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7 safety reporting requirements/data and

An adverse event is defined as any reaction, side effect, or untoward event that occurs during the course of the clinical trial associated with the use of a drug in humans, whether or not the event is considered related to the treatment or clinically significant. For this study, AEs will include events reported by the patient, as well as clinically significant abnormal findings on physical examination or laboratory evaluation. A new illness, symptom, sign or clinically significant laboratory abnormality or worsening of a pre-existing condition or abnormality is considered an AE. All AEs, including clinically significant abnormal findings on laboratory evaluations, regardless of severity, will be followed until return to baseline or stabilization of event. Serious adverse events that occur more than 30 days after the last administration of investigational agent/intervention and have an attribution of at least possibly related to the agent/intervention should be recorded and reported as per sections 7.2, 7.3, and 7.4. An abnormal laboratory value will be considered an AE if the laboratory abnormality is characterized by any of the following:
x Results in discontinuation from the study x Is associated with clinical signs or symptoms x Requires treatment or any other therapeutic intervention x Is associated with death or another serious adverse event, including hospitalization. x Is judged by the Investigator to be of significant clinical impact  
x If any abnormal laboratory result is considered clinically significant, the investigator will provide details about the action taken with respect to the test drug and about the patient's outcome.
7.1.2 Suspected adverse reaction Suspected adverse reaction means any adverse event for which there is a reasonable possibility that the drug caused the adverse event. For the purposes of IND safety reporting, 'reasonable possibility' means there is evidence to suggest a causal relationship between the drug and the adverse event. A suspected adverse reaction implies a lesser degree of certainty about causality than adverse reaction, which means any adverse event caused by a drug.
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7.1.3 unexpected adverse reaction

An adverse event or suspected adverse reaction is considered "unexpected" if it is not listed in the investigator brochure or is not listed at the specificity or severity that has been observed; or, if an investigator brochure is not required or available, is not consistent with the risk information described in the general investigational plan or elsewhere in the current application. "Unexpected", also refers to adverse events or suspected adverse reactions that are mentioned in the investigator brochure as occurring with a class of drugs or as anticipated from the pharmacological properties of the drug, but are not specifically mentioned as occurring with the particular drug under investigation.
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7.1.4 serious

An Unanticipated Problem or Protocol Deviation is serious if it meets the definition of Serious Adverse Event or if it compromises the safety, welfare or rights of subjects or others.
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7.1.5 serious adverse event

An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
x Death  
x A life-threatening adverse drug experience x Inpatient hospitalization or prolongation of existing hospitalization x Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions x A congenital anomaly/birth defect. x Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.
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7.1.6 disability

A substantial disruption of a person's ability to conduct normal life functions.
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7.1.7 life-threatening adverse drug experience

Any adverse event or suspected adverse reaction that places the patient or subject, in the view of the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it does not include a reaction that had it occurred in a more severe form, might have caused death.
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7.1.8 protocol deviation (nih definition)

Any change, divergence, or departure from the IRB approved research protocol. 7.1.9 Protocol Non-compliance (NIH Definition) The failure to comply with applicable NIH Human Research Protections Program (HRPP) policies, IRB requirements, or regulatory requirements for the protection of human research subjects.  
7.1.10 Unanticipated Problem Any incident, experience, or outcome that:
x Is unexpected in terms of nature, severity, or frequency in relation to
(a) the research risks that are described in the IRB-approved research protocol and informed consent document; Investigator's Brochure or other study documents, and (b) the characteristics of the subject population being studied; AND  
x Is related or possibly related to participation in the research; AND x Suggests that the research places subjects or others at a g*reater risk of harm* (including physical, psychological, economic, or social harm) than was previously known or recognized.
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7.2 nci-irb and clinical director

7.2.1 NCI-IRB and NCI CD Expedited Reporting of Adverse Events , and Deaths The Protocol PI will report in the NIH Problem Form to the NCI-IRB and NCI Clinical Director:
x All deaths, except deaths due to progressive disease x All Protocol Deviations x All Unanticipated Problems x All non-compliance Reports must be received within 7 days of PI awareness via iRIS. 7.2.2 NCI-IRB Requirements for PI Reporting at Continuing Review The protocol PI will report to the NCI-IRB:  
1. A summary of all protocol deviations in a tabular format to include the date the deviation occurred, a brief description of the deviation and any corrective action.  
2. A summary of any instances of non-compliance 3. A tabular summary of the following adverse events:
x All Grade 2 **unexpected** events that are possibly, probably or definitely related to the research; x All Grade 3 and 4 events that are possibly, probably or definitely related to the research; x All Grade 5 events regardless of attribution; x All Serious Events regardless of attribution.
NOTE: Grade 1 events are not required to be reported.  
7.2.3 NCI-IRB Reporting of IND Safety Reports Only IND Safety Reports that meet the definition of an unanticipated problem will need to be reported to the NCI IRB.
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7.3 ind sponsor reporting criteria

An investigator must **immediately** report to the sponsor using the mandatory MedWatch form 3500a any serious adverse event, whether or not considered drug related, including those listed in the protocol or investigator brochure and must include an assessment of whether there is a reasonable possibility that the drug caused the event. All Grade 5 (fatal) events (except death due to progressive disease) must be reported via email within 24 hours. A complete report must be submitted within one business day. All other serious adverse events including deaths due to progressive disease must be reported within one business day Study endpoints that are serious adverse events (e.g. all-cause mortality) must be reported in accordance with the protocol unless there is evidence suggesting a causal relationship between the drug and the event (e.g. death from anaphylaxis). In that case, the investigator must immediately report the death to the sponsor. Events will be submitted to the Center for Cancer Research (CCR) at: CCRsafety@mail.nih.gov and to the CCR PI and study coordinator.
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7.3.1 reporting pregnancy 7.3.1.1 maternal

If a patient becomes pregnant during the course of the study, the study treatment should be discontinued immediately and the pregnancy reported to the Sponsor. The potential risk of exposure of the fetus to the Tremelimumab should be documented in box B5 of the MedWatch form "Describe Event or Problem". Pregnancy itself is not regarded as an SAE. However, as patients who become pregnant on study risk intrauterine exposure of the fetus to Tremelimumab which may be teratogenic, the CCR is requesting that pregnancy should be reported in an expedited manner as Grade 3 "Pregnancy, puerperium and perinatal conditions - Other (pregnancy)" under the Pregnancy, puerperium and perinatal conditions SOC. Congenital abnormalities or birth defects and spontaneous miscarriages should 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, ectopic pregnancy, normal birth, or congenital abnormality) should be followed up and documented. If any pregnancy occurs in the course of the study, then the investigator should inform the Sponsor within 1 day, i.e., immediately, but no later than 24 hours of when he or she becomes aware of it. The designated Sponsor representative will work with the investigator to ensure that all relevant information is provided to the Sponsor within 1 to 5 calendar days for SAEs and within 30 days for all other pregnancies. The same timelines apply when outcome information is available.
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7.3.1.2 paternal exposure

Male patients should refrain from fathering a child or donating sperm during the study and for 3 months after the last dose of Tremelimumab.  
Pregnancy of the patient's partner is not considered to be an AE. However, the outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) occurring from the date of the first dose until 3 months after the last dose of Tremelimumab should, if possible, be followed up and documented.
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7.4 safety reporting criteria to

All safety reports must be reported in the defined timelines to CCRsafety@mail.nih.gov.  
The CCR Office of Regulatory Affairs will send all reports to the MedImmune at: MedImmune or designee (PharmaNet/i3, LLC) contact information:
Patient Safety PharmaNet/i3, LLC MedImmune One MedImmune Way Gaithersburg, MD 20878 Fax: +1 301 398 4205
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7.5 data and safety monitoring

7.5.1 Principal Investigator/Research Team The clinical research team will meet on a regular basis when patients are being actively treated on the trial to discuss each patient. Decisions about dose level enrollment and dose escalation if applicable will be made based on the toxicity data from prior patients. All data will be collected in a timely manner and reviewed by the principal investigator or a lead associate investigator. Adverse events will be reported as required above. Any safety concerns, new information that might affect either the ethical and or scientific conduct of the trial, or protocol deviations will be immediately reported to the IRB using iRIS and to the Sponsor. The principal investigator will review adverse event and response data on each patient to ensure safety and data accuracy. The principal investigator will personally conduct or supervise the investigation and provide appropriate delegation of responsibilities to other members of the research staff.
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7.5.2 sponsor monitoring plan

As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring program. The CCR's program allows for confirmation of: study data, specifically data that could affect the interpretation of primary study endpoints; adherence to the protocol, regulations, and SOPs; and human subjects protection. This is done through independent verification of study data with source documentation focusing on:
x Informed consent process  
x Eligibility confirmation x Drug administration and accountability x Adverse events monitoring x Response assessment.
The monitoring program also extends to multi-site research when the CCR is the coordinating center. This trial will be monitored by personnel employed by an NCI contractor. Monitors are qualified by training and experience to monitor the progress of clinical trials. Personnel monitoring this study will not be affiliated in any way with the trial conduct.
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8 statistical considerations

The primary objective of this pilot study is to determine if it is feasible to administer three doses of Tremelimumab to patients with hepatocellular carcinoma (HCC) and to determine clinical efficacy in several cohorts of patients. Secondary objectives include examining a variety of immunologic parameters prior to treatment and after treatment to determine if there is evidence of patients exhibiting an immune response to treatment, to assess safety and toxicity and to determine the feasibility of administering 3 doses of tremelimumab in addition to RFA in patients with biliary tract cancer.
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8.1 cohorts a and b

Relative to the feasibility endpoint, this will be decided in Cohorts A and B; all patients enrolled into Cohorts A and B at the 10 mg/kg dose level will be considered as one group for feasibility evaluation. Feasibility will be evaluated in the first 20 evaluable patients enrolled in in these two cohorts on this trial at the 10mg/kg dose level following a dose-escalation phase of 3-6 patients treated at 3.5mg/kg dose level. The safety of the 10 mg/kg dose level will be evaluated in the first 3-6 patients treated at that dose. If there are 2 or more DLTs among the first 3-6 patients treated at this level, then accrual would stop. Regarding feasibility, it would be desirable if the fraction of patients who could receive three doses of the monoclonal antibody were consistent with 80% or higher and greater than 50%. With 20 evaluable patients, if there are 14 or more patients who are able to receive three doses of the monoclonal antibody, then there is a 5.8%
probability of this being true if the true probability of an individual patient being able to receive this much antibody were 50% and there is a 91.3% probability of this being true if the true probability for an individual were 80%. Thus, 14 or more out of 20 patients receiving three doses of antibody would provide strong evidence that it is feasible to administer this antibody in a substantial fraction of patients, consistent with 80% or more and this would be considered a successful outcome for the trial. Prior to amendment G, administration of three doses has been determined to be feasible based on the first 20 total patients enrolled and the feasibility evaluation was considered to have ended at that point. Evaluations for clinical efficacy will be the primary objective from this point forward. With amendment G, there will be 20 patients enrolled in cohort A at 10mg/kg (10 receiving RFA and 10 receiving TACE). Each of these sub-cohorts will be evaluated for efficacy as follows. In each sub-cohort of 10 patients the trial will have 82% power to rule out 15% 6 month as the proportion stable at 6 months in favor of 50% being stable at 6 months, with each evaluation assuming that a one-sided 0.10 significance level exact binomial test would be performed. If there are 3 patients in 10 who are able to have stable disease at a 6 month evaluation, then the lower one-sided 90% confidence bound for 3/10 is 11.6% (the two sided 80% confidence interval extends from 11.6% to 55.2%). Similarly, with 4 in 10 with stable disease at 6 months, the lower one-sided 90% confidence bound for 4/10 is 18.8% (the two sided 80% confidence interval extends from 18.8% to 64.6%). Thus, in Cohort A, 3 or 4 patients out of 10 attaining stable disease at 6 months with either TACE or RFA would rule out 10-15% as the fraction who would do so, with 90% one sided confidence. The results from the two sub-cohorts of cohort A treated at 10 mg/kg may also have their results combined in an exploratory fashion to report their overall efficacy. Also by Amendment G, cohort B will be expanded to allow 20 evaluable patients to be enrolled for efficacy. With this number of patients, this cohort will have 97% power to rule out 15% as the proportion stable at 6 months in favor of 50% being stable at 6 months, with the evaluation assuming that a one-sided 0.10 significance level exact binomial test would be performed. If there are 6 patients in 20 who are able to have stable disease at a 6 month evaluation, then the lower one-sided 90% confidence bound for 6/20 is 16.6% (the two sided 80% confidence interval extends from 16.6% to 46.7%). Thus, in cohort B, having 6 or greater patients attaining stable disease at 6 months would rule out 15% as the fraction who would do so, with 90% onesided confidence.
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8.2 cohorts d- e

With amendment F, one additional cohort of N=10 patients will be added to explore the immune effects of combining tremelimumab with cryoablation (Cohorts D) and one cohort with RFA in a BTC population. Thus, there will be 2 new cohorts added at this time for a total of 20 additional patients. Results to date from cohorts A and B suggest that the overall procedure is very likely to meet its feasibility goal since 9/10 patients have done so as of the date this amendment was constructed. As a result, the goal of the two new cohorts is to determine in a preliminary fashion if the treatment proposed in each cohort is able to offer clinical benefit to patients. Data on similar patients suggests a median time to progression of approximately 2 months, and approximately 10-15% would have stable disease at 6 months. It would be a very meaningful improvement if the treatment proposed could be associated with results which were consistent with 50% of patients having stable disease at 6 months. With the goal of keeping the trial small, in each cohort of 10 patients the trial will have 82% power to rule out 15% as the proportion stable at 6 months in favor of 50% being stable at 6 months, with each evaluation assuming that a one-sided 0.10 significance level exact binomial test would be performed. As a practical matter, 10 patients will be enrolled in each of the two cohorts and if there are 3 patients in 10 who are able to have stable disease at a 6 month evaluation, then the lower one-sided 90% confidence bound for 3/10 is 11.6% (the two sided 80% confidence interval extends from 11.6% to 55.2%). Similarly, with 4 in 10 with stable disease at 6 months, the lower one-sided 90% confidence bound for 4/10 is 18.8% (the two sided 80% confidence interval extends from 18.8% to 64.6%). Thus, in any given cohort, 3 or 4 patients attaining stable disease at 6 months would rule out 10-15% as the fraction who would do so, with 90% one sided confidence. With amendment G, cohort E (cholangiocarcinoma patients) will be expanded to a total of 20 patients. This cohort will have 97% power to rule out 15% as the proportion stable at 6 months in favor of 50% being stable at 6 months, with the evaluation assuming that a one-sided 0.10 significance level exact binomial test would be performed. If there are 6 patients in 20 who are able to have stable disease at a 6 month evaluation, then the lower one-sided 90% confidence bound for 6/20 is 16.6% (the two sided 80% confidence interval extends from 16.6% to 46.7%). Thus, in cohort E, having 6 or greater patients attaining stable disease at 6 months would rule out 15% as the fraction who would do so, with 90% one-sided confidence. In addition to evaluations of response and 6 month disease stabilization, Kaplan-Meier curves for progression free survival (PFS) will be constructed based on each of cohorts A, B, and E.
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8.3 secondary and exploratory analyses

In all cohorts, the actual levels of changes of immune parameters will also be determined, and the fractions that are noted to have a change in the parameter values which would be considered immune responses will be reported. These will be considered secondary and exploratory analyses. Exploratory analyses may also be done informally comparing results for those receiving one procedure with another, e.g. RFA vs. TACE. In cohort B, 20 patients are expected to be enrolled (following amendment G); the same types of analyses are anticipated, but will be considered very tentative and hypothesis generating in view of the small numbers of patients to be evaluated. Safety and toxicity will also be evaluated and addressed by tabulating and monitoring the grades of toxicity experienced by patients in the study. At the conclusion of the trial, the clinical results and the immune parameter results may be used to arrive at an overall judgment involving which cohort or cohorts may merit expansion or further evaluation in subsequent trials.
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8.4 accrual

It is expected that up to 2 patients per month may be able to enroll onto this trial. Cohort A may theoretically enroll a maximum of 26 evaluable patients at both dose levels combined, and there also may be 20 evaluable patients in cohort B, 10 in cohort D, and 20 in cohort E. The accrual ceiling for the protocol will be set at 90 patients to allow for a small number of inevaluable patients. Thus, it is expected that 48-60 months may be needed to accrue all patients onto this trial.
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9 collaborative agreements 9.1 cooperative

A CRADA (02853) is in place with MedImmune, Inc. for supply of the investigational agent. 9.2 MATERIAL TRANSFER AGREEMENTS **(MTA)** MTA (38376-14) is in place with Hannover Medical School MTA (40860-16) is in place with Adaptive Biotechnologies
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10 human subjects protections 10.1

Subjects treated on this study, will be individuals with advanced hepatocellular carcinoma (HCC), which has recurred (or persisted) after appropriate standard treatment. Individuals of any race or ethnic group will be eligible for this study. Eligibility assessment will be based solely on the patient's medical status. Recruitment of patients onto this study will be through standard CCR mechanisms. No special recruitment efforts will be conducted.
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10.2 participation of children

Individuals under the age of 18 will not be eligible to participate in this study because they are unlikely to have hepatocellular or biliary tract carcinoma, and because of unknown toxicities in pediatric patients.
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10.3 participation of subjects unable

Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent may be necessary and there is a possibility, though unlikely, that subjects could become decisionally impaired. For this reason and because there is a prospect of direct benefit from research participation (section **10.5**), all subjects will be offered the opportunity to fill in their wishes for research and care, and assign a substitute decision maker on the "NIH Advance Directive for Health Care and Medical Research Participation" form so that another person can make decisions about their medical care in the event that they become incapacitated or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent Assessment Team for evaluation. For those subjects that become incapacitated and do not have pre-determined substitute decision maker, the procedures described in MEC Policy 87-4 for appointing a surrogate decision maker for adult subjects who are (a) decisionally impaired, and (b) who do not have a legal guardian or durable power of attorney, will be followed.
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10.4 evaluation of benefits and

This research study involves three CT guided biopsies collected for research purposes only. Subjects undergoing three optional biopsy collection will be exposed to 2.3 rem. This amount of radiation is below the guideline of 5 rem per year allowed for adult research subjects by the NIH Radiation Safety Committee.
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10.4.2 risk of optional biopsy

All care will be taken to minimize risks that may be incurred by tumor sampling. However, there are procedure-related risks (such as bleeding, infection and visceral injury) that will be explained fully during informed consent.
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10.4.3 other risks/benefits

The potential benefit to a patient that goes onto study is a reduction in the bulk of their tumor which may or may not have favorable impact on symptoms and/or survival. Potential risks include the possible occurrence of any of a range of side effects which are listed in the Consent Document. The procedure for protecting against or minimizing risks will be to medically evaluate patients on a regular basis as described.
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10.5 risks/benefits analysis

For patients with hepatocellular carcinoma and biliary cancer, median survival is in the range of 6 months. It is possible that treatment on this protocol may reduce tumor burden or lessen symptoms caused by the cancer. While treatment on this protocol may not individually benefit subjects. The knowledge gained from this study may help others in the future who have hepatocellular carcinoma. Potential risks include the possible occurrence of any of a range of side effects listed. If patients suffer any physical injury as a result of the biopsies, immediate medical treatment is available at the NIH's Clinical Center in Bethesda, Maryland. Although no compensation is available, any injury will be fully evaluated and treated in keeping with the benefits or care to which patients are entitled under applicable regulations.
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10.6 consent and assent process

Patients will meet with an associate or principal investigator on the trial in the GI oncology Clinic, during the initial evaluation for this study. During that meeting, the investigator will inform patients of the purpose, alternatives, treatment plan, research objectives and follow-up of this trial. The investigator will then provide a copy of the IRB-approved informed consent document that is included in this protocol. The patient will be allowed to take as much time as he wishes, in deciding whether or not he wishes to participate. If a prolonged period of time expires during the decision making process (several weeks, as an example), it may be necessary to reassess the patient for protocol eligibility. The original signed consent goes to Medical Records; copy placed in research record (NIH policy).  
All patients must have a signed informed consent form and an on-study (confirmation of eligibility) form filled out and signed by a participating investigator before entering on the study. 10.6.1 Telephone re-consent The informed consent document will be sent to the subject. An explanation of the study will be provided over the telephone after the subject has had the opportunity to read the consent form. The subject will sign and date the informed consent. A witness to the subject's signature will sign and date the consent. The original informed consent document will be sent back to the consenting investigator who will sign and date the consent form with the date the consent was obtained via telephone. A fully executed copy will be returned via mail for the subject's records. The informed consent process will be documented on a progress note by the consenting investigator and a copy of the informed consent document and note will be kept in the subject's research record. 10.6.2 Informed consent of non-English speaking subjects If there is an unexpected enrollment of a research participant for whom there is no translated extant IRB approved consent document, the principal investigator and/or those authorized to obtain informed consent will use the Short Form Oral Consent Process as described in MAS Policy M77-2, OHSRP SOP 12, 45 CFR 46.117 (b) (2), and 21 CFR 50.27 (b) (2)). The summary that will be used is the English version of the extant IRB approved consent document. Signed copies of both the English version of the consent and the translated short form will be given to the subject or their legally authorized representative and the signed original will be filed in the medical record. Unless the PI is fluent in the prospective subject's language, an interpreter will be present to facilitate the conversation (using either the long translated form or the short form). Preferably someone who is independent of the subject (i.e., not a family member) will assist in presenting information and obtaining consent. Whenever possible, interpreters will be provided copies of the relevant consent documents well before the consent conversation with the subject (24 to 48 hours if possible).  
69 We request prospective IRB approval of the use of the short form process for non-English speaking subjects and will notify the IRB at the time of continuing review of the frequency of the use of the Short Form.
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11 pharmaceutical information 11.1 tremelimumab

Tremelimumab is a human IgG2 anti-CTLA-4 mAb that is being developed as an immunotherapeutic agent for various cancers. Tremelimumab will be supplied by MedImmune.  
| Investigational Product   | Manufacturer   | Concentration and                                                                                                                                                                                                   |
|---------------------------|----------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Formulation as Supplied   |                |                                                                                                                                                                                                                     |
| Tremelimumab              | MedImmune      | Formulated at a nominal  concentration of 20 mg/mL in  20 mM histidine/histidine  hydrochloride, 222 mM  trehalose dihydrate, 0.02%  (w/v) polysorbate 80, and 0.27  mM disodium edetate dihydrate  (EDTA), pH 5.5. |  
Tremelimumab is to be administered as an IV solution of 10 mg/kg at a rate of 250 mL/hr, followed by observation for 60 minutes.
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11.1.1 investigational product dose preparation

Tremelimumab is supplied as a sterile IV solution, filled in 20 mL clear glass vials with a rubber stopper and aluminum seal. Each vial contains 20 mg/mL (with a nominal fill of 20 mL
accounting to 400 mg/vial) of Tremelimumab, in an isotonic solution at pH 5.5. Vials containing Tremelimumab must be stored in the refrigerator at 2-8oC. The 20 mg/mL solution will be diluted into a saline bag for IV infusion. Vials containing Tremelimumab may be gently inverted for mixing, but should not be shaken. For dose preparation steps, the following ancillary items are required:  
x IV infusion bags of 0.9% sodium chloride injection (250 mL size). Saline bags must be latex-free and can be made of polyvinyl chloride (PVC) or polyolefins (e.g. polyethylene), manufactured with bis (2-ethylhexyl) phthalate (DEHP) or DEHP-free.  
x IV infusion lines made of PVC/DEHP or PVC/tri octyl trimellitate (TOTM) or polyethylene or polyurethane. All DEHP-containing or DEHP-free lines are acceptable. Lines should FRQWDLQDRUȝPLQ-line filter. The in-line filter can be made of
polyethersulfone (PES) or polyvinylidene fluoride DRF (PVDF). Lines containing cellulose-based filters should not be used with Tremelimumab.  
x Catheters/infusion sets made of polyurethane or fluoropolymer with silicone and stainless steel and/or PVC components.  
x Syringes made of polypropylene and latex-free. Polycarbonate syringes should not be used with Tremelimumab.  
x Needles made of stainless steel.  
11.1.2 Dose Calculation
The subject's weight (in kilograms) must be measured prior to each dosing for dose calculation. Measurements can be taken in street clothes without shoes and a calibrated scale must be used for all measurements. The dose will be calculated at each dosing visit using the following formula:
Dose (mL) = [subject weight (kg) × dose level (10 mg/kg)] drug concentration (20 mg/mL)
The corresponding volume of investigational product should be rounded to the nearest tenth of a mL (0.1 mL). Each vial contains a small amount of overage and the overage should be utilized as much as possible before using another vial. The number of vials required for dose preparation is the next greatest whole number of vials from the following formula: Number of vials = Dose (mL) ÷ 20 (mL/vial) 11.1.3 Investigational Product Inspection Each vial selected for dose preparation should be inspected. If there are any defects noted with the investigational product, the investigator and site monitor should be notified immediately. Refer to the Product Complaint section (**10.1.6)** for further instructions. During the inspection if the solution is not clear or any turbidity, discoloration or particulates are observed, notify your site monitor and store the vial(s) in QUARANTINE at refrigerated (2-8ºC)
temperature for drug accountability and potential future inspection.  
Notify the IXRS that the unusable vials are damaged. The IXRS will indicate the replacement vials. Select appropriate replacement vials for the preparation of the subject's dose, and perform the same inspection on the newly selected vials. For accountability, record the total number of vials removed from site inventory. Used vials should be held for accountability purposes at ambient storage temperature.
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11.1.4 dose preparation steps

Tremelimumab does not contain preservatives and any unused portion must be discarded. Preparation of Tremelimumab and preparation of the IV bag are to be performed aseptically. Total in-use storage time for the prepared final IV bag should not exceed 24 hours at 2-8°C or 4 hours at room temperature (25°C). However, it is recommended that the prepared final IV bag be stored in the dark at 2-8°C until needed. The refrigerated infusion solutions in the prepared final IV bag should be equilibrated at room temperature for about 2 hours prior to administration. If storage time exceeds these limits, a new dose must be prepared from new vials. The investigational product manager or qualified personnel will be responsible for preparing the IV doses using the following steps: 1) Select the IXRS-assigned number of vials of investigational product required to prepare the subject's dose. 2) All investigational product vials should be equilibrated to room temperature for 30 minutes prior to dose preparation. 3) To prepare the IV bag, first, calculate the dose volume of investigational product required. Second, remove the volume of 0.9% sodium chloride IV solution equivalent to the calculated dose volume of investigational product from the IV bag. Lastly, add the calculated dose volume of investigational product to the IV bag. Gently mix the solution in the bag by inverting up and down. Avoid shaking the IV bag to prevent foaming. Example: A subject weighing 85 kg will require 42.5 mL (3 vials) of investigational product. Remove 42.5 mL of saline from the commercial IV bag. Add the 42.5 mL of investigational product to the IV bag and gently mix by inverting up and down. Tremelimumab should be stored at refrigerated temperatures (2°C to 8°C), and should not be frozen. Labels will be prepared in accordance with Good Manufacturing Practice (GMP). 11.1.5 Investigational Product Accountability The investigator's or site's designated investigational product manager is required to maintain accurate investigational product accountability records. Upon completion of the study, copies of investigational product accountability records will be returned to MedImmune. All unused investigational product will be returned to a MedImmune-authorized depot or disposed of upon authorization by MedImmune.
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11.1.6 reporting product complaints

Any defects with the investigational product must be reported *immediately* to the MedImmune Product Complaint Department by the site with further notification to the site monitor. All defects will be communicated to MedImmune and investigated further with the Product Complaint Department. During the investigation of the product complaint, all investigational products must be stored at labeled conditions unless otherwise instructed. Product defects may be related to component, product, or packaging and labeling issues. The list below includes, but is not limited to, descriptions of product complaints that should be reported. Component Issue: Defect in container or dosing mechanism of the investigational product. The component defect may be damaged, missing, or broken. Component examples include vials, stoppers, caps, spray barrels, spray nozzles, or plungers. Product Issue: Defect in the product itself. The product appearance has visual imperfections such as foreign particles, crystallization, discoloration, turbidity, insufficient volume, or anything that does not apply to the product description. Packaging/Labeling Issue: Defect in the packaging or labeling of the product. The packaging or labeling defects may be damaged or unreadable, or the label may be missing. When reporting a product complaint, site staff must be prepared to provide the following information: 1) Customer information: reporter name, address, contact number, and date of complaint 2) Product information: product name, packaging kit number or lot number, expiry date, and clinical protocol number 3) Complaint information: complaint issue category and description MedImmune contact information for reporting product complaints:
Email: productcomplaints@medimmune.com Phone: +1-301-398-2105 +1-877-MEDI-411 (+1-877-633-4411) Fax: +1-301-398-8800 Mail: MedImmune, LLC Attn: Product Complaint Department One MedImmune Way, Gaithersburg, MD USA 20878
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12 references

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76 43. Apetoh L, Ghiringhelli F, Tesniere A, et al. Toll-like receptor 4-dependent contribution of the immune system to anticancer chemotherapy and radiotherapy. Nat Med 2007;13:1050-9. 44. Suzuki Y, Mimura K, Yoshimoto Y, et al. Immunogenic tumor cell death induced by chemoradiotherapy in patients with esophageal squamous cell carcinoma. Cancer Res 2012;72:3967-76. 45. Dewan MZ, Galloway AE, Kawashima N, et al. Fractionated but not single-dose radiotherapy induces an immune-mediated abscopal effect when combined with anti-CTLA-4 antibody. Clin Cancer Res 2009;15:5379-88. 46. Demaria S, Kawashima N, Yang AM, et al. Immune-mediated inhibition of metastases after treatment with local radiation and CTLA-4 blockade in a mouse model of breast cancer. Clin Cancer Res 2005;11:728-34.  
47. Gulley JL, Madan RA, Tsang KY, et al. A pilot safety trial investigating a vector-based vaccine targeting carcinoembryonic antigen in combination with radiotherapy in patients with gastrointestinal malignancies metastatic to the liver. Expert Opin Biol Ther;11:1409-18. 48. Hiraki M, Nishimura J, Ohtsuka M, et al. Impact of stereotactic body radiotherapy on colorectal cancer with distant metastases. Oncology reports 2014;31:795-9. 49. Nouhaud E, Crehange G, Cueff A, et al. Stereotactic Body radiation therapy for liver tumors with or without rotational intensity modulated radiation therapy. BMC research notes 2013;6:492. 50. Habermehl D, Herfarth KK, Bermejo JL, et al. Single-dose radiosurgical treatment for hepatic metastases - therapeutic outcome of 138 treated lesions from a single institution. Radiation oncology 2013;8:175. 51. Lausch A, Sinclair K, Lock M, et al. Determination and comparison of radiotherapy dose responses for hepatocellular carcinoma and metastatic colorectal liver tumours. The British journal of radiology 2013;86:20130147. 52. Wang C, Wang H, Yang W, et al. A multicenter randomized controlled trial of percutaneous cryoablation versus radiofrequency ablation in hepatocellular carcinoma. Hepatology 2014. 53. Sidana A. Cancer immunotherapy using tumor cryoablation. Immunotherapy 2014;6:8593. 54. Valle J, Wasan H, Palmer DH, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. The New England journal of medicine 2010;362:1273-81. 55. El-Serag HB, Engels EA, Landgren O, et al. Risk of hepatobiliary and pancreatic cancers after hepatitis C virus infection: A population-based study of U.S. veterans. Hepatology 2009;49:116-23. 56. West J, Wood H, Logan RF, Quinn M, Aithal GP. Trends in the incidence of primary liver and biliary tract cancers in England and Wales 1971-2001. Br J Cancer 2006;94:1751-8. 57. Goeppert B, Frauenschuh L, Zucknick M, et al. Prognostic impact of tumour-infiltrating immune cells on biliary tract cancer. Br J Cancer 2013;109:2665-74.  
77 58. Ye Y, Zhou L, Xie X, Jiang G, Xie H, Zheng S. Interaction of B7-H1 on intrahepatic cholangiocarcinoma cells with PD-1 on tumor-infiltrating T cells as a mechanism of immune evasion. Journal of surgical oncology 2009;100:500-4.  
59. Nakakubo Y, Miyamoto M, Cho Y, et al. Clinical significance of immune cell infiltration within gallbladder cancer. Br J Cancer 2003;89:1736-42. 60. Ribas A, Puzanov I, Dummer R, et al. Pembrolizumab versus investigator-choice chemotherapy for ipilimumab-refractory melanoma (KEYNOTE-002): a randomised, controlled, phase 2 trial. Lancet Oncol 2015;16:908-18. 61. Nghiem PT, Bhatia S, Lipson EJ, et al. PD-1 Blockade with Pembrolizumab in Advanced Merkel-Cell Carcinoma. The New England journal of medicine 2016;374:2542-52. 62. Massard C, Gordon MS, Sharma S, et al. Safety and Efficacy of Durvalumab
(MEDI4736), an Anti-Programmed Cell Death Ligand-1 Immune Checkpoint Inhibitor, in Patients With Advanced Urothelial Bladder Cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2016;34:3119-25. 63. Reck M R-AD, Robinson AG et al. Pembrolizumab versus Chemotherapy for PD-L1- Positive Non-Small-Cell Lung Cancer. 2016. 64. Robert C RA, Hamid O et al. Three-year overall survival for patients with advanced melanoma treated with pembrolizumab in KEYNOTE-001 65. Lipson EJ, Sharfman WH, Drake CG, et al. Durable cancer regression off-treatment and effective reinduction therapy with an anti-PD-1 antibody. Clin Cancer Res 2013;19:462-8. 66. Champiat S, Lambotte O, Barreau E, et al. Management of immune checkpoint blockade dysimmune toxicities: a collaborative position paper. Ann Oncol 2016;27:559-74. 67. Naidoo J, Page DB, Li BT, et al. Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies. Ann Oncol 2016;27:1362. 68. Korangy F, Ormandy LA, Bleck JS, et al. Spontaneous tumor-specific humoral and cellular immune responses to NY-ESO-1 in hepatocellular carcinoma. Clin Cancer Res 2004;10:4332-41.
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13 appendices

| 13.1                                                                                                                                                                                       | APPENDIX A: PERFORMANCE STATUS CRITERIA                                 |                                                                    |             |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------|--------------------------------------------------------------------|-------------|
| ECOG Performance Status Scale                                                                                                                                                              | Karnofsky Performance Scale                                             |                                                                    |             |
| Grade                                                                                                                                                                                      | Descriptions                                                            | Percent                                                            | Description |
| 100                                                                                                                                                                                        | Normal, no complaints, no  evidence of disease.                         |                                                                    |             |
| Normal activity. Fully active, able                                                                                                                                                        |                                                                         |                                                                    |             |
| 0                                                                                                                                                                                          | to carry on all pre-disease  performance without restriction.           | Able to carry on normal activity;                                  |             |
| 90                                                                                                                                                                                         | minor signs or symptoms of  disease.                                    |                                                                    |             |
| Symptoms, but ambulatory.  Restricted in physically strenuous  activity, but ambulatory and able to  carry out work of a light or  sedentary nature (e.g., light  housework, office work). | 80                                                                      | Normal activity with effort; some  signs or symptoms of disease.   |             |
| 1                                                                                                                                                                                          | Cares for self, unable to carry on                                      |                                                                    |             |
| 70                                                                                                                                                                                         | normal activity or to do active  work.  Requires occasional assistance, |                                                                    |             |
| 60                                                                                                                                                                                         | but is able to care for most of  his/her needs.                         |                                                                    |             |
| In bed <50% of the time.  Ambulatory and capable of all selfcare, but unable to carry out any  work activities. Up and about more  than 50% of waking hours.                                                                                                                                                                                            |                                                                         |                                                                    |             |
| 2                                                                                                                                                                                          | 50                                                                      | Requires considerable assistance  and frequent medical care.       |             |
| 40                                                                                                                                                                                         | Disabled, requires special care and  assistance.                        |                                                                    |             |
| In bed >50% of the time. Capable  of only limited self-care, confined  to bed or chair more than 50% of  waking hours.                                                                     |                                                                         |                                                                    |             |
| 3                                                                                                                                                                                          | 30                                                                      | Severely disabled, hospitalization  indicated. Death not imminent. |             |
| 20                                                                                                                                                                                         | Very sick, hospitalization  indicated. Death not imminent.              |                                                                    |             |
| 100% bedridden. Completely  disabled. Cannot carry on any selfcare. Totally confined to bed or  chair.                                                                                                                                                                                            |                                                                         |                                                                    |             |
| 4                                                                                                                                                                                          | 10                                                                      | Moribund, fatal processes  progressing rapidly.                    |             |
| 5                                                                                                                                                                                          | Dead.                                                                   | 0                                                                  | Dead.       |  
| Points assigned   |                 |                 |            |
|-------------------|-----------------|-----------------|------------|
| Parameter         | 3               |                 |            |
| 1                 | 2               |                 |            |
| Ascites           | Absent          | Slight          | Moderate   |
| Bilirubin         | <2 mg/dL        | 2-3 mg/dL       | > mg/dL    |
| ( <34.2           | (34.2 to 51.3   | (>51.3          |            |
| micromol/liter)   | micromol/liter) | micromol/liter) |            |
| Albumin           | >.3.5 g/dL (35  | 2.8-3.5 g/dL    | < 2.8 g/dL |
| g/liter)          | (28 to 35       | ( <28 g/liter)  |            |
| g/liter)          |                 |                 |            |
| Prothrombin time  |                 |                 |            |
| Seconds over      | <4              | 4-6             | >6>        |
| control           |                 |                 |            |
| INR               | <1.7            | 1.7-2.3         | >2.3       |
| Ence phalopathy   | None            | Grade 1-2       | Grade 3-4  |  
13.2 A PPENDIX B: C HILD - P UGH CLASSIFICATION SYSTEM
Modified Child-Pugh classification of the severity of liver disease according to the degree of ascites, the plasma concentrations of bilirubin and albumin, the prothrombin time, and the degree of encephalopathy. A total score of 56 is considered grade A (well-compensated disease); 7-9 is grade B (significant functional compromise); and 10-15 is grade C (decompensated disease). These grades correlate with one- and two-year patient survival: grade A - 100 and 85 percent; grade B - 80 and 60 percent; and grade C - 45 and 35 percent.
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13.3 appendix c modified immune-related

This new classification is based on the recent learning from clinical studies with cancer immunotherapies that even if some new lesions appear at the beginning of a treatment or if the total tumor burden does not increase substantially, tumor regressions or stabilizations might still occur later. The irRC were created using bi-dimensional measurements (as previously widely used in the World Health Organization criteria). For this trial, the concepts of the irRC are combined with RECIST 1.1 to come up with the modified irRC. For modified irRC, only target and measurable lesions are taken into account. In contrast to the RECIST 1.1 criteria, the modified irRC criteria (a) require confirmation of both progression and response by imaging at 6 weeks after initial imaging and (b) do not necessarily score the appearance of new lesions as progressive disease if the sum of lesion diameters of target lesions (minimum of 10 mm per lesion, maximum of 5 target lesions, maximum of 2 per organ) and PHDVXUDEOHQHZOHVLRQVGRHVQRWLQFUHDVHE\ The same method of assessment and the same technique should be used to characterize each identified and reported target lesion(s) at baseline, during the trial, and at the end of trial visit. All measurements should be recorded in metric notation. The modified irRC based on RECIST 1.1 are displayed below.  
| Measurable Response                                                                                        | Non-Measurable Response   | Overall Response   |       |
|------------------------------------------------------------------------------------------------------------|---------------------------|--------------------|-------|
| Using Modified irRC                                                                                        |                           |                    |       |
| Index and New, Measurable                                                                                  | Non-Index Lesions         | New, Non-          |       |
| Lesions (Tumor Burden)¹                                                                                    | Measurable Lesions        |                    |       |
| Decrease 100%                                                                                              | Absent                    | Absent             | irCR² |
| Decrease 100%                                                                                              | Stable                    | Any                | irPR² |
| Decrease 100%                                                                                              | irPR²                     |                    |       |
| Unequivocal progression                                                                                    | Any                       |                    |       |
| Decrease ≥ 30%                                                                                             | Absent / Stable           | Any                | irPR² |
| Decrease ≥ 30%                                                                                             | Unequivocal progression   | Any                | irPR² |
| Decrease < 30% to increase <                                                                               | Absent / Stable           | Any                | irSD  |
| 20%                                                                                                        |                           |                    |       |
| Decrease < 30% to increase <                                                                               | Unequivocal progression   | Any                | irSD  |
| 20%                                                                                                        |                           |                    |       |
| Increase ≥ 20%                                                                                             | Any                       | Any                | irPD  |
| Decreases assessed relative to baseline                                                                    |                           |                    |       |
| 2 Assuming that the response (irCR and irPR) and progression (irPD) are confirmed by a second, consecutive |                           |                    |       |
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overall responses derived from changes

assessment at least 4 weeks apart (normally it should be done 6 weeks apart).
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13.4 appendix d medimmune sample

1. Draw maximum volume of blood into gold top SST tube (s). Record time of collection. 2. Gently invert 5 times. 3. Allow the blood to clot for 30 minutes at room temperature. 4. Centrifuge within 2 hours of collection at 1100 -1300 g for 15 minutes. 5. Transfer serum into labeled cryovials. 6. Immediately freeze the cryovials upright at -20ºC or colder. 7. Store at -20ºC or colder until shipment on dry ice.
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plasma- k2 edta tube

1. Draw maximum volume of blood into lavender top K2 EDTA tube(s). Record time of collection 2. Gently invert 8 to 10 times. 3. Centrifuge within 2 hours of collection at 1100 -1300 g for 10 minutes. 4. Transfer plasma into labeled cryovials. 5. Immediately freeze the cryovials upright at -20ºC or colder. 6. Store at -20ºC or colder until shipment on dry ice. Tube Label should include: 1. Patient Identifier 2. Sample ID (Serum 1, Cycle 1, Day 1etc.) 3. Sample type (plasma, serum) 4. Sample volume 5. Collection time 6. Barcode (if this system is available)