sample by gentle 
inversion 8-10 times (do not shake). One inversion is a complete turn of 
the wrist (180 degrees and back). Store at ambient temperature (15-
30°C). Do NOT freeze. 
Streck tube (DNA and RNA) should be shipped to the lab within 72 hours 
of collection via overnight courier at room temperature (Use CoolPak 
during hot season. Do NOT freeze). Proper insulation may be required for 
shipment during extreme temperature conditions. NOTE: Samples may 
be shipped on Friday for Monday delivery to the CBPF. 
Analysis may be performed by Dr. Bishoy Faltas lab and/or other labs, 
depending on available resources. 
14.4.3 Urine Sample Processing 
Sites should submit urine samples in as noted in Section 14.3.1. 
• 
Centrifuge the two 15 mL urine samples for 10 minutes at 3500 RPM. 
• 
The supernatant from each tube should be transferred into three (3) 5 mL properly 
labeled polypropylene tube for cryopreservation. 
• 
The cell pellet from each tube should be re-suspended in 1 mL phosphate-buffered 
saline (PBS) and individually transferred into one (1) properly labeled 
polypropylene tube for cryopreservation. Centrifuge polypropylene tube at 3500 
RPM for 10 minutes then aspirate the supernatant. 
• 
Store the samples in the freezer at ≤ -70°C or colder until it is shipped to central 
lab. DO NOT ALLOW SAMPLES TO THAW. 
Urine samples should be batched together and shipped approximately every 4 
months. Individual patients should only be included in the shipment if all of their 
samples have been completed through the Off Treatment Sample. Samples should be 
shipped Monday-Thursday. Samples must be shipped on dry ice via overnight courier 
to the CBPF. 


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15. 
Administrative 
15.1 
Protocol Compliance 
The study shall be conducted as described in this protocol. All revisions to the protocol must 
be discussed with, and be prepared by PrECOG and/or representatives. The Investigator 
should not implement any deviation or change to the protocol or consent without prior review 
and documented approval from PrECOG and/or representatives and the Institutional Review 
Board (IRB) of an amendment, except where necessary to eliminate an immediate hazard(s) 
to study patients. 
If a deviation or change to the approved protocol is implemented to eliminate an immediate 
hazard(s) prior to obtaining IRB approval, notification will be submitted to the IRB for review 
and approval as soon as possible afterward. Documentation of approval signed by the 
chairperson or designee of the IRB(s) should be in the study records. If PrECOG and/or 
representatives provides an amendment that substantially alters the study design or increases 
the potential risk to the patient; the consent form must be revised and submitted to the IRB(s) 
for review and approval; the revised form must be used to obtain consent from patients 
currently enrolled in the study if they are affected by the Amendment; and the new form must 
be used to obtain consent from new patients prior to study entry. Information as to who 
investigators should send correspondence will be provided in additional study documents. 
15.2 
Institutional Review Board (IRB) 
Before study initiation, the Investigator must have written and dated approval from their 
respective IRB for the protocol, consent form, patient recruitment materials/process and any 
other written information to be provided to patients. The Investigator should also provide the 
IRB with a copy of the Investigator Brochure or product labeling, and any updates. 
The Investigator should provide the IRB with reports, updates, and other information (e.g., 
Safety Updates, amendments, and administrative letters) according to regulatory 
requirements, IRB or study site procedures. 
15.3 
Informed Consent Procedures 
Investigators must ensure that patients who volunteer for clinical trials or their legally 
acceptable representative are clearly and fully informed about the purpose, potential risks and 
other information. 
A protocol specific informed consent form (ICF) template will be provided to sites. Preparation 
of the site-specific consent form is the responsibility of the site Investigator and must include 
all applicable regulatory and IRB requirements, and must adhere to Good Clinical Practices 
(GCP) and to the ethical principles that have their origin in the Declaration of Helsinki. All 
changes to the ICF template will be approved by PrECOG and/or their representatives prior to 
implementation. 
In accordance with the Health Information Portability and Accountability Act (HIPAA), the 
consent process will also include written authorization by patients to release medical 
information to allow PrECOG and/or its agents, regulatory authorities, and the IRB of record at 
the study site for access to patient records and medical information relevant to the study, 
including the medical history. This will be documented in the informed consent form or other 
approved form obtained at the time of informed consent per institutional policies. This form 
should also be submitted to PrECOG and/or its agents for review prior to its implementation. 
The Investigator must provide the patient or legally acceptable representative with a copy of 
the consent form and written information about the study in the language in which the patient 
is most proficient. The language must be non-technical and easily understood. The Investigator 
should allow time necessary for patient or patient's legally acceptable representative to inquire 
about the details of the study, then informed consent must be signed and personally dated by 


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the patient or the patient's legally acceptable representative and by the person who conducted 
the informed consent discussion. The patient or legally acceptable representative should 
receive a copy of the signed informed consent and any other written information provided to 
study patients prior to patient's participation in the trial. The investigator is responsible for 
assuring adequate documentation of this process and for storage and maintenance of the 
original signed consent form for each patient/subject.  
The informed consent and any other information provided to patients or the patient's legally 
acceptable representative, should be revised whenever important new information becomes 
available that is relevant to the patient's consent, and should receive IRB approval prior to use. 
The Investigator, or a person designated by the Investigator should inform the patient or the 
patient's legally acceptable representative of all pertinent aspects of the study and of any new 
information relevant to the patient's willingness to continue participation in the study. This 
communication should be documented in the patient record. During a patient's participation in 
the trial, any updates to the consent form and any updates to the written information will be 
provided to the patient. 
15.4 
Safety Communication 
Investigators will be notified of all AEs that are serious, unexpected, and definitely, probably, 
or possibly related to the investigational product. Upon receiving such notices, the Investigator 
must review and retain the notice with the Investigator Brochure and submit a copy of this 
information to the IRB according to local regulations. The Investigator and IRB will determine 
if the informed consent requires revision. The Investigator should also comply with the IRB 
procedures for reporting any other safety information. All revisions should be submitted to 
PrECOG and/or agents for review. 
15.5 
Monitoring 
Representatives and agents of PrECOG and, as applicable to the study, the manufacturer of 
investigational product must be allowed to visit all study site locations periodically to assess 
the data, quality and study integrity. The purpose of this visit is to review study records and 
directly compare them with source documents and discuss the conduct of the study with the 
Investigator, and verify that the facilities remain acceptable. Monitoring of drug accountability 
will also occur. 
The study may be evaluated by other auditors and government inspectors who must be 
allowed access to electronic Case Report Forms (eCRFs), source documents and other study 
files. The Investigator must notify PrECOG of any scheduled visits by regulatory authorities, 
and submit copies of all reports. Information as to who investigators should notify of an audit 
or where to address questions will be provided in additional study materials. 
15.6 
Study Records 
An Investigator is required to maintain adequate regulatory files with corresponding 
communication and approvals, accurate histories, observations and other data on each 
individual treated. Full details of required regulatory documents will be provided in additional 
study materials. Data reported on the eCRFs must be consistent with the source documents 
as part of the patient record. 
The confidentiality of records that could identify patients must be protected, respecting the 
privacy and confidentiality rules in accordance with the applicable regulatory requirement(s). 
A study specific signature record will be maintained to document signatures and initials of all 
persons at a study site who are authorized to make entries and/or corrections on eCRFs as 
well as document other study-specific roles. 


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15.7 
Electronic Case Report Form (eCRF) Information 
Additional information regarding eCRF instructions, timelines for data entry/ submission and 
query completion can be found in supplemental materials provided to the site. Sites will be 
expected to complete eCRFs as per the schedule provided and submit all relevant data as per 
the specified timelines. All items recorded on eCRFs must be found in source documents. 
The completed eCRF must be promptly reviewed, electronically signed, and dated by the 
Principal Investigator. 
Instructions for management of patients who do not receive any protocol therapy: 
If a patient is registered and does not receive any assigned protocol treatment, baseline, 
Serious Adverse Event and follow-up data will still be entered and must be submitted according 
to the eCRF instructions. Document the reason for not starting protocol treatment on the 
appropriate electronic off treatment form. 
15.8 
Records Retention 
FDA Regulations (21CFR 312.62) require clinical investigators to retain all trial-related 
documentation, including source documents for the periods described below for studies 
performed under a US Investigational New Drug (IND): 
• two years after the FDA approves the marketing application, or 
• two years after the FDA disapproves the application for the indication being studied, or 
• two years after the FDA is notified by the sponsor of the discontinuation of trials and that an 
application will not be submitted. 
The Investigator must retain investigational product disposition records, copies of eCRFs (or 
electronic files), and source documents for the maximum period required by applicable 
regulations and guidelines, or Institution procedures, whichever is longer. The Investigator 
must contact PrECOG and/or representatives prior to destroying any records associated with 
the study. 
Information as to who investigators should contact for questions will be provided in additional 
study documents. PrECOG and/or representatives will notify the Investigator when the trial 
records for this study are no longer needed. 
 


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16. 
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antibody in cancer. N Engl J Med. 2012;366:2443-54. 


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18. 
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35. 
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Recognition and Regulation of T Cells by NK Cells. Pallmer and Oxenius. Front Immunol. 2016; 
7: 251. 
45. 
Baras AS, Drake C, Liu JJ, et al. The ratio of CD8 to Treg tumor-infiltrating lymphocytes is 
associated with response to cisplatin-based neoadjuvant chemotherapy in patients with muscle 
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46. 
Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: 
revised RECIST guideline (Version 1.1). Eur J Cancer. 2009 Jan;45(2):228-47. 
 


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Appendix I 
ECOG Performance Status 
 
PS 0 
Fully active, able to carry on all pre-disease performance 
without restriction 
PS 1 
Restricted in physically strenuous activity but ambulatory 
and able to carry out work of a light or sedentary nature e.g. 
light house work, office work. 
PS 2 
Ambulatory and capable of all self-care but unable to carry 
out any work activities. Up and about more than 50% of 
waking hours. 
PS 3 
Capable of only limited self-care, confined to bed or chair 
more than 50% of waking hours. 
PS 4 
Completely disabled. Cannot carry on any self-care. Totally 
confined to bed or chair. 
Source: Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair 
 


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Date: 12/10/2019 
 
66 
Appendix II: Cockcroft-Gault Formula 
 
 
(140 - age [years]) (body wt [kg]) 
Creatinine clearance for males =  
————————————— 
(72) (serum creatinine [mg/dL]) 
 
 
 
(140 - age [years]) (body wt [kg]) 
Creatinine clearance for females =  ————————————— 
x 0.85 
(72) (serum creatinine [mg/dL]) 
Source: Gault MH, Longerich LL, Harnett JD, et al. Predicting glomerular function from adjusted serum 
creatinine (editorial). Nephron 1992; 62:249 
















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Appendix IV: RECIST Version 1.1 
Malignant Disease Evaluation 
Response and progression will be evaluated in this study using the international criteria proposed by the 
revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline Version 1.1. Changes in the largest 
diameter (unidimensional measurement) of the tumor lesions and the shortest diameter in the case of 
malignant lymph nodes are used in RECIST. 
To assess objective response, it is necessary to estimate the overall tumor burden at baseline to which 
subsequent measurements will be compared. Measurable disease is defined by the presence of at least one 
measurable lesion. 
All measurements should be recorded in metric notation by use of a ruler or calipers. The same method of 
assessment and the same technique should be used to characterize each identified lesion at baseline and 
during follow-up. All baseline evaluations should be performed as closely as possible to the beginning of 
treatment and never more than four weeks before registration. 
The term evaluable in reference to measurability will not be used because it does not provide additional 
meaning or accuracy. 
At baseline, tumor lesions will be characterized as either measurable or non-measurable. 
o 
Measurable 
Measurable tumor lesions are those that can be accurately measured in at least one dimension (longest 
diameter in the plane of measurement is to be recorded) with a minimum size of: 
• 
≥ 10 mm by CT scan (irrespective of scanner type) and MRI (no less than double the slice thickness 
and a minimum of 10 mm) 
• 
≥ 10 mm caliper measurement by clinical exam (when superficial) 
• 
≥ 20 mm by chest x-ray (if clearly defined and surrounded by aerated lung) 
If the measurable disease is restricted to a solitary lesion, its neoplastic nature should be confirmed by 
cytology/histology. 
o 
Malignant Lymph Nodes 
To be considered pathologically enlarged and measurable, a lymph node must be ≥ 15 mm in short axis 
(perpendicular to longest diameter) when assessed by CT scan. 
o 
Non-Measurable 
All other lesions (or sites of disease), including small lesions not meeting the criteria in “Measurable” and 
“Malignant Lymph Nodes” above, are considered non-measurable lesions. This includes lymph nodes 
measured at ≥ 10 to <15 mm in the short axis. NOTE: Lymph nodes measured at <10 mm in the short axis 
are considered normal. 
Lesions considered to be non-measurable include the following: leptomeningeal disease, ascites, 
pleural/pericardial effusions, inflammatory breast disease, lymphangitic involvement of the skin or lung, 
and abdominal masses/abdominal organomegaly identified by physical exam that is not measurable by 
reproducible imaging techniques. 
NOTE: 
‘Cystic lesions’ that meet the criteria for radiographically defined simple cysts should not be 
considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, if they 
meet the definition of measurability described above. However, if non-cystic lesions are present in the 
same patient, these are preferred for selection as target lesions. 


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Lytic bone lesions, with an identifiable soft tissue component, evaluated by CT or MRI, can be considered 
as measurable lesions if the soft tissue component otherwise meets the definition of measurability in 
“Measurable” above. Blastic bone lesions are non-measurable. 
Tumor lesions that are situated in a previously irradiated area, or in an area subjected to other loco-regional 
therapy, are usually not considered measurable unless there has been demonstrated progression in the 
lesion. 
Definitions of Response 
o 
Target Lesions 
All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, representative of all 
involved organs, should be identified as target lesions and recorded and measured at baseline. Target 
lesions should be selected on the basis of their size (those with the longest diameters), be representative 
of all involved organs, but in addition should be those that lend themselves to reproducible repeated 
measurements. It may be the case that, on occasion, the largest lesion does not lend itself to reproducible 
measurement in which circumstance the next largest lesion which can be measured reproducibly should 
be selected. 
The sum of the target lesions (longest diameter for non-nodal lesions, short axis for nodal lesions) will be 
calculated and reported as the baseline sum. If lymph nodes are to be included in the sum, then only the 
short axis is added into the sum. The baseline sum of the diameters/axes will be used as reference to 
further characterize any objective tumor regression in the measurable dimension of the disease. 
• 
Complete Response (CR) 
The disappearance of all target lesions. Any pathological lymph nodes (whether target or non-target) 
must have reduction in short axis to <10 mm (the sum may not be “0” if there are target nodes). To be 
assigned a status of complete response, changes in tumor measurements must be confirmed by 
repeat assessments performed ≥ 4 weeks after the criteria for response are first met. 
• 
Partial Response (PR) 
At least a 30% decrease in the sum of the diameters/axes of target lesions, taking as reference the 
baseline sum diameters/axes. To be assigned a status of partial response, changes in tumor 
measurements must be confirmed by repeat assessments performed ≥ 4 weeks after the criteria for 
response is met. 
• 
Progressive Disease (PD) 
At least a 20% increase in the sum of the diameters/axes of target lesions, taking as reference the 
smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to 
the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm 
over the nadir. (NOTE: the appearance of one or more new lesions is also considered progression). 
• 
Stable Disease (SD) 
Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as 
reference the smallest sum diameters/axes while on study. (NOTE: a change of 20% or more that 
does not increase the sum of the diameters by 5 mm or more is coded as stable disease). 
To be assigned a status of stable disease, measurements must have met the stable disease criteria 
at least once after study entry at a minimum interval of ≥ 4 weeks. 
o 
Non-Target Lesions 
All other lesions or sites of disease including any measurable lesions over and above the 5 target lesions 
and lymph nodes measured at ≥ 10 to <15 mm in the short axis should be identified as non-target lesions 
and should also be recorded at baseline. Measurements of these lesions are not required, but the presence 
or absence of unequivocal progression of each should be noted throughout follow-up. 


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• 
Complete Response (CR) 
The disappearance of all non-target lesions and normalization of tumor marker levels, if applicable. All 
lymph nodes must be non-pathological in size (<10 mm short axis). To be assigned a status of 
complete response, changes in tumor measurements must be confirmed by repeat assessments 
performed ≥ 4 weeks after the criteria for response are first met. 
NOTE: If tumor markers are initially above the upper normal limit, they must normalize for a patient to 
be considered in complete clinical response. 
• 
Non-CR/Non-PD 
The persistence of one or more non-target lesion(s) and/or the maintenance of tumor marker levels 
above the normal limits. To be assigned a status of Non-CR/Non-PD, measurements must have met 
the Non-CR/Non-PD criteria at least once after study entry at a minimum interval of ≥ 4 weeks. 
• 
Progressive Disease (PD) 
The appearance of one or more new lesion(s) and/or unequivocal progression of existing non-target 
lesions. Unequivocal progression should not normally trump target lesion status. It must be 
representative of overall disease status change, not a single lesion increase. 
When the patient also has measurable disease, there must be an overall level of substantial worsening 
in non-target disease such that, even in the presence of SD or PR in target disease, the overall tumor 
burden has increased sufficiently to merit discontinuation of therapy. A modest “increase” in the size 
of one or more non-target lesions is usually not sufficient to qualify for unequivocal progression status. 
The designation of overall progression solely on the basis of change in non-target disease in the face 
of SD or PR of target disease will therefore be extremely rare. 
When the patient only has non-measurable disease, the increase in overall disease burden should be 
comparable in magnitude to the increase that would be required to declare PD for measurable disease: 
i.e., an increase in tumor burden from “trace” to “large”, an increase in nodal disease from “localized” 
to “widespread”, or an increase sufficient to require a change in therapy. 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the treating 
physician should prevail in such circumstances. 
o 
Evaluation of New Lesions 
The appearance of new lesions constitutes Progressive Disease (PD). 
o 
Symptomatic Deterioration 
Patients with a global deterioration of health status requiring discontinuation of treatment without objective 
evidence of disease progression at that time should be reported as “symptomatic deterioration”. Every 
effort should be made to document the objective progression even after discontinuation of treatment. 
Evaluation of Patient’s Best Overall Response 
The best overall response is the best response recorded from the start of the treatment until confirmed disease 
progression or non-protocol therapy (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started). The patient's best response assignment will depend on the achievement 
of both measurement and confirmation criteria (Table V-1). 
To be assigned a status of complete or partial response, changes in tumor measurements must be confirmed 
by repeat assessments performed ≥ 4 weeks after the criteria for response are first met. 
To be assigned a status of stable disease, measurements must have met the stable disease criteria at least 
once after study entry at a minimum interval of ≥ 4 weeks. 
 




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should be the same as was used at baseline and the lesions should be measured/assessed on the same 
pulse sequence. It is beyond the scope of the RECIST guidelines to prescribe specific MRI pulse sequence 
parameters for all scanners, body parts, and diseases. Ideally, the same type of scanner should be used 
and the image acquisition protocol should be followed as closely as possible to prior scans. Body scans 
should be performed with breath-hold scanning techniques, if possible. 
o 
PET-CT 
At present, the low dose or attenuation correction CT portion of a combined PET-CT is not always of 
optimal diagnostic CT quality for use with RECIST measurements. However, if the site can document that 
the CT performed as part of a PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral 
contrast), then the CT portion of the PET-CT can be used for RECIST measurements and can be used 
interchangeably with conventional CT in accurately measuring cancer lesions over time. Note, however, 
that the PET portion of the CT introduces additional data which may bias an investigator if it is not routinely 
or serially performed. 
o 
Ultrasound 
Ultrasound is not useful in assessment of lesion size and should not be used as a method of measurement. 
Ultrasound examinations cannot be reproduced in their entirety for independent review at a later date and, 
because they are operator dependent, it cannot be guaranteed that the same technique and 
measurements will be taken from one assessment to the next. If new lesions are identified by ultrasound 
in the course of the study, confirmation by CT or MRI is advised. If there is concern about radiation 
exposure at CT, MRI may be used instead of CT in selected instances. 
o 
Endoscopy, Laparoscopy 
The utilization of these techniques for objective tumor evaluation is not advised. However, such techniques 
may be useful to confirm complete pathological response when biopsies are obtained or to determine 
relapse in trials where recurrence following CR or surgical resection is an endpoint. 
o 
Tumor Markers 
Tumor markers alone cannot be used to assess response. If markers are initially above the upper normal 
limit, they must normalize for a patient to be considered in complete clinical response. 
o 
Cytology, Histology 
These techniques can be used to differentiate between PR and CR in rare cases (e.g., residual lesions in 
tumor types, such as germ cell tumors, where known residual benign tumors can remain). 
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens during 
treatment when the measurable tumor has met criteria for response or SD is mandatory to differentiate 
between response or SD (an effusion may be a side effect of the treatment) and PD. 


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Appendix V: Bladder Cancer TNM Staging 
American Joint Committee on Cancer TNM Staging System for Bladder Cancer 
Pathologic T Staging 
Tx – 
Primary tumor cannot be assessed 
T0 – 
No evidence of primary tumor 
Ta – 
Noninvasive papillary carcinoma which does not invade into the lamina propria 
Tis – 
Carcinoma in situ 
T1 – 
Tumor invades into the lamina propria but not into the muscularis propria 
T2 – 
Tumor invades into the muscularis propria 
T2a – Tumor invades into the inner half of the muscularis propria 
T2b – Tumor invades into the outer half of the muscularis propria 
T3 – 
Tumor invades into the perivesical tissue 
T3a – Tumor microscopically invades the perivesical tissue 
T3b – Tumor macroscopically invades the perivesical tissue 
T4 – 
Tumor invades into adjacent organs 
T4a – Tumor invades the prostatic stroma, uterus, or vagina 
T4b – Tumor invades into the pelvic wall, or abdominal wall 
Pathologic N Staging 
Nx – 
Lymph nodes cannot be assessed 
N0 – 
No lymph node metastasis 
N1 – 
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, 
external iliac, or presacral lymph node) 
N2 – 
Multiple regional lymph node metastases in the true pelvis (hypogastric, obturator, 
external iliac, or presacral lymph nodes) 
N3 – 
Lymph node metastases to the common iliac lymph nodes 
Pathologic M Staging 
M0 – 
No distant metastasis 
M1 – 
Distant metastasis 


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Appendix VI: Investigator’s Statement 
1. 
I have carefully read this protocol entitled “Phase Ib Feasibility Trial of Neoadjuvant 
Nivolumab/Lirilumab in Cisplatin-Ineligible Muscle-Invasive Bladder Cancer”, 
Version 3.0 dated 12/10/2019 (Protocol Number PrE0807) and agree that it contains 
all the necessary information required to conduct the study. I agree to conduct the study 
as outlined in the protocol. 
2. 
I agree to conduct this study according to the moral, ethical and scientific principles 
governing clinical research as set out in the Declaration of Helsinki, the principles of 
Good Clinical Practice (GCP) as described in 21 Code of Federal Regulations (CFR) 
and any applicable local requirements. 
3. 
I understand that this trial and any subsequent changes to the trial will not be initiated 
without approval of the appropriate Institutional Review Board, and that all 
administrative requirements of the governing body of the institution will be complied 
with fully. 
4. 
Informed written consent will be obtained from all participating patients in accordance 
with institutional and Food and Drug Administration (FDA) requirements as specified in 
Title 21, CFR, Part 50. 
5. 
I understand that my signature on the electronic Case Report Form (eCRF) indicates 
that I have carefully reviewed each page and accept full responsibility for the contents 
thereof. 
6. 
I understand that the information presented in this study protocol is confidential, and I 
hereby assure that no information based on the conduct of the study will be released 
without prior consent from PrECOG, LLC unless this requirement is superseded by the 
FDA. 
Principal Investigator (PI): 
PI Name: 
 
 
 
 
 
 
 
 
 
 
Site Name: 
 
 
 
 
 
 
 
 
 
 
Signature of PI: 
 
 
 
 
 
 
 
 
 
Date of Signature: 
 
 
\ 
 
\ 
 
 
 
 
 
 
 
MM 
 
DD 
 
YYYY 

SAP_001.pdf: 
PrECOG Protocol Number: PrE0807 
Date: 2/06/2020 
 
1 
 
 
PrE0807 Statistical Analysis Plan (SAP) 
Phase Ib Feasibility Trial of Neoadjuvant Nivolumab/Lirilumab 
in Cisplatin-Ineligible Muscle-Invasive Bladder Cancer 
 
NCT#: 
NCT03532451 
Version Number: 
1.1 
Version Date: 
2/06/2020 
 


Statistical Analysis Plan  
PrECOG/PrE0807 
Final Version 1.1/ 06 Feb 2020 
 
 
1 
 
 
 
 
Statistical Analysis Plan 
Study code 
PrE0807 
Version 
Final V1.1 
Date 
6 Feb 2020 
Phase Ib Feasibility Trial of Neoadjuvant Nivolumab/Lirilumab in Cisplatin-Ineligible 
Muscle-Invasive Bladder Cancer. 


Statistical Analysis Plan  
PrECOG/PrE0807 
Final Version 1.1/ 06 Feb 2020 
 
 
2 
 
 
 
 
 
DOCUMENT: 
 
Statistical Analysis Plan 
PROTOCOL 
 
 
Number: 
 
PrE0807 
Version and Date: 
 
V3.0, 10Dec2019 
Title: 
 
 
Phase Ib Feasibility Trial of Neoadjuvant Nivolumab/Lirilumab 
in Cisplatin-Ineligible Muscle-Invasive Bladder Cancer 
 
 
 
SAP STATUS 
 
Final Version 1.1 
SAP VERSION DATE 
 
06 Feb 2020 
 
SPONSOR: 
 
PrECOG, LLC    
1818 Market Street 
Suite 3000 
Philadelphia, PA 19103 
 
 
PREPARED BY: 
 
 
Senior Biostatistician 
Quality Data Services, Inc. 
 
 
 
 
 




Statistical Analysis Plan  
PrECOG/PrE0807 
Final Version 1.1/ 06 Feb 2020 
 
 
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TABLE OF CONTENTS 
TITLE PAGE ....................................................................................................................... 1 
1. LIST OF ABBREVIATIONS ............................................................................................. 10 
2. INTRODUCTION .......................................................................................................... 17 
2.1. Objective of the Statistical Analysis Plan .................................................................. 17 
3. STUDY OBJECTIVES ..................................................................................................... 17 
3.1. Primary Objective .................................................................................................... 17 
3.2. Secondary Objectives ............................................................................................... 18 
3.3. Exploratory Objectives ............................................................................................. 19 
4. STUDY DESIGN ............................................................................................................ 20 
4.1. General Study Design and Plan ................................................................................. 20 
4.2. Study Population ..................................................................................................... 21 
4.3. Treatment Administration ........................................................................................ 21 
4.3.1. Study treatment ............................................................................................................ 21 


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4.3.2. Dose Delays ................................................................................................................... 21 
4.3.3. Discontinue treatment .................................................................................................. 22 
5. EFFICACY MEASUREMENTS ......................................................................................... 22 
5.1. Tumor Response ...................................................................................................... 22 
5.2. CD8+ T-Cell Density .................................................................................................. 22 
5.3. %CD8+ Tumor-Infiltrating T-Cells .............................................................................. 23 
5.4. Pathologic Tumor Response Definitions ................................................................... 23 
5.4.1 Pathologic Complete Response................................................................................... 23 
5.4.2 Pathologic Non-Response ........................................................................................... 23 
5.5. Tumor IHC Staining Intensity Definitions .................................................................. 24 
5.6. Recurrence-Free Survival (RFS) as per RECIST 1.1 ...................................................... 24 
5.7. Overall Survival (OS) ................................................................................................ 24 
5.8. Other Efficacy Measurements .................................................................................. 24 
6. SAFETY MEASUREMENTS ............................................................................................ 25 
6.1. Adverse Events ........................................................................................................ 25 


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6.2. Concomitant Medications and Procedures ............................................................... 26 
6.3. Clinical Laboratory Assessments ............................................................................... 26 
6.4. Physical Examination and Medical History ................................................................ 26 
6.5. Electrocardiogram .................................................................................................... 27 
7. GENERAL STATISTICAL CONSIDERATIONS .................................................................... 27 
7.1. Study Design and Sample Size Considerations........................................................... 27 
7.2. Methodology ........................................................................................................... 27 
7.3. Handling of Dropouts or Missing Data ...................................................................... 28 
7.4. Endpoints ................................................................................................................ 28 
7.4.1. Primary Endpoint .......................................................................................................... 28 
7.4.2. Secondary Endpoints .................................................................................................... 28 
7.4.3. Exploratory Objective Endpoints .................................................................................. 31 
7.5. Analysis Populations ................................................................................................ 32 
7.5.1. Safety Population .......................................................................................................... 32 
7.5.2. Efficacy Population ........................................................................................................ 32 


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7.6. Safety Analysis ......................................................................................................... 33 
7.6.1. Disposition..................................................................................................................... 33 
7.6.2. Demographics and Baseline Characteristics ................................................................. 33 
7.6.3. Medical and surgical History ......................................................................................... 34 
7.6.4. Concomitant Medications and Procedure .................................................................... 34 
7.6.5. Study treatment and Surgery ........................................................................................ 34 
7.6.6. Adverse Events .............................................................................................................. 34 
7.6.7. Clinical Laboratory Data ................................................................................................ 35 
7.6.8. Vital Signs Data.............................................................................................................. 36 
7.7. Efficacy Analysis ....................................................................................................... 36 
7.7.1. The mean change of CD8+ TIL density in each cohort .................................................. 36 
7.7.2. The average percent (%) change of CD8+ TIL density in each cohort .......................... 36 
7.7.3. Pathology response in each cohort .............................................................................. 37 
7.7.4. RFS survival analysis in each cohort .............................................................................. 37 
7.7.5. Overall Survival (OS) ...................................................................................................... 37 
7.7.6. IHC markers in relationship with tumor response in each cohort................................ 38 
7.7.7. PBMC in relationship with tumor response in each cohort .......................................... 38 


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7.8. Interim Analysis ....................................................................................................... 38 
8. SUMMARY OF CHANGES FROM PROTOCOL-SPECIFIED ANALYSES ................................ 39 
9. REPORTING CONVENTIONS ......................................................................................... 39 
10. REFERENCES .............................................................................................................. 40 
11. TABLES, FIGURES, AND LISTINGS ............................................................................... 41 
12. APPENDIX ................................................................................................................. 41 
12.1. Appendix I. Study procedure and Parameters ......................................................... 42 
12.2. Appendix II. Bladder Cancer TNM Staging ............................................................... 47 
13. DOCUMENT HISTORY ................................................................................................ 49 
 
 


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1.   LIST OF ABBREVIATIONS 
Abbreviation 
Term 
ADL 
Activities of Daily Living 
AE 
Adverse Event 
AJCC 
American Joint Commission on Cancer 
ALT 
Alanine Aminotransferase 
AML 
Acute Myeloid Leukemia 
ANC 
Absolute Neutrophil Count 
ASCO 
American Society of Clinical Oncology 
AST 
Aspartate Aminotransferase 
BC 
Bladder Cancer 
BCG 
Bacilllus Calmette Guerin 
BID 
Twice Daily 
BMS 
Bristol-Myers Squibb 
BSA 
Body Surface Area 
BUN 
Blood Urea Nitrogen 
C 
Celsius 
CABG 
Coronary Artery Bypass Graft 
CBC 
Complete Blood Count 
cc 
Cubic Centimeter 
CFR 
Code of Federal Regulations 


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Abbreviation 
Term 
CHF 
Congestive Heart Failure 
CR 
Complete Response 
CrCl 
Creatinine Clearance 
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
ctDNA 
Circulating Tumor Deoxyribonucleic Acid 
CTLA-4 
Cytotoxic T Lymphocyte Antigen-4 
CVA 
Cerebrovascular Accident 
DAB 
Diamiobenzidine 
DBP 
Diastolic Blood Pressure 
DEHP 
Non-Di-2-Ethylhexyl Phthalate 
dL 
Deciliter 
DNA 
Deoxyribonucleic Acid 
DSMB 
Data Safety Monitoring Board 
E-A CBPF 
ECOG-ACRIN Central Biorepository Pathology Facility 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic Case Report Form 
eDC 
Electronic Data Capture 
FDA 
Food and Drug Administration 


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Abbreviation 
Term 
F 
Fahrenheit 
FFPE 
Formalin-Fixed Paraffin-Embedded 
FT3 
Free-Triiodothyronine 
FT4 
Free-Thyroxine 
GCP 
Good Clinical Practice 
g 
Gram 
G-CSF 
Granulocyte-Colony Stimulating Factor 
GI 
Gastrointestinal 
HBsAg 
Hepatitis B Surface Antigen 
HBV 
Hepatitis B Virus 
HCV 
Hepatitis C Virus 
HIPAA 
Health Information Portability and Accountability Act 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 
HPF 
High Powered Field 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
ID 
Infectious Disease 
IF 
Immunofluorescence 


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Abbreviation 
Term 
Ig 
Immunoglobulin 
IHC 
Immunohistochemistry 
IL-2 
Interleukin-2 
IND 
Investigational New Drug 
I-O 
Immuno-Oncology 
IRB 
Institutional Review Board 
IV 
Intravenous; Intravenously 
IVIG 
Intravenous Immunoglobulin 
KIRs 
Killer Cell Immunoglobulin-Like Receptors 
kg 
Kilogram 
LFT 
Liver Function Tests 
LLN 
Lower Limit of Normal 
LN 
Lymph Node 
mAb 
Monoclonal antibody 
mg 
Milligram 
MHC 
Major Histocompatibility Complex 
MI 
Myocardial Infarction 
MIBC 
Muscle-Invasive Bladder Cancer 
min 
Minute 
mL 
Milliliter 


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Abbreviation 
Term 
mm 
Millimeter 
MRI 
Magnetic Resonance Imaging 
MTD 
Maximum Tolerated Dose 
NA 
Not Applicable 
NCI 
National Cancer Institute 
NCI CTCAE 
National Cancer Institute Common Terminology Criteria for Adverse 
Events 
NK-Cells 
Natural Killer Cells 
NKG2D 
Natural Killer Group 2, Member D 
NMIBC 
Non-Muscle-Invasive Bladder Cancer 
NS 
Normal Saline 
NSAID 
Nonsteroidal Anti-Inflammatory Drug 
NYHA 
New York Heart Association 
OS 
Overall Survival 
PBMC 
Peripheral Blood Mononuclear Cell 
PBS 
Phosphate-Buffered Saline 
PD 
Progressive Disease (disease progression) 
PD-1 
Programmed Death-1 
PD-L1 
Programmed Death-Ligand 1 
PET 
Positron Emission Tomography 


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Abbreviation 
Term 
PK 
Pharmacokinetic(s) 
PLND 
Pelvic Lymph Node Dissection 
PO 
Orally; By Mouth 
PR 
Partial Response 
PS 
Performance Status 
Q2W 
Every 2 Weeks 
Q4W 
Every 4 Weeks 
RC 
Radical Cystectomy 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RFS 
Recurrence-Free Survival 
RNA 
Ribonucleic Acid 
RPM 
Revolutions Per Minute 
SAE 
Serious Adverse Event 
SBP 
Systolic Blood Pressure 
SD 
Stable Disease 
SITC 
Society for Immunotherapy Cancer 
SRM 
Study Reference Manual 
T. Bili 
Total Bilirubin 
TCGA 
The Cancer Genome Atlas 
TIA 
Transient Ischemic Attack 


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Abbreviation 
Term 
TIL 
Tumor-Infiltrating Lymphocytes 
TMA 
Tissue Microarray 
TSH 
Thyroid Stimulating Hormone 
TURBT 
Transurethral Resection of Bladder Tumor 
UC 
Urothelial Carcinoma 
ULN 
Upper Limit of the Normal Range 
US 
United States 
vs 
Versus 
WBC 
White Blood Cell 
WOCBP 
Women of Childbearing Potential 
 
 
 


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2.   INTRODUCTION 
2.1.   Objective of the Statistical Analysis Plan 
This statistical analysis plan (SAP) describes the planned analysis of the safety and efficacy data from this study.  A detailed description of the 
planned tables, figures and listings (TFLs) to be presented in the Clinical Study Report (CSR) is provided in the accompanying TFL template 
document.  
The intent of this document is to provide guidance for the analysis of data related to safety and efficacy to describe any applicable statistical 
procedures.  In general, the analyses come directly from the protocol, unless they have been modified by agreement between the Sponsor and 
Quality Data Services, Inc. (QDS).  A limited amount of information concerning this study (e.g., objectives, study design) is summarized to help the 
reader interpret the accompanying TFL templates.  That information is not a synopsis of the study and does not require review or approval because 
it is simply extracted from the protocol.  Attached signatures indicate approval of the statistical analysis sections of the SAP, as well as 
accompanying TFL templates.  These sections must be agreed upon prior to database lock.  When the SAP and TFL templates are agreed upon and 
finalized, they will serve as the template for a portion of this study’s CSR. 
This SAP supersedes the statistical considerations identified in the protocol; where considerations are substantially different, they will be so 
identified.  If additional analyses are required to supplement the planned analyses described in this SAP, they may be performed and will be 
identified in the appropriate section of the CSR.  Any substantial deviations from this SAP will be agreed upon between the sponsor and QDS.  
Deviations from this SAP, both substantial and non-substantial, will be documented in the CSR.  Any updates to their respective analyses, study 
designs, and TFL presentations after this SAP is finalized and approved will be documented in a running Note to the SAP document. 
 
3.   STUDY OBJECTIVES 
3.1.   Primary Objective 
The primary objective of this study is to assess the safety of nivolumab (Cohort 1) and combination of nivolumab/lirilumab (Cohort 2). 


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3.2.   Secondary Objectives 
The secondary objectives of this study are:  
• 
To assess the change in CD8+ TIL density from pre-treatment Transurethral Resection of Bladder Tumor (TURBT) to post-treatment 
Radical Cystectomy (RC) tissues separately in patients treated with nivolumab or combination of nivolumab/lirilumab. 
• 
To assess percentage (%) change in CD8+ TIL density from pre-treatment TURBT to post-treatment RC tissues separately in patients 
treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To describe the rate of patients in each cohort who do not get RC within 6 weeks after completion of neoadjuvant treatment specifically 
and directly related to treatment-related adverse events (AEs). 
• 
To assess the antitumor efficacy of nivolumab and combination of nivolumab/lirilumab as measured by pathologic complete (pT0N0) 
and partial (<pT2N0) response rate in the two cohorts. 
• 
To assess the rate of recurrence-free survival (RFS) at the two-year time point from the time of registration in patients treated with 
nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive value of the expression of baseline immunohistochemistry (IHC) markers of interest (e.g. PD-1, 
PD-L1, PD-L2, NKG2D, KIR2DL1/2/3), and change in expression, for pathologic partial and complete tumor response (defined by cystectomy 
pathologic staging <pT2N0 and pT0N0, respectively), in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive value of peripheral blood mononuclear cell (PBMC) T-cell subset status (%CD4+ T-cells, %CD8+ T-
cells, %Treg T-cells, %Myeloid Derived Suppressor Cells, %Natural Killer cells, etc.) and change in status, as assessed by flow cytometry analysis, 
for pathologic partial and complete tumor response (defined by cystectomy pathologic staging < pT2N0 and pT0N0, respectively), in patients 
treated with nivolumab and combination of nivolumab/lirilumab. 
 


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3.3.   Exploratory Objectives 
• 
To compare CD8+ TIL density in post-treatment RC tissues in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive relationship between pre- and post- treatment TIL and NK-cell level and activation and 
pathologic partial and complete response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in 
patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess impact of prior BCG exposure on rates of pathologic partial and complete response (defined by cystectomy pathologic staging 
<pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive relationship of tumor mutational load, neo-epitope burden, intrinsic molecular subtypes (basal 
vs. luminal), and T-cell clonality with pathologic partial and complete response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, 
respectively) as well as two-year RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive relationship of pre- and post-treatment peripheral blood T-cell subsets, CD4+/CD8+ and 
CD4+/FOXP3+ ratios and plasma cytokine multiplex panels with pathologic partial and complete response (defined by cystectomy pathologic 
staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess the prognostic and predictive relationship between pre- and post-neoadjuvant treatment levels in plasma cytokine biomarkers 
of interest (e.g. IFN-α, TGF-β, IL-10, IL-4, IL-5, IL-13, IFN-γ, etc.) and pathologic partial and complete response (defined by cystectomy pathologic 
staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
• 
To assess prognostic and predictive associations between baseline tumor and/or tumor infiltrating lymphocyte tissue and ctDNA 
genomic alterations, gene expression, and methylation signatures for pathologic partial and complete response (defined by cystectomy 
pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 


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• 
To assess prognostic and predictive value of serum circulating antibody profiles on pathologic partial and complete response (defined by 
cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 
• 
To assess CD8+ TIL density by central pathology review using image analysis in both cohorts. 
 
4.   STUDY DESIGN 
4.1.   General Study Design and Plan 
This is a Phase Ib open-label clinical trial for patients with cisplatin-ineligible MIBC (T2-T4a, N0-N1, M0). Patients will be sequentially enrolled first 
into Cohort 1 treated with nivolumab alone (N=12). In the absence of the occurrence of high rate of treatment related AEs as defined in protocol 
Section 5.4 and 13.1.1 with neoadjuvant nivolumab treatment, the study will proceed with enrollment into Cohort 2 of neoadjuvant treatment 
with combination nivolumab/lirilumab. (In both cohorts, neoadjuvant treatment must start within 8 weeks of transurethral resection of the first 
TURBT that showed muscularis propria invasion). Each group will receive a total of 4 weeks (week 0 and 4) of neoadjuvant therapy followed by 
radical cystectomy (RC) with bilateral (standard or extended) pelvic lymph node dissection (PLND). 
The RC with bilateral (standard or extended) PLND will occur as soon as possible but within 6 weeks after the last neoadjuvant dose in either 
cohort. 
 
Off treatment visit will occur approximately 30 days following cystectomy (cystectomy is not performed, Off Treatment visit should be 
performed at next scheduled appointment or treating physician discretion, as clinically indicated) and patients will be followed for 100 days after 
neoadjuvant treatment for AEs. Adverse events may be reviewed at the next visit ≥ 100 days after last dose of neoadjuvant therapy or phone 
follow-up may be done to review adverse events. 


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Patients will be followed clinically and radiographically for at least 2 years post-cystectomy or when study-wide follow-up ends per standard of 
care. Date of diagnosis for recurrence, first subsequent therapy and survival shall be reported. Phone follow-up may also be done for patients 
unable or unwilling to return for follow-up evaluations. 
 
4.2.   Study Population 
The study will aim to screen 43 eligible patients in order to enroll 36 patients in the trial (assuming about 20% tumor tissue assessment screen 
failure rate). Estimate at least 2-3 patients per month at approximately 8 sites. The estimated time for accrual completion will be approximately 
18 months. 
4.3.   Treatment Administration 
Neoadjuvant treatment must start within 8 weeks of transurethral resection of the first bladder tumor (TURBT) that showed muscularis propria 
invasion. 
4.3.1.   Study treatment 
Patients enrolled in the trial will be administered one of two of the following treatment regimens: 
Cohort 1: Nivolumab 480 mg IV every 4 weeks for 2 neo-adjuvant doses (week 0 and 4). 
Cohort 2: Nivolumab 480 mg IV + lirilumab 240 mg IV every 4 weeks for 2 neo-adjuvant doses (week 0 and 4). 
4.3.2.   Dose Delays 
A +/-3 day window is allowed for scheduled therapy. Dose delays are permitted. NO dose modifications will be allowed. 


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4.3.3.   Discontinue treatment 
If the Grade 3 toxicity does not resolve to ≤ Grade 1 within 21 days, all study therapy will be permanently discontinued. 
If the patient experiences Grade 4 treatment related hematologic toxicity in either study cohort, all study therapy must be permanently 
discontinued regardless of the time to resolution ≤ Grade 1. 
 
5.   EFFICACY MEASUREMENTS  
Patients should be evaluated for pathologic tumor response at post-treatment radical cystectomy time point. Tumor recurrence will be evaluated 
in this study using the new international criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline Version 
1.1 (Protocol Appendix V).  
Efficacy measurements listed below: 
5.1.   Tumor Response  
Only those patients who have received at least one dose of therapy, and undergo radical cystectomy will be considered evaluable for tumor 
response. RECIST response assessments will be performed locally for the trial. 
5.2.   CD8+ T-Cell Density 
The CD8+ T-cell density is defined as the number of CD8+ tumor-infiltrating T-cells per 100 tumor cells within a 400x high power field (HPF).  
The CD8+ T-cell density will be calculated as: 
Tumor Infiltrating CD8+ T-cell density (CD8+ T-cells per 100 tumor cells) = (Total # of CD8+ TILS)/ (Total # of tumor cells per HPF) x 100 


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Five representative tumor fields with the greatest gross tumor infiltrating lymphocyte fields (minimum 100 tumor cells per representative field) 
will be chosen for measurement by microscope analysis by the pathologist with the final CD8+ T-cell density determined as the mean of the 
CD8+ T-cell density across the five fields. 
5.3.   %CD8+ Tumor-Infiltrating T-Cells 
The %CD8+ tumor-infiltrating T-cells will be quantified by immunohistochemistry (IHC) analysis of tissue. Using semi-automated image analysis, a 
staining percentage determined by dividing the area of brown 3,3'-Diaminobenzidine (DAB) staining by the area of epithelial cells will be 
obtained. 
Five representative tumor fields with the greatest gross tumor infiltrating lymphocyte fields will be chosen for measurement by the pathologist 
with the final %CD8+ tumor-infiltrating T-cells determined as the mean of the %CD8+ tumor-infiltrating T-cells across the five fields 
5.4.   Pathologic Tumor Response Definitions 
Pathologic response (<ypT2N0M0) is defined by post-treatment radical cystectomy tumor stages with N0 and M0 status with the following T-
stages: T0, Ta, Tis, T1. 
Pathologic tumor stage reported according to American Joint Commission on Cancer (AJCC) Staging system T, N, M categories for bladder cancer 
(SAP Appendix II). 
5.4.1 
Pathologic Complete Response 
Pathologic response (ypCR) is defined by post-treatment radical cystectomy tumor stages with N0 and M0 status with the following T-stages: T0. 
5.4.2 
Pathologic Non-Response 
Pathologic non-response (ypNR) is defined by post-treatment radical cystectomy tumor stages with any node-positive (N1, N2, N3) or 
metastases-positive (M1) status. In addition, patients with N0 and M0 status with the following T-stages are also classified as pathologic non-
responders: T2, T2a, T2b, T3, T3a, T3b, T4, T4a, T4b. 


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5.5.   Tumor IHC Staining Intensity Definitions 
For validated IHC targets, standardized IHC staining intensity cutoffs will be utilized. For all other IHC targets, IHC staining will be categorized as: 
Grade 
Stain 
0 
<1% cells stained 
1+ 
1 to <5% cells stained 
2+ 
5 to  10% cells stained 
3+ 
≥ 10% cells stained 
 
5.6.   Recurrence-Free Survival (RFS) as per RECIST 1.1 
Recurrence is defined as the Progressive Disease (PD) in Overall Response assessed by ERECIST 1.1 or death after radical cystectomy. RFS time is 
defined as the duration of time from start of treatment to time of first documented recurrence (after radical cystectomy) or death, whichever 
occurs first. 
5.7.   Overall Survival (OS) 
OS is defined as the duration of time from start of treatment to time of death. 
5.8.   Other Efficacy Measurements 
ECOG performance status will be assessed at screening, TURBT, day 1 at each infusion, surgery and at the off treatment visits. 
 
 


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6.   SAFETY MEASUREMENTS 
Safety will be evaluated by  
• 
Adverse events  
• 
Concomitant medications and procedures 
• 
Clinical laboratory tests,  
• 
Physical examination findings,   
• 
Vital signs measurements, and  
6.1.   Adverse Events 
Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of a pre-existing medical condition in a patient administered 
a medicinal product in a clinical investigation and which does not necessarily have a causal relationship with this treatment. An AE can therefore 
be any unfavorable and unintended sign (e.g., including an abnormal laboratory finding), symptom, or disease temporally associated with the use 
of a product (investigational or marketed), whether or not considered related to the product (investigational or marketed). 
 
After informed consent, but prior to initiation of study treatment (nivolumab and lirilumab), only AEs/SAEs caused by a protocol-mandated 
intervention will be collected (e.g., SAEs related to invasive procedures such as biopsies). After the initiation of study treatment, all identified AEs 
and SAEs must be recorded and described on the appropriate page of the electronic Case Report Form (eCRF). If known, the diagnosis of the 
underlying illness or disorder should be recorded, rather than individual symptoms. The following information should be documented for all AEs: 
date of onset and resolution, severity of the event; the investigator’s opinion of the relationship to investigational product (see definitions below); 
treatment required for the AE treatment required for the AE; cause of the event (if known); and information regarding resolution/outcome. 
 


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Only clinically significant laboratory abnormalities that require active management will be recorded as AEs or SAEs on the eCRF (e.g., abnormalities 
that require study drug dose delay, discontinuation of study treatment, more-frequent follow-up assessments, further diagnostic investigation, 
etc.). 
 
The categories and definitions of severity used for clinical trials AEs are defined in the NCI’s Common Terminology Criteria (CTCAE) V5.0 
(http://www.ctep.cancer.gov). 
The categories of causal relationship or attribution to study drug are presented as Definite, Probable, Possible, Unlikely, Unrelated.  Categories 
‘Definite’, ‘Probable’ and ‘Possible’ are considered study drug related. Categories ‘Unlikely’ and ‘Unrelated’ are considered not study drug-related. 
AEs related to nivolumab and lirilumab should be followed for 100 days after last dose of study therapy until ≤ grade 1 or stabilization, and reported 
as SAEs if they become serious. Any AE’s (serious or not) that occur more than 100 days after the last dose of study therapy but that are deemed 
to be at least possibly related to study therapy shall be reported. 
6.2.   Concomitant Medications and Procedures  
Concomitant medications and procedures will be collected during the trial and recorded in the CRF page.  
6.3.   Clinical Laboratory Assessments 
Clinical laboratory tests will be collected at screening, day 1 of cycles 1 through 4, end of cycle 4, day 1 of each additional cycle and day 1 of cycle 
9 or end of treatment. 
6.4.   Physical Examination and Medical History 
Physical examination findings will be collected at screening, day 1 of each infusions, surgery and end of treatment. Medical and surgical history 
will also be collected during screening.  


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Physical examination and medical history data will not be analyzed and displayed in this SAP. The weight and height will be summarized in baseline 
characteristics table. 
6.5.   Electrocardiogram 
ECG will be obtained during screening. ECG data will not be analyzed and reported in this SAP.  
7.   GENERAL STATISTICAL CONSIDERATIONS 
This section will go into detail about the statistical approaches and methodology for this study analysis.  Statistical analysis and programming of 
tables and listings will be conducted by QDS, using SAS® Release 9.4 (SAS Institute Inc., Cary, North Carolina, USA).   
7.1.   Study Design and Sample Size Considerations 
This is a Phase Ib study evaluating whether the addition of lirilumab to nivolumab is feasible and safe in patients with cisplatin-ineligible muscle-
invasive urothelial carcinoma of the bladder in the neoadjuvant therapy setting. Eligible patients will be assigned sequentially to either 
nivolumab monotherapy in Cohort 1, and if there is no negative safety signal (assessed by interim safety analyses) after the first 12 patients, 
subsequent patients will be assigned to Cohort 2 treated with nivolumab/lirilumab.  
There will be 12 patients in cohort 1 treated with nivolumab and 24 patients in cohort 2 treated with nivolumab+ lirilumab for the final analysis. 
7.2.   Methodology 
Continuous data will be summarized with the following descriptive statistics: number of observations (n), mean, standard deviation (SD), median, 
minimum (min), and maximum (max). Categorical data will be summarized with frequencies and percentages. Hypothesis testing for categorical 
data will use nonparametric methods. 
In general, listings will be presented by patient.  Tables will be summarized and presented by cohort  in specific analysis populations. 


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7.3.   Handling of Dropouts or Missing Data 
All attempts will be made to prevent any missing values.  Missing or invalid data will be treated as missing, not imputed. 
No data imputation will be done for safety parameters except for the adverse events (AEs) with missing starting date.  If the AE onset date is 
unknown, then the date of first study treatment will be used for classification of AEs that were experienced following administration of study drug. 
If the relationship between AE and study medication (nivolumab or lirilumab) is missing, then the “related” is assigned in the AE analysis. 
7.4.   Endpoints 
7.4.1.   Primary Endpoint 
The primary endpoint of this study is the rate of Grade 3 or higher adverse events during neoadjuvant treatment. 
 
Analytic Plan for Primary Objective: The rates of Grade 3 or higher treatment-related AE during neoadjuvant treatment will be reported along with 
90% exact binomial confidence intervals. In Cohort 1 the maximum width of the confidence interval is 0.51 while in Cohort 2 it is 0.36. 
7.4.2.   Secondary Endpoints 
The secondary objective endpoints for this study are listed below:  
7.4.2.1.   The key secondary endpoint is the change in tumor-infiltrating CD8+ T-cell density from TURBT to radical cystectomy in each cohort 
Analytic Plan for This Key Secondary Objective:  


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In each cohort, a one-sample Wilcoxon signed-rank test will be used to test whether the mean change in TIL density differs significantly from 
zero. Our hypothesis is that the change in TIL density between TURBT and radical cystectomy will be approximately 3.0 CD8+ TILs per 100 tumor 
cells within HPF.  
Additionally, the TIL density at radical cystectomy will be compared between the two cohorts using a Wilcoxon rank sum test. 
7.4.2.2.   The average percentage (%) change in the CD8+ TIL density from TURBT to RC in each of the two cohorts. Each individual patient’s 
percent change will be defined as [(Cystectomy TIL Density) – (TURBT TIL Density)] / (TURBT TIL Density).       
Analytic Plan for this secondary endpoint: The mean percent change of CD8+ TIL density from pre-treatment (TURBT) to post-treatment 
(Radical Cystectomy, RC) samples in all 12 patients in Cohort 1 and all 24 patients in Cohort 2 will be calculated and compared between the two 
cohorts using a Wilcoxon rank sum test. 
7.4.2.3.   Proportion of patients in each cohort who do not get a radical cystectomy specifically and directly related to treatment related AEs 
within 6 weeks of the last dose of neoadjuvant treatment. 
Analytic Plan for this secondary endpoint: The proportion of patients in each treatment cohort who do not get radical cystectomy 
specifically and directly related to treatment related AEs within 6 weeks of the completion of neoadjuvant treatment, will be reported along with 
exact binomial 90% confidence intervals for each cohort and compared between the two cohorts using Fisher’s exact test. 
7.4.2.4.   Proportion of patients with pathologic complete (pT0N0) and partial (<pT2N0) response in the two cohorts. 
Analytic Plan for this secondary endpoint: The proportion of patients in each treatment cohort with pathologic complete response (CR) 
and pathologic partial response (PR) will be reported along with exact binomial 90% confidence intervals for each cohort 
7.4.2.5.   Proportion of patients who are alive and free of disease in each cohort at 2 years from registration.       
Analytic Plan for this secondary endpoint: Recurrence-free survival (defined as patients who are alive and without evidence of disease 
recurrence) from the time of registration will be estimated using Kaplan-Meier method for each treatment cohort and compared between the 
two cohorts using a log-rank test. The two-year disease-free survival estimates and confidence intervals will be provided for each cohort. 
 


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7.4.2.6.   The relationship between the expression of baseline IHC markers of interest (e.g. PD-1, PD-L1, PD-L2, NKG2D, KIR2DL1/2/3), and 
change in expression, for pathologic partial and complete tumor response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, 
respectively), in patients treated with nivolumab and combination of nivolumab/lirilumab. To also compare the association of study cohort 
and pathologic response stratified by levels of expression of these biomarkers of interest. 
Analytic Plan for this secondary endpoint:  As a general strategy, IHC marker levels in responders vs. non-responders will be compared by a t-test 
or Wilcoxon rank sum test as appropriate. In addition to evaluating expression on a continuous scale we will explore quantile values for each 
marker as potential thresholds to discretize the marker levels. The two-year RFS will then be compared between marker groups with a Fisher’s 
exact test as well as via time-to-even analyses using standard methods for survival analysis. Changes in biomarker levels will be computed and 
compared between groups using a Wilcoxon rank sum test. 
7.4.2.7.   The relationship between peripheral blood mononuclear cell (PBMC) T-cell subset status (%CD4+ T-cells, %CD8+ T-cells, %Treg T-
cells, %Myeloid Derived Suppressor Cells, %Natural Killer cells, etc.) and change in status, as assessed by flow cytometry analysis, for 
pathologic partial and complete tumor response (defined by cystectomy pathologic staging < pT2N0 and pT0N0, respectively), in patients 
treated with nivolumab and combination of nivolumab/lirilumab. 
Analytic Plan for this secondary endpoint: The PBMC T-cell subset status in responders vs. non-responders will be compared by a t-test or 
Wilcoxon rank sum test as appropriate.  
 


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7.4.3.   Exploratory Objective Endpoints 
7.4.3.1.   To compare the CD8+ TIL density at radical cystectomy between the patients treated with nivolumab and combination of 
nivolumab/lirilumab. 
7.4.3.2.   The prognostic and predictive relationship between pre- and post- treatment TIL and NK-cell level and activation and pathologic partial 
and complete response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated 
with nivolumab and combination of nivolumab/lirilumab. 
7.4.3.3.   To assess impact of prior BCG exposure on rates of pathologic partial and complete response (defined by cystectomy pathologic staging 
<pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
7.4.3.4.   To assess the prognostic and predictive relationship of tumor mutational load, neo-epitope burden, intrinsic molecular subtypes (basal 
vs. luminal), and T-cell clonality with pathologic partial and complete response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, 
respectively) as well as two-year RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab 
7.4.3.5.   To assess the prognostic and predictive relationship of pre- and post-treatment T-cell subsets, CD4+/CD8+ and CD4+/FOXP3+ ratios and 
plasma cytokine multiplex panels with pathologic partial and complete response (defined by cystectomy pathologic staging <pT2N0 and pT0N0, 
respectively) as well as two-year RFS, in patients treated with nivolumab and combination of nivolumab/lirilumab. 
7.4.3.6.   To assess the prognostic and predictive relationship between pre- and post-neoadjuvant treatment levels in plasma cytokine 
biomarkers of interest (e.g. IFN-α, TGF-β, IL-10, IL-4, IL-5, IL-13, IFN-γ, etc.) and pathologic partial and complete response (defined by cystectomy 
pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 
7.4.3.7.   To assess prognostic and predictive associations between baseline tumor and/or tumor infiltrating lymphocyte tissue and ctDNA 
genomic alterations, gene expression, and methylation signatures for pathologic partial and complete response (defined by cystectomy 


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pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination of 
nivolumab/lirilumab. 
7.4.3.8.   To assess prognostic and predictive value of serum circulating antibody profiles on pathologic partial and complete response (defined 
by cystectomy pathologic staging <pT2N0 and pT0N0, respectively) as well as two-year RFS, in patients treated with nivolumab and combination 
of nivolumab/lirilumab. 
7.4.3.9.   To assess CD8+ TIL density by central pathology review using image analysis in TURBT and radical cystectomy in each arm 
 
7.5.   Analysis Populations 
The study will aim to screen 43 eligible patients in order to enroll 36 patients in the trial. There will be 12 patients in cohort 1 and 24 patients in 
cohort 2. There will be a safety population for safety analysis and an efficacy population for efficacy analysis. 
7.5.1.   Safety Population 
The safety population is defined as all patients treated with at least one dose of nivolumab and/or lirilumab. It is the same as “Evaluable for 
Toxicity” population that used in protocol. All safety data collected up to the end of the study (i.e., through the last follow-up evaluation) are 
included in the safety analysis.  
7.5.2.   Efficacy Population 
The efficacy population is defined as all patients who received at least one dose of trial therapy, undergo radical cystectomy and have at least one 
of the following tumor evaluations listed below.  Patients who exhibited objective disease recurrence prior to the end of treatment will also be 
considered as part of the efficacy population. 
Below is the list of tumor evaluations: 
1. CD8+ T-Cell Density 


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2. %CD8+ Tumor-Infiltrating T-Cells 
3. Pathologic Tumor Response 
4. Tumor IHC Staining Intensity Definitions 
7.6.   Safety Analysis 
The safety evaluations include AEs, concomitant medication, clinical laboratory assessments, vital signs, and physical examination. Safety analysis 
will be assessed for the safety population. 
 
The results of this study will be reported using summary tables, figures, and data listings. Continuous variables will be summarized using mean, 
SD, median, minimum, and maximum.  Categorical variables will be summarized by presenting the number (frequency) and percentage in each 
cohort.  
If any screening safety data is repeated, the measurement taken closest to dosing will be used in the analysis as pre-study baseline.  If any post-
dose safety data is repeated, the measurement taken first at the particular visit in question will be used in the analysis. 
7.6.1.   Disposition  
Disposition data (e.g. informed consent, treated patients, surgery, etc.) will be summaries descriptive by cohort and overall patients for the 
patients who enrolled into the study. Patients who signed informed consent and registered are considered as enrolled into the study.     
7.6.2.   Demographics and Baseline Characteristics 
Demographic data (e.g. age, gender, race, height, screening body weight, cancer pathology, etc.) will be summarized descriptively (number of 
patients (frequency), mean, SD, median, minimum, and maximum) by cohort and overall in the safety population.   


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7.6.3.   Medical and surgical History 
Medical and surgical history data (e.g. surgical procedure, prior cancer therapy signs and symptoms, etc.) that collected during screening will be 
summaries by cohort and overall.   
7.6.4.   Concomitant Medications and Procedure 
The use of concomitant medications and procedure will be recorded on the CRFs.  The concomitant medications will be coded to a World Health 
Organization Drug Dictionary (WHO-DD) term. 
The use of concomitant medications and procedures will be summarized by cohort and overall group for the safety population.  In each of these 
summary tables, the number and percentage of patients taking each medication will be presented by ATC Classification. 
7.6.5.   Study treatment and Surgery 
The count and percentage of Nivolumab and Lirilumab administration completion and dose delay by cohort will be displayed. The 
number of patients who receive radical cystectomy will be summarized as well,   
 
7.6.6.   Adverse Events 
7.6.6.1.   Primary Endpoint, Grade 3 or Higher Treatment-related AE 
The rates of Grade 3 or higher treatment-related AE during neoadjuvant treatment will be reported along with 90% exact binomial confidence 
intervals.  
 


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7.6.6.2.   Secondary Endpoint, Patient who Did not Get Radical Cystectomy Due to AE  
The proportion of patients in each treatment cohort who do not get radical cystectomy specifically and directly related to treatment related AEs 
within 6 weeks of the completion of neoadjuvant treatment, will be reported along with exact binomial 90% confidence intervals for each cohort 
and compared between the two cohorts using Fisher’s exact test. This is one of secondary objective endpoints. 
The Identification of the AEs that cause patients do not get radical cystectomy by selecting “Caused Study Discontinuation” in AE CRF page, and 
with related to Nivolumab/Lirilumab, and patients do not have radical cystectomy surgery.  
7.6.6.3.   AE Summary Analysis by System Organ Class and Preferred Term  
Treatment-emergent AEs (TEAEs) are those that occur after administration of the first study dose until 100 days after last dose of study medication. 
In the case where the start date of the AE is unknown, it will be assumed to be treatment-emergent. TEAEs will be summarized by System Organ 
Class (SOC) and preferred term (PT) using the Medical Dictionary for Regulatory Activities (MedDRA®). The latest version of MedDRA (V 20.0) will 
be used.  The frequency of patients who experience TEAEs will be summarized by cohort and overall. Patients, having the same AE more than once 
per group, will be counted once for each PT and once within each SOC.  
All AEs, TEAEs, treatment-related AEs, Grade 3 or higher treatment-related AEs, SAEs, TEAEs caused stopping study medications, TEAEs leading to 
early termination, fatal TEAEs will be summarized by cohort and overall group. Also, above AE categories will be summarized by SOC and PT as 
well. 
Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0) will be used to manifest AE grade. 
7.6.7.   Clinical Laboratory Data 
Numeric clinical laboratory data will be summarized at each visit (clinical data collection point) using descriptive statistics.  Non-numeric laboratory 
tests will be summarized separately using frequency counts on unique responses.  Individual change from baseline in lab values will be calculated 
and summarized descriptively. The Lab shift table will be displayed at each visit for each laboratory test. 


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7.6.8.   Vital Signs Data 
Vital sign collected value and change from baseline will be summarized by visit and displayed by cohort and overall treatment group.  
7.7.   Efficacy Analysis 
All Efficacy analyses are performed for efficacy population except Recurrent-Free Survival and Overall Survival analyses. The RFS and OS analyses 
are performed for safety population. 
7.7.1.   The mean change of CD8+ TIL density in each cohort 
There are 2 CD8+ TIL density readings for each patient. One is prior and another one is after study treatment.  Patients obtained prior treatment 
CD8+ TIL density from TURBT. Patents obtained post treatment CD8+ TIL density from radical cystectomy. The mean change in CD8+ TIL density 
of each cohort will be calculated by averaging the change in TIL densities of all patients in the cohort. 
In each cohort a one-sample Wilcoxon signed-rank test will be used to test whether the mean change in TIL density differs significantly from 
zero. This is key secondary objective (SAP section 7.4.2.1). 
Additionally, the TIL density at radical cystectomy (post study treatment) will be compared between the two cohorts using a Wilcoxon rank sum 
test. This is the first exploratory objective (SAP section 7.4.3.1).    
7.7.2.   The average percent (%) change of CD8+ TIL density in each cohort 
Each individual patient’s percent change is defined as: 
100* [(Cystectomy TIL Density) – (TURBT TIL Density)] / (TURBT TIL Density). 
The mean percent change of CD8+ TIL density from pre-treatment (TURBT) to post-treatment (radical cystectomy) samples in all 12 patients in 
Cohort 1 and all 24 patients in Cohort 2 will be calculated and compared between the two cohorts using a Wilcoxon rank sum test. This is one of 
secondary objective endpoints. 


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7.7.3.   Pathology response in each cohort 
The proportion of patients in each treatment cohort with pathologic complete response (CR) and pathologic partial response (PR) will be 
reported along with exact binomial 90% confidence intervals for each cohort. This is one of secondary objective endpoints. Pathologic response 
(<ypT2N0M0) is defined by post-treatment radical cystectomy tumor stages with N0 and M0 status with the following T-stages: T0, Ta, Tis, T1. 
The pathologic complete response (CR) is defined as: The pT0N0M0 is assigned at cystectomy tumor stage that based on bladder cancer TNM 
staging system. This stage indicates the patient is no evidence of primary tumor (T0) and no lymph node metastasis (N0). 
The pathologic partial response (PR) is defined as: The stages that are less than T2N0M0 stage (<pT2N0M0) at cystectomy. Tumor stages with N0 
and M0 status with the following T-stages: T0, Ta, Tis, and T1 are considered as partial response. 
Pathologic non-response (NR) is defined by post-treatment radical cystectomy tumor stages with any node-positive (N1, N2, N3) or metastases-
positive (M1) status. In addition, patients with N0 and M0 status with the following T-stages are also classified as pathologic non-responders: T2, 
T2a, T2b, T3, T3a, T3b, T4, T4a, T4b. 
7.7.4.   RFS survival analysis in each cohort 
Recurrence-free survival (defined as patients who are alive and without evidence of disease recurrence) from start of treatment to first 
documented recurrence will be estimated using Kaplan-Meier method for each treatment cohort and compared between the two cohorts using 
a log-rank test. The two-year recurrence-free survival estimates and confidence intervals will be provided for each cohort. If patients do not have 
recurrence tumor or death event then they are censored at the last RECIST assessment date.  
The proportion of patients with recurrence-free survival at the two-year time point from registration will be displayed for each cohort.  
7.7.5.   Overall Survival (OS) 
OS is defined as the duration of time from start of treatment to time of death. Patients will be censored at the last date known alive. The Kaplan-
Meier method for each treatment cohort and compared between the two cohorts using a log-rank test. The two-year OS estimates and 
confidence intervals will be provided for each cohort. 


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7.7.6.   IHC markers in relationship with tumor response in each cohort 
The marker levels in responders vs. non-responders will be compared by a t-test or Wilcoxon rank sum test as appropriate. In addition to 
evaluating expression on a continuous scale we will explore quantile values for each marker as potential thresholds to discretize the marker 
levels. The two-year RFS will then be compared between marker groups with a Fisher’s exact test as well as via time-to-even analyses using 
standard methods for survival analysis. Changes in biomarker levels will be computed and compared between groups using a Wilcoxon rank sum 
test. 
7.7.7.   PBMC in relationship with tumor response in each cohort 
The same strategy of above (SAP section 8.7.5) will be applied for this analysis. 
7.8.   Interim Analysis 
There will be 3 interim safety analyses in this study. After 6 and 12 patients on Cohort 1 and 6 patients on Cohort 2 complete surgery, the study 
will be monitored for nivolumab or nivolumab/lirilumab treatment-related toxicities as noted below.  
• Any Grade hypophysitis, meningitis, or immune-related neurologic AEs 
• Grade 2 or higher myocarditis 
• Persistent Grade 2 immunologic AEs (such as colitis, pneumonitis, and nephritis) that do not recover to Grade 1 or resolve within 6 
weeks after the last dose of study drug (Exceptions: rash, fatigue, amylase/lipase elevations, other electrolyte abnormalities). 
• Grade 3 or higher immunologic AEs such as uveitis, pericarditis, hepatitis, colitis/diarrhea, nephritis, pancreatitis, myositis, endocrine, 
rash, etc., except Grade 3 hypothyroidism or Grade 3 infusion reaction. 
• Grade 4 non immunologic AEs, as well as Grade 4 hypothyroidism or Grade 4 infusion reaction. 


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The first interim safety analysis will be performed as soon as the 6th patient in cohort 1 complete radical cystectomy (RC) surgery. A treatment-
related AE by toxicity grade and SOC summary tables will be provided to clinical team review to determine whether 3 or more patients meet 
above specified AEs. If 3 or more patients are identified, the study will be suspended for a safety review. 
An AE listing will also be provided for clinical team review.  
The 2nd interim safety analysis will be performed as soon as the 12th patient in cohort 1 complete RC surgery. The same AE analysis as the first 
interim analysis will be performed for the all 12 patients. If 6 or more patients experience above specified AEs, the study will be suspended for a 
safety review. 
The 3rd interim safety analysis will be performed as soon as the 6th patient in cohort 2 complete RC surgery. The same AE analysis will be 
repeated for the all 18 patients. If 9 or more patients experience above specified AEs, the study will be suspended for a safety review.   
8.   SUMMARY OF CHANGES FROM PROTOCOL-SPECIFIED ANALYSES 
No changes are planned.  
9.   REPORTING CONVENTIONS 
The mean and median will be displayed to one decimal place greater than the original value and the standard deviation will be displayed to two 
decimal places greater than the original value. All statistical programming and analyses will be performed using SAS® Release 9.4 (SAS Institute 
Inc., Cary, North Carolina, USA). 
The following standards will be used in the data presentation: 
• 
Section 14 tables should be in landscape format.  Output should adhere to US / International Conference on Harmonization (ICH) margins and 
should not require changes for European page size.  For item 14 tables, a blank row will separate the header from the content of the table 
listing.  For tables that have “n (%)”, the placement should be centered below “N=xx” in the column header.  Frequency tables will be center 
justified.  Descriptive statistics will be decimal aligned.   


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• 
Percentages presented in in-text tables should be rounded to one decimal using the SAS rounding function.  If “%” is part of the column 
heading, do not repeat the “%” sign in the body of the table.  Unless specified otherwise, “%” should reflect the total population of the 
treatment groups.  Any deviation from that should be part of the footnote.  For 0 counts, leave the corresponding percentage blank. 
• 
The format for minimum and maximum should be “Min, Max”.  SD should be the default for representing scale, unless standard error has been 
specified.  Standard deviation should be abbreviated as “SD”, and presented next to the mean value, without any +/- sign.  The SD should have 
one additional decimal place beyond that of the mean (e.g. mean has one decimal place, SD should have two). 
• 
 “N” will represent the entire treatment group for the population group being analyzed, while “n” will represent a subset of the treatment 
group.  For tables with population designated as a row heading, “N” should be used (i.e. tables where all participant data is not available for 
every variable within a treatment group).  As a guideline, if the number is used in a denominator it should be presented as “N”.  If the number 
is used in the numerator, it should be presented as an “n”. 
• 
The heading should consist of four lines.  Line 1:  Sponsor identifier.  Line 2:  Protocol identifier.  Line 3: blank line.  Line 4:  Table/Appendix 
number  Table Title – Population.  The title for in-text tables should begin with the Table/Appendix number. 
• 
All data listings will be sorted by Patient Number and time point (if applicable). 
• 
The date format for all dates is DDMMMYYYY.  
A solid line should appear both above and below the column headings of a table.  A solid line should appear at the end of the table or at the bottom 
of each page if the table extends to more than one page.  Footnotes should start after the bottom solid line. 
 
10.   REFERENCES 
References are provided in the protocol.  


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11.   TABLES, FIGURES, AND LISTINGS 
See separate template document. 
 
12.   APPENDIX 
 
 


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12.1.   Appendix I. Study procedure and Parameters  
1. All pre-study assessments and scans should be done ≤ 4 weeks prior to registration with exception of first TURBT that showed 
muscularis propria invasion which can be done within 56 days. 
 
Procedures 
Screening 
TURBT1 
(if needed) 
Infusion 1 
Infusion 2* 
Surgery 
 
Off 
Treatment16 
Follow-
Up18 
Day 1 
Day 1 
 
 
 
 
 
Written Informed Consent 
X 
 
 
 
 
 
 
 
 
Pathology1 
X1 
X1 
 
 
 
 
 
 
 
Disease Characteristics2 
X 
 
 
 
 
 
 
 
 
Medical/Surgical History 
X 
 
 
 
 
 
 
 
 
Assessment of Baseline Signs & 
Symptoms 
X 
 
 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
 
Physical Exam including Weight 
X 
X 
X 
X 
X 
 
X 
 
 
Vital Signs3 
(Temperature, Pulse, Blood 
Pressure) 
X 
X 
X 
X 
X 
 
X 
 
 
Performance Status 
X 
X 
X 
X 
X 
 
X 
 
 
CBC/Differential/Platelets4 
X 
X 
X 
X 
X 
 
X 
 


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Procedures 
Screening 
TURBT1 
(if needed) 
Infusion 1 
Infusion 2* 
Surgery 
 
Off 
Treatment16 
Follow-
Up18 
Day 1 
Day 1 
 
 
 
 
 
Chemistry5 
X 
X 
X 
X 
X 
 
X 
 
 
Hepatitis B & C Testing6 
X 
 
 
 
 
 
 
 
 
TSH, FT3, FT47 
X 
 
 
X7 
X 
 
X 
 
 
Serum Pregnancy Test8 
X 
 
X8 
X8 
 
 
 
 
 
Serum Cortisol Level 
X 
 
 
 
X 
 
 
 
 
ECG 
X 
 
 
 
 
 
 
 
 
Chest/Abdomen/Pelvic CT with 
Contrast or MRI9 
X 
 
 
 
X15 
 
 
X 
 
Research Blood Specimens10 
X 
(Streck 
DNA tube 
only) 
 
X 
X 
X 
 
X 
X10 
 
Research Urine Specimens10 
 
 
X 
X 
X 
 
X 
X10 
 
Research Tissue Specimens11 
 
X 
 
 
X 
 
 
X11 
 
Treatment Administration12 
 
 
X 
X 
 
 
 
 
 
Oxygen Saturation by Pulse 
Oximetry13 
 
 
X 
X 
 
 
 
 


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Procedures 
Screening 
TURBT1 
(if needed) 
Infusion 1 
Infusion 2* 
Surgery 
 
Off 
Treatment16 
Follow-
Up18 
Day 1 
Day 1 
 
 
 
 
 
Radical Cystectomy with Pelvic 
Lymph Node Dissection14 
 
 
 
 
X 
 
 
 
 
Concomitant Medication Review 
X 
 
X 
X 
X 
 
X 
 
  Adverse Events Assessment 
 
 
X 
X 
X 
 
X17 
 
 
Survival Status 
 
 
 
 
 
 
 
X 
* 
Scheduled Visits: +/-3 day window is allowed for scheduled study therapy, required tests and/or visits except as otherwise noted. Delay due to holidays, 
weekends, bad weather or other unforeseen circumstances will be permitted. 
1 
Cystoscopy with TURBT showing muscularis propria should be performed within 8 weeks (56 days) of starting study therapy. Patients must have sufficient 
baseline tumor tissue from either the initial or repeat TURBTs. Tumor tissue content for CD8+ T-cell density assessment must be qualified as 
sufficient (≥ 20% tumor content in the specimen in initial or repeat TURBT with highest tumor content) for analysis and must be documented by 
the local pathologist prior to registration. (The actual CD8+ T-analysis does not need to be done by the Central Laboratory prior to registration.) This 
documentation can occur at any time prior to registration. Patients will complete all other screening studies (i.e. labs, imaging, history, exam, etc.) within 28 
days of starting study therapy. 
2 
Record date of diagnosis and stage. 
3 
Patients will have Temperature, Pulse and Blood Pressure taken at each visit. In addition, patients will have their blood pressure and pulse measured before, during and 
after the infusions at the following times: 
• 
At the beginning of the infusion 
• 
After nivolumab infusion and before lirilumab infusion for patients receiving lirilumab 
• 
At the end of the infusion 
4 
CBC with differential and platelet count which includes WBC, ANC, Platelets, Hemoglobin, and Hematocrit required prior to each dose of study therapy. 
Results known prior to treatment administration. 


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5 
Albumin, BUN/creatinine, uric acid, sodium, potassium, chloride, glucose, calcium, alkaline phosphatase, AST, ALT, total bilirubin, and total protein. 
6 
Hepatitis B surface antigen (HBsAg), and Hepatitis C (HCV) testing within 4 weeks of registration. These tests may be repeated during the course of the 
study, if clinically indicated. 
7 
TSH, FT3, FT4 at Screening and before Infusion 2, Day 1. 
8 
Required for sexually active females of child-bearing potential. Infusion 1 and Infusion 2: Must be within 24 hours prior to treatment with nivolumab. 
9 
CT with IV contrast is the preferred method. MRI exams of the chest/abdomen/pelvis may be performed, if CT of chest/abdomen/pelvis cannot be obtained. 
10 Research blood and urine samples shall be obtained at time points noted below. Refer to Section 14 for details. NOTE: Blood draw order is specified in the PrE0807 Lab 
Manual. 
Screening 
One 10 mL Streck DNA tube (for germline) 
Before First and Second Neoadjuvant Dose 
Peripheral Blood: One 10 mL red top tube, two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
Pre-Radical Cystectomy 
Peripheral Blood: One 10 mL red top tube, two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
Off Treatment Visit (approximately 30 days after Cystectomy) 
Peripheral Blood: One 10 mL red top tube and two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
At Time of Recurrence, if feasible 
Peripheral Blood: One 10 mL red top tube, two 10 mL green top tubes, one 10 mL Streck DNA tube and one 10 mL Streck RNA 
Urine: At least 30 mL in standard urine cup 
 
 
 
11 Research tumor tissue samples shall be obtained at time points noted below. Refer to Section 14 for details. 


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Screening/Study Entry 
FFPE: Up to 3 blocks preferred or 1 H&E slide plus minimum of 20 unstained slides (30 preferred) 
Radical Cystectomy 
FFPE: Up to 3 blocks preferred or 1 H&E slide plus minimum of 20 unstained slides (30 preferred) 
At Time of Recurrence, if feasible 
FFPE: Up to 3 blocks preferred or 1 H&E slide plus minimum of 20 unstained slides (30 preferred) 
12 See Section 6 for Treatment Plan and Section 7 for Dose Delays. 
Cohort 1: 
Nivolumab 480 mg IV over approximately 30 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) followed by radical cystectomy 
with bilateral (standard or extended) pelvic lymph node dissection as soon as possible but within 6 weeks after the last neoadjuvant infusion. 
Cohort 2: 
Nivolumab 480 mg IV over approximately 30 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) with at least a 30 minute rest between 
infusions followed by lirilumab 240 mg IV over approximately 60 minutes every 4 weeks for 2 neo-adjuvant doses (week 0 and 4) followed by radical 
cystectomy with bilateral (standard or extended) pelvic lymph node dissection as soon as possible but within 6 weeks after the last neo-adjuvant infusion. 
13 Record oxygen saturation by pulse oximetry at rest and after exertion at each on-study visit prior to dosing. 
14 Radical cystectomy with bilateral (standard or extended) pelvic lymph node dissection to be performed as soon as possible but within 6 weeks after the last 
neoadjuvant infusion. 
15 Obtain CTs (or MRI as noted above) after second dose of nivolumab +/- lirilumab and before surgery. 
16 Thirty (30) days +/- 7 days after cystectomy. If patient is removed from treatment for reason(s) other than progression, follow with regular tumor assessments per 
standard of care until progression or start of new treatment. Once a patient has initiated a new therapy, no further imaging assessments for this study are required. 
       NOTE: If cystectomy is not performed, Off Treatment visit should be performed at next scheduled appointment or treating physician discretion, as clinically indicated.         
                                                                        
17 Patients will be followed for adverse events for 100 days after their last dose of neoadjuvant therapy. Adverse events may be reviewed at the next visit ≥ 100 days after 
last dose of neoadjuvant therapy or phone follow-up may be done to review adverse events. However, an adverse event occurring at any time after discontinuation of 
study therapy that is felt to be at least possibly related to study therapy should be recorded. 
18 Patients will be followed clinically and radiographically for at least 2 years post-cystectomy or when study-wide follow-up ends per standard of care. Date of diagnosis for 
progression, first subsequent therapy and survival shall be reported. Phone follow-up may also be done for patients unable or unwilling to return for follow-up 
evaluations. 


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12.2.   Appendix II. Bladder Cancer TNM Staging  
American Joint Committee on Cancer TNM Staging System for Bladder Cancer 
 
Pathologic T Staging 
 
Tx – 
Primary tumor cannot be assessed 
 
T0 – 
No evidence of primary tumor 
 
Ta – 
Noninvasive papillary carcinoma which does not invade into the lamina propria 
 
Tis – 
Carcinoma in situ 
 
T1 – 
Tumor invades into the lamina propria but not into the muscularis propria 
 
T2 – 
Tumor invades into the muscularis propria 
 
T2a – 
Tumor invades into the inner half of the muscularis propria 
 
T2b – Tumor invades into the outer half of the muscularis propria 
 
T3 – 
Tumor invades into the perivesical tissue 
 
T3a – 
Tumor microscopically invades the perivesical tissue 
 
T3b – Tumor macroscopically invades the perivesical tissue 
 
T4 – 
Tumor invades into adjacent organs 
 
T4a – 
Tumor invades the prostatic stroma, uterus, or vagina 


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T4b – Tumor invades into the pelvic wall, or abdominal wall 
 
Pathologic N Staging 
Nx – 
Lymph nodes cannot be assessed 
N0 – 
No lymph node metastasis 
N1 – 
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node) 
N2 – 
Multiple regional lymph node metastases in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph nodes) 
N3 – 
Lymph node metastases to the common iliac lymph nodes 
 
Pathologic M Staging 
M0 – 
No distant metastasis 
M1 – 
Distant metastasis 
 
 


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13.
DOCUMENT HISTORY
Version Date 
Modified By 
Summary of Changes 
28Feb2019 
First draft, version 1.0 
26Mar2019 
Second draft, version 2.0 
1.
Added interim safety analysis in SAP section 7.8. Accordingly
identified 2 tables and 1 listing to be the 3 interim analysis
deliverables.
2.
Added study medication administration and summary analysis
in the SAP text and updated mock table.
3.
Removes one-year RFS analysis. There is only 2-year RFS.
Consistently used Recurrence-free instead of progression-free
11Apr2019 
Draft Version 2.1 
1.
Add specification of pathology response definition at section
7.7.3
2.
Add censoring date for RFS at section 7.74
29Apr2019 
Draft final Version 1.0 
Made from draft v2.1 by removing all comments to have a clear version. 
Updated the dates.  


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16May2019 
Final Version 1.0 
1.
Remove RFS and OS from Efficacy Population requirement items
5, and 6.
2.
The RFS and OS analyses are performed for Safety Population.
06Feb2020 
Final Version 1.1 
Update SAP to be consistent with protocol V3.0 10Dec2019