untitled h1
untitled h2

UMCC 2018.052 Multi-center Trial of ESK981 in Combination With Nivolumab in Patients With Metastatic Renal Cell Carcinoma NCT03562507 PROTOCOL UMCC 2018.052 ERICA: Phase 2 Multi-Center Trial of ESK981 in Combination with Nivolumab **in Patients With**
Metastatic Renal Cell Carcinoma  
| Principal Investigator:   | Ajjai Alva, MD Hematology/Oncology University of Michigan  7310 Cancer Center 1500 E. Medical Center Drive Ann Arbor, MI 48109 Phone: (734) 936-0091 Fax: (734) 615-2719 Email: ajjai@umich.edu      |
|---------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| IND #:                    | 139688                                                                                                                                                                                               |
| Coordinating Center       | University of Michigan                                                                                                                                                                               |
| Biostatistician:          | Ryan Ross, MS Cancer Data Sciences Shared Resource -Biostatistics M4011 SPH II, University of Michigan 1415 Washington Heights Ann Arbor MI 48109-2029 Phone: (734) 764-5450 Email: rydaro@umich.edu |
| Study Drug:               | ESK981 (other names: CEP-11981) - Investigational  Nivolumab (Opdivo) - Standard of care                                                                                                             |
| Initial version:          | April 10, 2018                                                                                                                                                                                       |
| Amended:                  | June 8, 2018 November 30, 2018 April 4, 2019 April 2, 2020 (COVID-19 Appendix) August 7, 2020                                                                                                        |  
NOTE: To effectively manage the COVID-19 pandemic restrictions, changes to protocol-required item were made to minimize or eliminate immediate hazards or to protect the life and well-being of research participants (e.g., to limit exposure to COVID-19). These changes are listed in **Appendix 3** of the protocol (**Study Management during COVID-19**).  
TABLE OF CONTENTS  
| ABBREVIATIONS                                                                                                                                                   |                                                                                                                        |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------|
| STUDY SCHEMA .                                                                                                                                                  |                                                                                                                        |
| STUDY SYNOPSIS .                                                                                                                                                |                                                                                                                        |
| D Disease Background ........................................................................................................................................ 7 |                                                                                                                        |
| 1.1                                                                                                                                                             |                                                                                                                        |
| 1.2                                                                                                                                                             | Study Agent(s) Background and Associated Known Toxicities ............................................ 9               |
| 1.3                                                                                                                                                             | RATIONALE                                                                                                              |
| STUDY OBJECTIVES AND ENDPOINTS                                                                                                                                  |                                                                                                                        |
| 2.0                                                                                                                                                             |                                                                                                                        |
| 2.1                                                                                                                                                             | Primary Objective                                                                                                      |
| 2.2                                                                                                                                                             | Secondary Objectives .                                                                                                 |
| 2.3                                                                                                                                                             | Exploratory Objective                                                                                                  |
| 2.4                                                                                                                                                             | Primary Endpoint                                                                                                       |
| 2.5                                                                                                                                                             | Secondary Endpoints                                                                                                    |
| 2.6                                                                                                                                                             | Exploratory Endpoint .                                                                                                 |
| PATIENT ELIGIBILITY                                                                                                                                             |                                                                                                                        |
| 3.0                                                                                                                                                             |                                                                                                                        |
| 3.1                                                                                                                                                             | Inclusion Criteria                                                                                                     |
| 3.2                                                                                                                                                             | Exclusion Criteria .                                                                                                   |
| 4.0                                                                                                                                                             | SUBJECT SCREENING AND REGISTRATION PROCEDURES .                                                                        |
| TREATMENT PLAN .                                                                                                                                                |                                                                                                                        |
| 5.0                                                                                                                                                             |                                                                                                                        |
| 5.1                                                                                                                                                             | Treatment Dosage and Administration                                                                                    |
| 5.2                                                                                                                                                             | Toxicities and Dosing Delays/Dose Modifications ................................................................... 27 |
| 5.3                                                                                                                                                             | Concomitant Medications/Treatments                                                                                     |
| 5.4                                                                                                                                                             | O OTHER MODALITIES OR Procedures                                                                                       |
| 5.5                                                                                                                                                             | D Duration of Therapy                                                                                                  |
| OFF Treatment Criteria                                                                                                                                          |                                                                                                                        |
| 5.6                                                                                                                                                             |                                                                                                                        |
| 5.7                                                                                                                                                             | Patient Replacement                                                                                                    |
| 6.0                                                                                                                                                             | SCHEDULE OF ASSESSMENTS                                                                                                |
| MEASUREMENT OF EFFECT                                                                                                                                           |                                                                                                                        |
| 7.0                                                                                                                                                             |                                                                                                                        |
| 7.1                                                                                                                                                             | Antitumor Effect- Solid Tumors .                                                                                       |
| 7.2                                                                                                                                                             | Safety/Tolerability                                                                                                    |
| 8.0                                                                                                                                                             | ADVERSE EVENTS                                                                                                         |
| 8.1                                                                                                                                                             | ESK981 (formally known as CEP-11981) .                                                                                 |
| Nivolumab                                                                                                                                                       |                                                                                                                        |
| 8.2                                                                                                                                                             |                                                                                                                        |
| 8.3                                                                                                                                                             | Adverse Event Reporting Requirements .                                                                                 |
| 8.4                                                                                                                                                             | Definitions                                                                                                            |  
| 8.5                                 | Adverse Event Characteristics                                                                                                                |
|-------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------|
| 8.6                                 | Serious Adverse Event Reporting Guidelines .                                                                                                 |
| 8.7                                 | Routine Reporting                                                                                                                            |
| 8.8                                 | Reporting of Unanticipated Problems ..................................................................................................... 41 |
| 8.9                                 | Early Stopping Rules                                                                                                                         |
| 9.0                                 | DRUG INFORMATION .                                                                                                                           |
| 9.1                                 | ESK981 .                                                                                                                                     |
| 9.2                                 | Nivolumab                                                                                                                                    |
| 10.0 SPECIAL STUDIES .              |                                                                                                                                              |
| Sample Collection Guidelines .      |                                                                                                                                              |
| 10.1                                |                                                                                                                                              |
| 10.2                                | Specimen Banking .                                                                                                                           |
| 1.0 STATISTICAL CONSIDERATIONS .    |                                                                                                                                              |
| 1.1                                 | Study Design/Study Endpoints                                                                                                                 |
| 11.2                                | Sample Size and Accrual                                                                                                                      |
| 1.3                                 | Early Stopping Due to Toxicity                                                                                                               |
| 1.4                                 | DATA ANALYSES Plans                                                                                                                          |
| 12.0   DATA MANAGEMENT .            |                                                                                                                                              |
| 13.0   DATA AND SAFETY MONITORING.  |                                                                                                                                              |
| 1.0 QUALITY ASSURANCE AND AUDITS .  |                                                                                                                                              |
| 15.0 CLINICAL MONITORING PROCEDURES |                                                                                                                                              |
| 16.0 REFERENCES                     |                                                                                                                                              |
| APPENDICES                          |                                                                                                                                              |
| APPENDIX 1                          | Karnofsky Performance Scale                                                                                                                  |
| APPENDIX 2                          | Medications with the Potential for Drug-Drug Interactions ............................... 57                                                 |
| APPENDIX 3                          | Study Management During COVID-19 .                                                                                                           |
untitled h1
abbreviations 1

| AE         | Adverse Event                                  |
|------------|------------------------------------------------|
| ALT        | Alanine Aminotransferase                       |
| ALC        | Absolute Lymphocyte Count                      |
| AST        | Aspartate Aminotransferase                     |
| BUN        | Blood Urea Nitrogen                            |
| CBC        | Complete Blood Count                           |
| CMP        | Comprehensive Metabolic Panel                  |
| CR         | Complete Response                              |
| CT         | Computed Tomography                            |
| CTCAE      | Common Terminology Criteria for Adverse Events |
| CTSU       | Clinical Trials Support Unit                   |
| DLT        | Dose Limiting Toxicity                         |
| DSMC       | Data and Safety Monitoring Committee           |
| ESK981     | Study Drug                                     |
| H&P        | History & Physical Exam                        |
| HRPP       | Human Research Protections Program             |
| IND        | Investigational New Drug                       |
| IRB        | Institutional Review Board                     |
| IV (or iv) | Intravenously                                  |
| MTD        | Maximum Tolerated Dose                         |
| NCI        | National Cancer Institute                      |
| ORR        | Overall Response Rate                          |
| OS         | Overall Survival                               |
| PBMCs      | Peripheral Blood Mononuclear Cells             |
| PD         | Progressive Disease                            |
| PFS        | Progression Free Survival                      |
| PI         | Principal Investigator                         |
| p.o.       | per os/by mouth/orally                         |
| PR         | Partial Response                               |
| PRC        | Protocol Review Committee                      |
| RCC        | Renal Cell Carcinoma                           |
| SAE        | Serious Adverse Event                          |
| SD         | Stable Disease                                 |
| SGOT       | Serum Glutamic Oxaloacetic Transaminase        |
| SPGT       | Serum Glutamic Pyruvic Transaminase            |
| UaP        | Unanticipated Problem                          |
| WBC        | White Blood Cells                              |  
  
2  
| STUDY SYNOPSIS Title                                                                                                                    | ERICA: Phase 2 Multi-Center Trial Of ESK981 and Nivolumab In  Patients With Metastatic Renal Cell Carcinoma                                                                                                                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                      |
|-----------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------|
| Phase                                                                                                                                   | II                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |                                                                                                                                                      |
| Methodology                                                                                                                             | Single arm; two cohorts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |                                                                                                                                                      |
| Study Duration                                                                                                                          | 54-60 months (24-30 months for accrual, estimated 6 months for  treatment, and 24 months of follow-up)                                                                                                                                                                                                                                                                                                                                                                                                                                     |                                                                                                                                                      |
| Study Center(s)                                                                                                                         | Multi-Center: 2 sites total including lead site: University of Michigan Primary Objectives  To determine the clinical efficacy of ESK981 in combination with  nivolumab therapy in patients with metastatic renal cell  carcinoma. Secondary Objectives   To assess the clinical efficacy of ESK981 monotherapy in  patients with metastatic renal cell carcinoma.                                                                                                                                                                       |                                                                                                                                                      |
| Objectives                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | To determine the safety and tolerability of ESK981 monotherapy  and in combination with nivolumab in patients with metastatic  renal cell carcinoma. |
| Exploratory Objectives  To determine the quality of life of patients enrolled on the study  as reflected in patient-reported outcomes. |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                                      |
| Number of Subjects                                                                                                                      | 47 objective response evaluable patients  Histologic diagnosis of renal cell carcinoma (any histology  except medullary carcinoma or collecting duct carcinoma is acceptable) with radiologic or histologic evidence of metastatic  disease.  Prior treatment with up to one (and only one) anti-VEGF or  VEGFR inhibitor (small molecule or antibody).  Must have measurable disease as per Response Evaluation  Criteria in Solid Tumors, version 1.1 (RECIST 1.1) criteria.  Must be of age ≥ 18 years at time of informed consent. |                                                                                                                                                      |
| Inclusion Criteria                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | Ability to understand and the willingness to sign a written  informed consent.                                                                       |
|                                                                                                                                        | Karnofsky performance status ≥ 60.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |                                                                                                                                                      |
|                                                                                                                                        | Most recent systemic therapy or most recent radiation therapy ≥2 weeks of first study drug dose.                                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                                                      |
|                                                                                                                                        | Recovery to baseline or < Grade 1 CTCAE v.4.03 from toxicities  related to any prior treatments, unless AE(s) are clinically nonsignificant and/or stable on supportive therapy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                                      |  
|                   | Women of childbearing potential must have a negative serum or  urine pregnancy test within 28 days prior to registration. Women  of non-childbearing potential are defined as those who have no  uterus, ligation of the fallopian tubes, or permanent cessation of ovarian function due to ovarian failure or surgical removal of the  ovaries. All others are considered women of child bearing  potential.                                                                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                        |
|--------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                   | Adequate organ and marrow function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |                                                                                                                                                                                                        |
|                   | Prior treatment for metastatic disease with >1 antiVEGF/VEGFR inhibitor.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                                                                                        |
|                   | Prior treatment with anti-PD/PD-L1/CTLA4/IDO antibody (for  Cohort B patients only) or ESK981 (for Cohort A and Cohort B  patients). o Prior mTOR inhibitors or glutaminase inhibitors are  allowed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                        |
|                   | Untreated brain metastases or spinal cord compression.  o Patients with suspected or known treated brain  metastases at screening should have a MRI (preferred)  or CT preferably with IV contrast of the brain prior to  study entry. Patients whose brain metastases have been  treated may be considered if they have completed their  treatment for brain metastasi(e)s at least 4 weeks prior  to study registration AND they show radiographic and  clinical stability (by CT or MRI brain imaging, obtained  after treatment to the brain metastases). In addition, any  neurologic symptoms that developed either as a result of  the brain metastases or their treatment must have  resolved or be stable without the use of steroids at daily  doses greater than 10 mg prednisone or equivalent for  at least 14 calendar days prior to the start of treatment. |                                                                                                                                                                                                        |
| Exclusion Criteria |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | Uncontrolled hypertension defined as blood pressure >150/90  despite at least 2 anti-hypertensive medications as assessed by  2 blood pressure readings taken at least 1 hour apart during  screening. |
|                   | Major surgical procedure or significant traumatic injury within 6  weeks prior to study registration (> 6 weeks prior to registration  is permitted as long as they have fully recovered from any such  procedure).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |                                                                                                                                                                                                        |
|                   | History of another primary malignancy except for: malignancy  treated with curative intent and no known active disease for ≥2 years, adequately treated non-melanoma skin cancer without  current evidence of active disease, adequately treated  carcinoma in situ without current evidence of active disease,  Gleason ≤ 6 prostate cancer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                        |
|                   | Angina, myocardial infarction symptomatic congestive heart  failure, cerebrovascular accident, transient ischemic attack,  arterial embolism, pulmonary embolism, PTCA or CABG within  the past 3 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |                                                                                                                                                                                                        |  
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | History of gastrointestinal perforation or fistula in the past 6  months, or while previously on antiangiogenic therapy, unless  underlying risk has been resolved (e.g. through surgical  resection or repair).                                                                                                                                                                                                                                                                                                                                                                                                            |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | The patient has known hypersensitivity to gelatin or lactose  monohydrate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | The patient has received any investigational drug within 28 days prior to registration or 5 half-lives of the investigational drug, whichever is shorter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | History of bleeding disorders (e.g. pulmonary hemorrhage,  significant hemoptysis, menometrorrhagia not responding to  hormonal treatment) ≤ 6 weeks before Cycle 1 Day1.                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | The patient is on a chronic daily medication known to be a  severe or moderate inhibitor or inducer by Micromedex of  CYP1A2, CYP2C8, or CYP3A4 at registration.                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | Systemic corticosteroids greater than the equivalent of 10 mg of  prednisone or equivalent alternative steroid (except physiologic  dose for adrenal replacement therapy) or other  immunosuppressive agents (such as cyclosporine or  methotrexate) and any other medications that could potentially  impact the efficacy or safety of the study as judged by the  treating investigator are NOT permitted from time of registration  to subjects completing protocol therapy unless clinically  indicated to manage adverse events or life threatening or  serious conditions as determined by the treating investigator. |
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | Have any condition that, in the opinion of the investigator, would  compromise the ability of the subject to meet or perform study  requirements.                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |
| Cohort A (n = 11) - ESK981 given PO 160 mg 5 consecutive days  followed by a 2-day off drug in each week, repeated weekly in 28 day  cycles Cohort B (n = 36): ESK981 given PO 160 mg 5 consecutive days  followed by a 2-day off drug in each week, repeated weekly in 28 day  cycles in combination with nivolumab 480 mg IV on D1 every 28 day cycles as safety lead-in. If no safety signals are identified, we will accrue  19 additional subjects for a total of 36 subjects in the combination cohort  B. |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
| Study Product(s), Dose,  Route, Regimen Duration of Administration                                                                                                                                                                                                                                                                                                                                                                                                                                               | Until disease progression or intolerable toxicity or subject withdraws  consent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
| Reference Therapy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | None for Cohort A; Nivolumab alone (historical) for Cohort B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |  
| The primary objective of the study is to determine the efficacy of ESK981  in combination with Nivolumab in Cohort B. Cohort B will use the Minimax Simon two-stage design. A null response rate is assumed to be  25% with a response rate of interest of 45%. Assuming a 5% type I error  and 80% power, the first stage will accrue 17 objective response  evaluable patients. If the study passes the criteria at the interim  analysis, then stage 2 will open and accrue another 19 response  evaluable patients for a total of 36 patients.                         |                                                                                                                                                                                                                                                                                 |
|-------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Statistical Methodology | Cohort A will determine the efficacy of ESK981 monotherapy. Assuming  a response rate of clinical interest with monotherapy is 25% and null  response proportion of 5% with a 1-sided type I error=0.102 there is 80%  power with 11 patients to detect a response rate of 25%. |  
6
untitled h1
1.0 background and rationale

1.1 **Disease Background**
Renal cell carcinoma is inherently resistant to cytotoxic chemotherapy, radiation, and hormone therapy [2], [3]. Until 2005, the mainstay of treatment was immunotherapy with IL-2 or interferon, both of which result in modest response rates at the expense of significant toxicity. Advances in the understanding of renal cell carcinoma (RCC) tumor biology led to the discovery that most patients with RCC have mutations of the von Hippel–Lindau (VHL) tumor suppressor gene that lead to gene silencing [4]. Silencing of the VHL gene was found to result in Vascular Endothelial Growth Factor
(VEGF) overexpression. VEGF (also known as vascular permeability factor and VEGF-A) is a tumor-secreted cytokine with critical importance in both normal and tumor-associated angiogenesis. When the VHL gene is mutated or inactivated, the VHL protein cannot bind to hypoxia inducing factor alpha (HIFα). This leads to the accumulation of HIF1α and binding of HIF1α to HIF1β. The HIF1α/HIF1β heterodimer translocates to the nucleus and activates transcription of target genes such as VEGF and PDGF [5].  
Elevated VEGF levels have important pathologic consequences as VEGF is able to induce endothelial cell division and migration [6], promote endothelial cell survival through protection from apoptosis [7] and reverse endothelial cell senescence [8]. Because of these factors, VEGF has been called the most potent proangiogenic protein described to date [9]. Sustained angiogenesis is one of the six essential alterations in cell physiology that dictates malignant growth [10]. All cells, including malignant ones, are unable to survive unless they are within 100 μm of a capillary vessel. Thus, budding cancerous cells must develop angiogenic ability to continue to grow and multiply [10]. Vascular endothelial growth factor (VEGF) is a signal protein that stimulates angiogenesis and is the major regulator of angiogenesis in normal and malignant tissue [11].  
The discovery of the importance of VEGF in RCC tumor biology led to the development of VEGF targeted therapy for patients with metastatic kidney cancer. Since 2006, seven different VEGF tyrosine kinase inhibitors have been approved for the treatment of RCC. Initial response rates to treatment with a front line VEGF TKI are 30-40%. However, these responses are not sustainable and disease progression occurs after a median of 9-14 months [12], [13], [14].  
There are various hypotheses regarding why resistance to VEGF inhibitors develops. One of the most probable is the development of alternative pathways for angiogenesis. Studies in RCC xenograft models have shown that during initial treatment with a VEGF tyrosine kinase inhibitor, there is necrosis and devascularization of the microvasculature, ultimately leading to complete cessation of blood flow. However, just prior to the development of resistance, there is restoration of blood flow suggesting that the tumor has escaped the previously achieved block on angiogenesis [15].  
One of the most likely angiogenesis escape mechanisms is upregulation of the Ang2/Tie2 axis. Tie2 is a tyrosine kinase whose expression is largely restricted to endothelial cells [16]. It has four known ligands, angiopoietin-1 (Ang-1), angiopoietin-2 (Ang- 2), angiopoietin 3 (Ang-3) and angiopoietin-4 (Ang-4) [17], [18], [19], [20]. Ang1/Tie2 signaling plays an important role in the maturation and stabilization of the vasculature by recruitment of peri-endothelial cells [21]. In contrast, Ang2 functions as a natural antagonist of Ang1 and the Tie2 receptor, and is only expressed at sites of vascular remodeling with active angiogenesis, including pathologic angiogenesis as seen in tumors [17]. It has been shown that VEGFR-2 inhibition leads to upregulation of members of the angiopoietin family [22] and at times of disease progression in RCC
patients treated with sunitinib, Ang2 levels were shown to increase [23].  
Several pre-clinical xenograft studies have demonstrated that Ang-2 blockade leads to suppression of tumor growth [24] (Figure 1), [25]. Additional evidence shows that Ang-2 mediated angiogenesis may be a later phenomenon in tumor development. In a mouse xenograft model tumor growth inhibition was more robust when treatment was initiated in more established tumors, suggesting that larger tumors are more dependent on Ang2 [25]. Finally, there is some evidence that Ang2 may contribute to metastases as overexpression of Ang2 lead to distant metastases in a breast cancer xenograft model [26].  
  
While Ang2 may have a role in many tumor types, it may be particularly important in the  
  
tumorigenesis of renal cell carcinoma as demonstrated by the significantly higher levels of Ang2 in RCC as compared to other tumor types [27] (Figure 2).  
Given the extensive pre-clinical data suggesting the deleterious effect of Ang-2 on tumor growth and angiogenesis, Ang2 inhibitors have been evaluated for the treatment of patients with metastatic renal cell carcinoma. In a phase II study by Atkins et al [28], trebananib (an Ang1/2 inhibitor) was combined with sunitinib for the treatment of treatment naïve metastatic renal cell carcinoma. This combination led to impressive response rates of 58-63%, notably higher than front line response rates with sunitinib or pazopanib of 25-31% [29] (Figure 3).  
Figure 3: Maximum change from baseline in the sum of longest diameters (SLD) of target lesions at the time of the primary analysis for patients who received (A) trebananib 10 mg/kg once per week in cohort A or (B) trebananib 15 mg/kg once per week in Cohort B
Median overall survival was also improved as compared to historical controls treated with sunitinib or pazopanib with a median overall survival of 36 months  
  
(as compared to historical controls of 28-29 months [29]). Unfortunately, the combination of these drugs was associated with increased toxicity as compared to sunitinib alone and the combination has not been further evaluated in metastatic renal cell carcinoma.
untitled h1
1.2 study agent(s) background and

1.2.1 **Treatment Background**
ESK981, formally known as CEP-11981, is a novel oral multi-TKI originally developed by Cephalon
[30]. The compound was initially identified as an oral angiogenesis inhibitor targeting several important pathways involved in the angiogenic response, but without the off-target activities of other TKIs, like sunitinib and sorafenib, resulting in adverse events. ESK981 has potent activity in kinases implicated in angiogenesis including vascular endothelial growth factor receptor 1 (VEGFR-1), VEGFR-2, and Tie-2, (IC50 of 3, 4, 22nM, respectively).  
ESK981 treatment potently inhibited HUVEC capillary tube formation and aortic ring explant angiogenesis in vitro, and inflammation-induced angiogenesis in Tucker mice and several VEGF-induced angiogenesis models in vivo. ESK981 was tested in a dose-escalating phase I clinical trial to determine its pharmacokinetics and pharmacodynamics in patients with advanced, relapsed, or refractory solid tumors[31]. ESK981 was acceptably tolerated up to a dose of 97.4 mg/m2
(maximum tolerated dose) that was determined to be the recommended phase II dose. Most adverse events were grade 1 or grade 2 and included fatigue, nausea, diarrhea, Figure 4. Kinases overexpressed in mCRPC (in red) and their in vitro inhibition with 25 nM ESK981 (blue).  
Log-fold change of kinases in mCRPC relative to benign prostate assessed from a compendia of RNA-seq data. Rank ordered inhibition profile of 25 nM ESK981 determined in *in vitro* kinase assays. Intensity of color is associated with log-fold change or inhibitory activity.  
decreased appetite, abdominal pain, back pain, vomiting, constipation, headache, dizziness, and dyspnea. Grade 3/4 neutropenia was observed in the highest-dose cohorts. More importantly, up to 85% of patients achieved stable disease when measured at ≥6 weeks in cohorts receiving ≥73.0 mg/m2.  
After Cephalon was acquired by TEVA, further development of the compound was halted due to TEVA's decision to discontinue internal oncology drug development and focus on other therapeutic areas. Due to the exciting data seen in pre-clinical prostate cancer models highlighted in this proposal, Esanik Therapeutics (in which Dr. Chinnaiyan serves on the Scientific Advisory Board), acquired the rights to develop ESK981 in prostate cancer and other indications. To better understand the mechanism of action in prostate cancer, the kinase screen was repeated with modern kinase assays and lower drug concentrations, identifying novel mutant oncogenic kinases inhibited by ESK981 at single digit nanomolar potency. The new screen also confirmed the potency of ESK981 against TKs involved in angiogenesis as well as a number of other kinases involved in cancer processes including PDGFRA, PDGFRB, RET, FGFR1, FGFR2, AURKA, and AURKB among others (IC50 of 43, 12, 9, 92, 80, 12, and 17nM, respectively). We carried out a preliminary analysis of the top kinases overexpressed (by RNA-seq) in mCRPC and kinases most inhibited by ESK981 to provide leads to identify the kinase target in mCRPC (Figure 2). Importantly, as our preliminary data will cover, ESK981, at nanomolar levels, induces robust vacuolization associated with activation of the autophagy pathway, suggesting that a kinase involved in this pathway was being inhibited. Other MTKIs, such as cabozantib and crizotinib, did not have this autophagic vacuolization effect even at high micromolar concentrations. In vitro data also suggested combined effects with enzalutamide and continued sensitivity in enzalutamide-resistant cell lines. Interestingly, in addition to AR+ prostate cancer cell lines, AR- prostate cancer cell lines were similarly sensitive to ESK981 intimating its potential use in small cell/neuroendocrine variants of prostate cancer. In vivo, ESK981 monotherapy inhibited castrated VCaP xenograft growth in a dosedependent fashion. Tumors from mice treated with ESK981 displayed vacuolization associated with autophagy as well as marked decreases in proliferation (by Ki67 staining).  
 Adapted from Yang et al.[1] The ULK kinase pathway is the key proximal kinase complex that controls autophagy. It can be regulated by a number of up-stream kinases including receptor tyrosine kinase (RTKs), PI3K, AKT, and TOR. The beclin1 complex is a mediator of autophagy. LC3 processing is a key step in autophagosome maturation. Chloroquine and Bafilomycin A1 block late stage autophagy by blocking lysosomal fusion. ESK981 presumably activates autophagy in CRPC by inhibiting an upstream TK.  
Interestingly, in addition to AR+ prostate cancer cell lines, AR- prostate cancer cell lines were similarly sensitive to ESK981, intimating its potential use in small cell/neuroendocrine variants of prostate cancer. In vivo, ESK981 monotherapy inhibited castrated VCaP xenograft growth in a dosedependent fashion. Tumors from mice treated with ESK981 displayed vacuolization associated with autophagy as well as marked decreases in proliferation (by Ki67 staining). Interestingly, autophagy is an evolutionarily conserved and orderly process of degradation and destruction of cellular components (Figure 3). As part of this process, double membraned vesicles known as autophagosomes are formed by engulfing cytoplasmic constituents, which then fuse with lysosomes to initiate degradation and recycling [1]. Exaggerated activation of the autophagic process can be observed as gross vacuolization of cells. Monoallelic loss of beclin-1, a gene critical for the autophagy pathway, has been found in 40 to 75% of human breast, prostate, and ovarian cancers[1, 32]. Thus, autophagy has been considered an important tumor suppressive pathway, and sustained activation of autophagy in tumor cells leads to apoptosis. A number of approaches to regulate the autophagy pathway are being explored clinically in the treatment of cancer [1].  
1.2.2 **Nonclinical activity**
ESK981 is an orally active inhibitor of a number of receptor tyrosine kinases, specifically human TIE2, VEGFR-1 and VEGFR-2, and FGFR-1, with concentrations resulting in 50% inhibition of activity
(IC50) of 22±6 nM, 4±1 nM, 3±1 nM, and 13±2 nM, respectively, in enzyme-based assays. These kinase targets have been shown to have essential and non-redundant roles in tumor angiogenesis and vascular maintenance, and ESK981 is designed to inhibit tumor growth by blocking these processes. ESK981 shows comparable activity against a number of other kinases including tropomyosin receptor kinase (Trk) A (3 nM), TrkB (5 nM), receptor tyrosine kinase (RET) (5 nM), B lymphocyte kinase (Blk) (8 nM), hemopoietic cell kinase (Hck) (13 nM), lymphocyte-specific protein tyrosine kinase (Lck) (12 nM), TGF-ß activated kinase 1 (TAK1) (14 nM), and mammalian STE20-like kinase 2 (MST2) (21 nM). Some of these kinases are also known to be involved in tumor growth and survival. ESK981 demonstrates a significant concentration-related activity in a range of experimental systems, including VEGF-A, -C, -D-induced, Angiopoietin-1-induced, and fibroblast growth factor-2 (FGF2)-induced human and murine endothelial cell proliferation, chemotaxis, migration, and survival in vitro; and microvessel outgrowth and branching in primary rat aortic ring explant cultures *ex vivo*.
untitled h1
preclinical studies

Significant oral anti-angiogenic efficacy has been observed in VEGF-A-induced, tumor-induced and inflammation-induced neo-vascularization models in rodents. Sustained dose-related anti-tumor activity has been demonstrated with ESK981 *in vitro* across a panel of human and murine tumor cell lines. Significant dose-related and exposure driven *in vivo* anti-tumor efficacy is observed with ESK981 in multiple subcutaneous (melanoma, glioblastoma, breast carcinoma, prostate carcinoma) and orthotopic human and rodent solid (colon carcinoma, renal carcinoma, and glioblastoma) and hematologic (acute leukemia) tumor xenograft models in normal and immunocompromised hosts. Depending upon tumor models with differing dosing regimens, ESK981 exhibits dose-related tumor growth inhibitory and anti-angiogenic effects as well as sustained partial and complete tumor regressions when administered as monotherapy. Specific intermittent oral dosing schedules (drug dosing/drug holidays) of ESK981 using once daily and twice daily dosing regimens demonstrate significant anti-tumor efficacy (tumor growth inhibition and partial and complete regressions). In both solid and hematologic tumor models, however, daily and twice daily continuous administration is optimal. ESK981 is generally well tolerated when administered chronically with cytotoxic agents (e.g., temozolomide [TMZ]), and the combination of ESK981 with TMZ conferred a significant benefit on median survival of orthotopic human glioblastoma-bearing animals relative to that achieved with TMZ alone. In a series of pharmacologic anti-tumor and anti-angiogenic studies conducted in various murine strains, the maximum tolerated dose of ESK981 is 60 mg/kg/day or higher in syngeneic, nude, and severe immunocompromised mice (SCID) mice, and 30 mg/kg/day or higher in non-obese diabetic, severely immunocompromised (NOD-SCID) tumor-bearing mice.  
ESK981 has been intensively evaluated pre-clinically in human prostate cancer at the University of Michigan. In our preliminary assessment we evaluated the growth inhibitory effect of ESK981 against a library of tyrosine kinase inhibitors consisting of 167 compounds in DU145 cells. We found that ESK981 exhibited potent growth inhibition at 300nM concentration compared to Src inhibitors (KX2391, Dasatinib and HER2 inhibitor (Mubritinib) that were reported to be efficacious in DU145 cells, whereas crizotinib and cabozantinib exhibited no such growth inhibitory effect at comparable concentrations (Fig. 6a). Among the 168 compounds, only ESK981 triggered a cytoplasmic vacuolization morphology that prompted us to further investigate its functional significance (Fig. 6b). Using 7 prostate cancer cell lines, we examined their sensitivity to ESK981 in long-term survival assays. After 2 weeks of growth, cells were stained with crystal violet and subsequently quantified.  
ESK981 exhibited IC50 values ranging from 35nM to 192nM. In contrast, cabozantinib and crizotinib exhibited only micromolar IC50 values in the cell lines tested (Fig. 6c).  
The morphological alterations triggered by ESK981 led us to explore whether the autophagy pathway is involved. Initially, we investigated ESK981-associated cellular vacuole in combination with various autophagic pathway inhibitors. The anti-malarial drug, chloroquine, has been used as an inhibitor of autophagy and lysosomal fusion. Strikingly, chloroquine completely negated the cellular vacuolization effects of ESK981 in DU145 cells after a 6-hour incubation. The phenotype was recapitulated by another lysosome inhibitor bafilomycin (BF) as well as early autophagasome inhibitor 3- Methyladenine (3-MA). This strongly suggested that ESK981-induced vacuolization involves the autophagy process (Fig. 7a). We next employed CYTO-ID autophagy detection kit (Enzo) to visualize cytoplasmic vacuoles in DU145 cells (Fig. 7b); quantified fluorescent intensity showed dosedependent induction of autophagy signal in LNCaP and VCaP cells as well (Fig. 7c). Five prostate cell lines (VCaP, LNCaP, MDA-PCa-2b, LNCaP-AR and PC3) have been tested thus far exhibited LC3 cleavage in a ESK981 dose-dependent manner (Fig. 7d) suggesting that autophagy activation. We observed that ESK981 increased cytokine CXCL10 secretion in cell culture medium in an autophagy-dependent manner, thus, we hypothesized that ESK981 may play a role in immune cell recruitment. These preliminary data led us to expand our investigation to immune response using syngeneic mouse prostate cancer Myc-CaP cells. We confirmed that ESK981 is effective in Myc-CaP
cells and has lower IC50 than cabozantinib or crizotinib (Fig. 8a) and autophagy and CXCL10 were increased upon ESK981 treatment in Myc-CaP cells (Fig. 8b-c). Finally, we wanted to test whether ESK981 is able to potentiate immune checkpoint blockade. In immune competent mice, ESK981 and immune checkpoint inhibitor, anti-PD1 in combination exerted maximum tumor inhibition (Fig. 9a-b). With tumor inhibition, autophagy was observed in individual tumors upon ESK981 treatment (Fig. 9c).  
Overall, our data demonstrate that ESK981, alone or in combination with anti-PD1 therapy, is a promising candidate for clinical development; it targets a novel pathway and shows greater efficacy than tyrosine kinase inhibitors commonly in use.  
  
A, Percentage viability of DU145 for 300nM ESK981 and other 167 tyrosine kinase inhibitors compared to vehicle control. Top 5 most inhibitory compounds are listed in the table, as well as cabozantinib and crizotinib (highlighted in orange). ESK981 is highlighted in red.  
B, Morphological differences of 300nM ESK981, crizotinib or cabozantinib treated nuclear restricted RFP expressing DU145. C, A long-term survival assay was used to calculate half-maximum inhibitory concentration (IC 50 ) after 2 weeks of incubation with serial dilutions of indicated drugs. Top, Long-term survival assays of VCaP prostate cancer cells exposed to MTKIs. Bottom, (IC 50 ) of ESK981, crizotinib and cabozantinib in a panel of prostate cancer cell lines.  
13 Figure 7. ESK981 induced cellular vacuolization is part of autophagy activation.  
  
  
  
A, Autophagy inhibitors negated ESK981 induced cellular vacuolization. Morphology of DU145-RFP
cells treated with ESK981, and various autophagy inhibitors 3-Methyladenine (3-MA), chloroquine (CQ), bafilomycin (BF) alone and in combination of for 6 hours. Red indicates nuclei. B, Autophagic vacuoles were visualized by green fluorescence in DU145 treated with either control or ESK981 for 24 hours, and nuclei were indicated by blue. C, VCaP and LNCaP cells were treated with increasing concentration of ESK981 for 24 hours, and autophagic activity were measured by CYTO-ID kit, and quantification of autophagy activity is shown on right. Rapamycin served as a positive control for autophagy induction. D, Protein levels of LC3 in indicated prostate cancer cell lines.  
  
  
Preclinical work in three kidney carcinoma cell lines demonstrated that ESK981 remains potent in inhibiting kidney cancer cell proliferation with nanomolar IC so concentration (Figure. 6, unpublished data). Additionally, ESK981 is able to robustly induce dose-dependent autophagy (Figure. 7, unpublished data). Meanwhile, ESK981 enhances the Th1-type chemokines CXCL9 and CXCL10 expression (Figure. 8, unpublished data) through STAT1-dependent pathway (Figure. 9, unpublished data). Thus treatment with ESK981 alone led to higher levels of CXCL9 and CXCL10 expression and when in combination with an anti-PD1 agent, the immune response should be dramatically enhanced.  
A 7 0 4 C a k i-1A 4 9 8  
  
2 0 0 4 0 0 6 0 0 8 0 0 1 0 0 0 E S K 9 8 1 IC 5 0 , n M
untitled h1
1.2.3 clinical activity phase i

ESK981 was tested in an open-label dose-escalating Phase 1 clinical trial to determine its pharmacokinetics (PK) and pharmacodynamics (PD) in patients with advanced, relapsed, or refractory solid tumors (Study C11981/1047/ON/US, NCT00875264) [31]. After daily oral administration of ESK981 to cancer patients, the median tmax values for ESK981 were typically in the range of 2 to 4 hours (Table1 and Table 2). However, for most of the dose groups there appeared to be considerable inter-patient variability in this pharmacokinetic parameter. The reason(s) for the large inter-patient variability in tmax is(are) not presently known, but may be related to the fed/fasted state of the patients or other unknown factors which could potentially influence drug absorption (e.g., disease state, concomitant medications).  
| Daily Oral Administration of ESK981                                                                                                                      |                      |                |              |             |            |           |
|----------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------|----------------|--------------|-------------|------------|-----------|
| Dose                                                                                                                                                     | trav                 | AUC6.24        | AUC 9 ...    | tin         |            |           |
| (mg/m)                                                                                                                                                   | (g/mL)               | (hr)           | (ng*hr/mL)   | (ng•hr/mL)  | (hr)       | Rprod     |
| 3.0 (n=3)                                                                                                                                                | 13.7 (6.1)           | 6.0 [2.0-6.1]  | 127 (16)     | 151 (36)    | 8.0 (2.8)  | 1.2 (0.2) |
| 16.8 (4.9)                                                                                                                                               | 4.0 [1.0-6.0]        | 19 (14)        | 1.2 (0.1)    |             |            |           |
| 4.2 (n=3)                                                                                                                                                | 136 (6)              | 7.8 (3.7)      |              |             |            |           |
| 5.9 (n=5)                                                                                                                                                | 26.0 (6.5)           | 2.1 [1.5-4.0]  | 195 (67).    | 210(78)     | 5.9 (1.1)  | 1.1 (0.1) |
| 1.8 (n=3)                                                                                                                                                | 84.9 (23.0)          | 1.6 [1.5-3.0]  | 517 (126)    | 569 (196)   | 6.0 (3.7)  | 1.1 (0.1) |
| 19.7 (n=3)                                                                                                                                               | 135.7 (76.5)         | 4.0 [1.0-4.3]  | 874 (358)    | 928 (408)   | 5.1 (1.3)  | 1.0 (0.1) |
| 29.6 (n=4)                                                                                                                                               | 266.9 (182.0)        | 2.3 [1.0-3.1]  | 2376 (2064)  | 3195 (3199) | 85 (5.5)   | 1.2 (0.2) |
| 41.4 (n=3)                                                                                                                                               | 351.9 (94.4)         | 2.0 [1.0-4.0]  | 220 (2070)   | 3572 (3177) | 8.1 (4.5)  | 1.2 (0.2) |
| 5.0 (n=4)                                                                                                                                                | 272.6 (127.5)        | 3.0 [3.0-3.2]  | 274 (666)    | 2675 (508)  | 8.9 (2.5)  | 1.2 (0.1) |
| 73.0 (n=3)                                                                                                                                               | 44.2 (149.4)         | 4.0 [3.0-4.1]  | 39 (1966)    | 4659 (2634) | 8.1 (2.2)  | 1.2 (0.1) |
| 97.4 (n=9)                                                                                                                                               | 526.4 (185.7)        | 4.0 [2.0-6.0]  | 5320 (1459). | 6915 (2115) | 10.3 (4.6) | 1.3 (0.3) |
| 126.6 (n=2)                                                                                                                                              | 751.2 (780.5, 721.9) | 5.0 [8.0, 2.0] | 5767 1       | NC          | NC         | NC        |
| Overall Mean®                                                                                                                                            | 8.0 (3.7)            | 1.2 (0.2)      |              |             |            |           |
| * Values presented for t,,, are the median [range]; 'Excludes data from patient 1019 due to receipt of improper dose of study medication; 6 Overall mean |                      |                |              |             |            |           |
| for all dose groups; * n = 1.                                                                                                                            |                      |                |              |             |            |           |
| NC: Not calculable                                                                                                                                       |                      |                |              |             |            |           |  
Rprrr: - AUCo.../AUCo.  
Table 2. Mean (SD) Pharmacokinetic Parameters for ESK981 in Cancer Patients on Day 15 of Daily Oral Administration of ESK981  
| Cmax                                                                                                                                                      | AUC,               |                  |                |                |             |             |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------|------------------|----------------|----------------|-------------|-------------|
| Dose                                                                                                                                                      | tran               | t12              |                |                |             |             |
| (mg/m )                                                                                                                                                   | (ng/mL)            | (hr)             | (ng hr/mL)     | (hr)           | Roos        | R s         |
| 3.0 (n=3)                                                                                                                                                 | 16.1 (2.3)         | 2.9 [1.5-4.0]    | 165 (83)       | 8.0 (2.9)      | 1.3 (0.6)   | 1.1 (0.5)   |
| 4.2 (n=3)                                                                                                                                                 | 24.3 (9.2)         | 3.9 [1.5-4.0]    | 202 (47)       | 9.9 (4.6)      | 1.8 (0.6)   | 1.5 (0.4)   |
| 5.9 (n=5)                                                                                                                                                 | 32.4 (8.4)         | 3.0 [1.5-6.0]    | 278 (69)       | 6.6 (1.5)      | 1.5 (0.6)   | 1.4 (0.6)   |
| 1.8 (n=3)                                                                                                                                                 | 98.1 (5.6)         | 20 [1.6-2.1]     | 764 (128)      | 12.3 (9.7)     | 1.5 (0.2)   | 1.4 (0.3)   |
| 19.7 (n=3)                                                                                                                                                | 128.5 (98.4)       | 4.0 [1.5-4.0]    | 1102 (735)     | 5.4 (1.2)      | 1.2 (0.3)   | 1.1 (0.2)   |
| 218.8 (130.3)                                                                                                                                             | 4.5 [2.0-8.0]      |                  |                |                |             |             |
| 29.6 (n=4)                                                                                                                                                | 2924 (2940)        | 8.7 (5.7)        | 1.1 (0.2)      | 0.9 (0.1)      |             |             |
| 41.4 (n=3)                                                                                                                                                | 412.6 (93.9)       | 2.1 [1.7-3.1]    | 3256 (1816)    | 10.3 (6.3)     | 1.3 (0.5)   | 1.1 (0.5)   |
| 5.0 (n=4)*                                                                                                                                                | 320.7 (75.1)       | 5.2 [3.0-8.0]    | 4313 (1091)    | 12.8 (4.3)     | 1.9 (0.2)   | 1.6 (0.1)   |
| 713.0 (734.5, 691.6)                                                                                                                                      | 9429 (12253, 6605) |                  |                |                |             |             |
| 73.0 (n=2)                                                                                                                                                | 3.3 [3.5, 3.1]     | 13.9 (20.6, 7.2) | 1.9 (2.0, 1.8) | 1.7 (1.6, 1.7) |             |             |
| 97.4 (n=7)                                                                                                                                                | 7431.3 (336.7)     | 2.7 [1.5-6.0]    | 6623 (3283) d  | 1.0 (6.2) a    | 1.5 (0.9) a | 1.2 (0.7) f |
| 126.6 (n=1)                                                                                                                                               | 1481.5             | 8.0              | 23565          | 14.7           | NC          | NC          |
| Overall Mean a                                                                                                                                            | 9.9 (5.3)          | 1.5 (0.5)        | 1.3 (0.5)      |                |             |             |
| * Values presented for t … , are the median [range]; 'Excludes data from patient 1019 due to receipt of improper dose of study medication; ' Overall mean |                    |                  |                |                |             |             |
| Roto = AUC,/AUC, 24, ay 1                                                                                                                                 |                    |                  |                |                |             |             |  
R,, = AUC/AUCo.n, env l-
After reaching peak plasma levels, ESK981 declined in a bi-phasic manner that was characterized by an initial phase of drug distribution and a slower terminal elimination phase. For some profiles, however, only the later phase was evident due to what appeared to be a more prolonged period of drug absorption. The mean t 112 of the terminal elimination phase was generally in the range of approximately 8 to 10 hr; however, the values tended to be slightly larger after multiple doses at the higher dose levels (i.e., doses ≥55 mg/m²) (Table 1 and Table 2).  
The systemic exposures (i.e., C max and AUC) of patients to ESK981 generally increased with increasing dose across the dose range evaluated on both days 1 and 15 (Table 1 and Table 2). There were some dose groups for which the mean values of C max and AUC did not show an increase relative to the values from the preceding 1 or 2 dose levels; however, this result was not surprising given the 19 large inter-patient variability and the fact that most dose increments were less than 40%. Nonetheless, the overall results obtained are not suggestive of the presence of any obvious non-linearity in absorption and/or elimination of ESK981 in this dose range.  
After once-daily administration of ESK981 at doses ranging from 3.0 to 126.6 mg/m2, there was a small to moderate amount of accumulation of the compound in plasma at each dose level. The overall mean observed accumulation ratio (Robs) for ESK981 was 1.5 (range = 1.1 to 1.9), which was slightly larger than the value predicted from the single-dose data (overall mean Rpred = 1.2; range = 1.0 to 1.3)
(Table 1 and Table 2). Although the mean Robs was slightly larger than the Rpred, this is not believed to be a strong indication of the presence of any time-dependent pharmacokinetic processes.
untitled h1
1.2.4 clinical safety and efficacy

All 43 patients experienced ≥1 adverse event, and 38 patients (88.3 %) were deemed to have had adverse events possibly, probably, or definitely related to study drug. The most frequently reported adverse event of any grade was fatigue (n= 22, or 51 %). Other frequently reported adverse events (≥20 % of patients) were nausea (47 %), diarrhea (33 %), decreased appetite (33 %), abdominal pain
(30 %), back pain (28 %), vomiting (28 %), constipation (28 %), headache (28 %), dizziness (28 %), and dyspnea (23 %). These adverse events were reported at a similar frequency between dosage cohorts, and no relationship with dose was evident. Most adverse events were grade 1 or grade 2. Grade 3 or 4 adverse events occurred in 16 (37 %) patients across dosing cohorts (14 [32.6 %] Grade 3 and Grade 2 [4.7 %] Grade 4). Treatment-related grade 3 or 4 adverse events were most frequent in the 97.4 mg/m2cohort. Grade 3 or 4 laboratory hematologic toxicities were reported in 8 (18.6 %)
patients across dosage cohorts. The most common grade 3 or 4 laboratory hematologic toxicity was lymphopenia, which occurred in 8 patients and across dosage cohorts (5.9, 29.6, 55.0, 97.4, and 126.6 mg/m2). Grade 4 leukopenia occurred in 1 patient in the 126.6 mg/m2cohort. Grade 3 or Grade 4 neutropenia also occurred in 2 patients in the 97.4 mg/m2cohort (Grade 3) and in 1 patient in the 126.6 mg/m 2cohort (Grade 4).  
Serious adverse events occurred in 12 patients; most were deemed unlikely or not related to CEP- 11981. Three patients (1 patient in the 97.4 mg/m 2cohort and 2 patients in the 126.6 mg/m 2cohort)
experienced serious adverse events that were categorized as possibly or definitely related to ESK981:
pyrexia, hemolytic anemia, hyperbilirubinemia, dyspnea, neutropenia, ECG change, and chest discomfort. No deaths occurred during the study.
untitled h1
tumor response

Of 43 patients who received ≥1 dose of study drug, 37 patients were evaluated for tumor response. Although no enrolled patients had complete or partial response according to RECIST criteria, 19 of 37
(51 %) patients evaluated for tumor response had stable disease at ≥6 weeks; 18 had disease progression. The frequency of stable disease (defined as <30 % decrease and <20 % increase in the sum of the longest diameter of the target lesions) was higher in cohorts receiving doses ≥73.0 mg/m2 (8 of 14 [57.1 %] patients) compared with cohorts receiving ≤55.0 mg/m2(11 of 29 [37.9 %] patients)
(Figure 14).
untitled h1
figure 14. best overall tumor

Depicts tumor response, with bars above the x-axis indicating patients (n = 19) who achieved stable disease and bars below the x-axis indicating patients (n = 18) with disease progression. aNo patient achieved complete or partial response. bSix patients were not evaluable at dosages of 19.7, 29.6, 55.0, and 126.6 mg/m2(n = 1, each); 97.4 mg/m2(n = 2)
1.3 Rationale
untitled h1
esk981 monotherapy

ESK981 has cleared a dose-escalating phase I clinical trial and demonstrated favorable pharmacokinetics and pharmacodynamics in patients with advanced, relapsed, or refractory solid tumors with up to 85% of patients achieving stable disease at doses ≥73.0 mg/m2.  
ESK981 is an orally active multi-targeted receptor tyrosine kinase inhibitor that inhibits the human receptor for Angiopoietin-1 and Angiopoietin-2 (TIE-2), vascular endothelial growth factor receptor-2
(VEGFR-2), vascular endothelial growth factor receptor-1 (VEGFR-1), and fibroblast growth factor receptor-1 (FGFR-1) receptor tyrosine kinases. In addition to its effects on the angiogenesis promoting receptors VEGF and TIE-2, ESK981 treatment also induced robust cellular vacuolization indicative of cell death by autophagy, a mechanism not observed with other multiple tyrosine kinase inhibitors like crizotinib and cabozantinib. A phase 1 study has shown the compound to be safe and tolerable [31]. The most frequently reported adverse event of any grade was fatigue (n=22, or 51 %). Other frequently reported adverse events (≥20 % of patients) were nausea (47 %), diarrhea (33 %), decreased appetite (33 %), abdominal pain (30 %), back pain (28 %), vomiting (28 %), constipation (28 %), headache
(28 %), dizziness (28 %), and dyspnea (23 %). These adverse events were reported at a similar frequency between dosage cohorts, and no relationship with dose was evident. Most adverse events were grade 1 or 2. Although no enrolled patients had complete or partial response according to RECIST criteria, 19 of 37 (51 %) patients evaluated for tumor response had stable disease at ≥6 weeks. Of note, the majority of patients on this trial had tumor types that have been historically refractory to TKIs. The 0% response rate is similar to response rates seen when other VEGF-TKIs have been tried in non-kidney cancers such as colorectal cancer [33]. Given the significant pre-clinical rationale for use of an Ang-2 inhibitor in renal cell carcinoma that has become resistant to VEGF inhibition and the safety shown in a prior phase 1 trial, we propose a single center phase 2 trial of ESK981 in patients with metastatic renal cell carcinoma who have progressed despite treatment with a VEGF-TKI.  
Nivolumab in renal cell **carcinoma** Nivolumab (Opdivo) a PD-1 antibody, is FDA approved for the treatment of advanced renal cell carcinoma after disease progression on prior anti-angiogenic therapy. In the CHECKMATE-025 trial, nivolumab demonstrated improved overall survival compared with everolimus in the randomized clinical trial setting (25 months vs 19.6 months, HR 0.73, p-value 0.0018) [34].
untitled h1
esk 981 in combination with

VEGF inhibition in combination with immunotherapy in the form and anti-PD1 or anti-PD-L1 therapy has already been demonstrated in other drug combinations. Bevacizumab, an anti-VEGF therapy, in combination with atezolizumab (anti-PD-L1), was studied in ten patients with previously untreated metastatic RCC, and was well-tolerated. In this small cohort, there were 4 partial responses and 4 patients with stable disease [35]. A randomized multi-arm phase III clinical trial is currently ongoing evaluating the combination of lenvatinib, a multikinase inhibitor, with either everolimus or pembrolizumab compared with sunitinib in patients with advanced renal cell carcinoma
(NCT02811861).  
Given the superior activity of ESK981 compared to other small molecule VEGFR inhibitors especially potent inhibition of Tie-2 and additional autophagy inducing activity of ESK981, and the emerging clinical data on synergy between VEGFR inhibition and anti-PD1/L1 antibody immunotherapy, we propose a two-cohort phase II study. We first seek to evaluate the safety of ESK981 monotherapy in a safety cohort of 11 patients (Cohort A), after which accrual of Cohort B will begin, with a safety lead-in of six patients to establish a safe dose of ESK981 in combination with flat dose nivolumab at 480 mg IV. Subsequently, an expansion of Cohort B will be accrued to evaluate the clinical efficacy of the combination of ESK981 at the previously established safe dose in conjunction with nivolumab. Subjects in cohort A cannot cross-over into Cohort B.
untitled h1
2.0 study objectives and endpoints

2.1 **Primary Objective**
2.1.1 To determine the clinical efficacy of ESK981 in combination with nivolumab therapy in patients with metastatic renal cell carcinoma.  
2.2 **Secondary Objectives**
2.2.1 To assess the clinical efficacy of ESK981 monotherapy in patients with metastatic renal cell carcinoma.  
2.2.2 To determine the safety and tolerability of ESK981 monotherapy and in combination with nivolumab in patients with metastatic renal cell carcinoma.  
2.3 **Exploratory Objective**
2.3.1 To determine the quality of life of patients enrolled on the study as reflected in patientreported outcomes.  
2.4 **Primary Endpoint**
2.4.1 To assess the objective response rate (complete response and partial response) by RECIST
1.1 in metastatic renal cell cancer to the combination of ESK981 and nivolumab therapy.  
2.5 **Secondary Endpoints**
2.5.1 To assess the objective response rate (complete response and partial response) by RECIST
1.1 in metastatic renal cell cancer to ESK981 monotherapy.  
2.5.2 To determine frequency and severity of adverse events by CTCAE criteria of ESK981 in patients with metastatic renal cell carcinoma.  
2.5.3 To evaluate secondary efficacy measures such as overall survival, progression free survival, duration of therapy, duration of response to ESK981 monotherapy in Cohort A and to the combination in Cohort B; response by combined RECIST v1.1 and irRECIST and irRECIST progression free survival (Cohort B only).
2.6 **Exploratory Endpoint**
2.6.1 Health-related quality of life assessment changes from baseline using EuroQoL-5D will be described using descriptive statistics.  
3.0 **PATIENT ELIGIBILITY**
Subjects must meet all of the inclusion and exclusion criteria to be enrolled to the study. Study treatment may not begin until a subject is enrolled. No eligibility waivers will be granted for this clinical trial.  
3.1 **Inclusion Criteria**
3.1.1 Histologic diagnosis of renal cell carcinoma (any histology except medullary carcinoma or collecting duct carcinoma is acceptable) with radiologic or histologic evidence of metastatic disease.
3.1.2 Prior treatment with up to one (and only one) anti-VEGF or VEGFR inhibitor (small molecule or antibody).  
3.1.3 Must have measurable disease as per Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST 1.1) criteria.
3.1.4 Must be of age ≥ 18 years at time of informed consent. 3.1.5 Ability to understand and the willingness to sign a written informed consent.  
3.1.6 Karnofsky performance status ≥ 60.  
3.1.7 Most recent systemic therapy or most recent radiation therapy ≥2 weeks of first study drug dose.  
3.1.8 Recovery to baseline or ≤ Grade 1 CTCAE v.4.03 from toxicities related to any prior treatments, unless AE(s) are clinically non-significant and/or stable on supportive therapy.  
3.1.9 Women of childbearing potential must have a negative serum or urine pregnancy test within 28 days prior to prior to registration. Women of non-childbearing potential are defined as those who have no uterus, ligation of the fallopian tubes, or permanent cessation of ovarian function due to ovarian failure or surgical removal of the ovaries. All others are considered women of child bearing potential.  
| System                                                                          | Laboratory Value                                                                                                                                       |
|---------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------|
| Hematological Absolute Neutrophil Count                                         | ≥ 1.5 K/mm3                                                                                                                                            |
| (ANC) Hemoglobin (Hgb)                                                          | ≥ 9 g/dL                                                                                                                                               |
| Platelets (Plt)                                                                 | ≥ 100,000/mm3                                                                                                                                          |
| Renal Calculated creatinine clearance                                           | Serum creatinine ≤ 1.5 times the upper limit  of normal OR creatinine clearance  >30mL/min by Cockcroft-Gault formula                                  |
| Hepatic Total Bilirubin                                                         | ≤ 1.5 × upper limit of normal (ULN)                                                                                                                    |
| Aspartate aminotransferase                                                      | ≤ 2.5 × ULN (≤ 3 × ULN with known hepatic                                                                                                              |
| (AST)                                                                           | metastases)                                                                                                                                            |
| Alanine aminotransferase (ALT)                                                  | ≤ 2.5 × ULN (≤ 3 × ULN with known hepatic  metastases)                                                                                                 |
| Prothrombin time (PT) and  activated partial thromboplastin  time (aPTT) levels | ≤ 1.5x ULN  (If patient is receiving anticoagulation that is  expected to alter these levels, should be in  targeted therapeutic range for that agent) |  
3.1.10 Adequate organ and marrow function as defined below:
untitled h1
3.2 exclusion criteria

3.2.1 Prior treatment for metastatic disease with >1 anti-VEGF/VEGFR inhibitor.  
3.2.2 Prior treatment with anti-PD/PD-L1/CTLA4/IDO antibody (for Cohort B patients only) or ESK981 (for Cohort A and Cohort B patients).  
Prior mTOR inhibitors or glutaminase inhibitors are allowed.  
3.2.3 Untreated brain metastases or spinal cord compression.  
Patients with suspected or known treated brain metastases at screening should have a MRI (preferred) or CT preferably with IV contrast of the brain prior to study entry. Patients whose brain metastases have been treated may be considered if they have completed their treatment for brain metastasi(e)s at least 4 weeks prior to study registration AND they show radiographic and clinical stability (by CT or MRI
brain imaging, obtained after treatment to the brain metastases). In addition, any neurologic symptoms that developed either as a result of the brain metastases or their treatment must have resolved or be stable without the use of steroids at daily doses greater than 10 mg prednisone or equivalent for at least 14 calendar days prior to the start of treatment.  
3.2.4 Uncontrolled hypertension defined as blood pressure >150/90 despite at least 2 antihypertensive medications as assessed by 2 blood pressure readings taken at least 1 hour apart during screening 3.2.5 Major surgical procedure or significant traumatic injury within 6 weeks prior to study registration. (>6 weeks prior to registration is permitted as long as they have fully recovered from any such procedure).  
3.2.6 History of another primary malignancy except for: malignancy treated with curative intent and no known active disease for ≥2 years, adequately treated non-melanoma skin cancer without current evidence of active disease, adequately treated carcinoma in situ without current evidence of active disease, Gleason ≤ 6 prostate cancer.  
3.2.7 Angina, myocardial infarction symptomatic congestive heart failure, cerebrovascular accident, transient ischemic attack, arterial embolism, pulmonary embolism, percutaneous angioplasty or Coronary arterial bypass surgery within the past 3 months.  
3.2.8 History of gastrointestinal perforation or fistula in the past 6 months, or while previously on antiangiogenic therapy, unless underlying risk has been resolved (e.g. through surgical resection or repair).  
3.2.9 The patient has known hypersensitivity to gelatin or lactose monohydrate.  
3.2.10 The patient has received any investigational drug within 28 days prior to registration or 5 half-lives of the investigational drug, whichever is shorter.  
3.2.11 History of bleeding disorders (e.g. pulmonary hemorrhage, significant hemoptysis, menometrorrhagia not responding to hormonal treatment) ≤ 6 weeks before Cycle 1 Day 1.  
3.2.12 The patient is on a chronic daily medication known to be a severe or moderate inhibitor or inducer by Micromedex of CYP1A2, CYP2C8, or CYP3A4 at registration.  
3.2.13 Systemic corticosteroids greater than the equivalent of 10 mg of prednisone or equivalent alternative steroid (except physiologic dose for adrenal replacement therapy) or other immunosuppressive agents (such as cyclosporine or methotrexate) and any other medications that could potentially impact the efficacy or safety of the study as judged by the treating investigator are NOT permitted from time of registration to subjects completing protocol therapy unless clinically indicated to manage adverse events or life threatening or serious conditions as determined by the treating investigator.  
3.2.14 Have any condition that, in the opinion of the investigator, would compromise the ability of the subject to meet or perform study requirements.
untitled h1
4.0 subject screening and registration

Patient registration for this trial will be centrally managed by the Coordinating Center of The University of Michigan Rogel Cancer Center as described below:
A potential study subject who has been screened for the trial and who has signed the Informed Consent document will be initially documented by the participating site on a Screening and Enrollment Log. It is the responsibility of the local site investigator to determine patient eligibility prior to submitting patient registration request to the Coordinating Center. After patient eligibility has been determined, a copy of the completed Eligibility Worksheet together with all the pertinent de-identified source documents will be submitted by the requesting site to the Coordinating Center, by email to CTSU-OncologyMultisite@med.umich.edu.  
The Multi-Site Coordinator (MSC) of the Coordinating Center will review the submitted documents and process the registration. Sites should inform the Multi-Site Coordinator of a potential registration by 5 p.m. on the day prior to registration. Same day registrations cannot be guaranteed. An email will be sent by the MSC to the requesting site registrar to confirm patient registration and to provide the study identification number that has been assigned to the patient. In addition, a copy of the completed Eligibility Worksheet signed and dated by the MSC, will be sent back to the requesting site registrar.  
Patients found to be ineligible for participation after being consented will be considered screen failures, and documented as such in a Screening and Enrollment Log. These patients will not have study identification number assigned to them, and will not receive study treatment.
untitled h1
5.0 treatment plan

5.1 **Treatment Dosage and Administration**
Protocol treatment must start within 14 business days of enrollment to the study.  
There are 2 cohorts for accrual with Cohort A being accrued first. Cohort B will follow and will have 2 stages of accrual. Cohort A will accrue 11 patients to ESK981 monotherapy treatment. Then Cohort B (combination therapy) will begin accrual of 17 patients to the first stage and if the interim analysis permits, the second stage will accrue an additional 19 patients.  
5.1.1 Therapy with ESK981 will include starting dose of 160 mg (4 capsules) PO daily for 5 consecutive days followed by a 2-day off drug in each week, repeated weekly in 28 day cycles. Patients will continue treatment until disease progression or intolerable toxicity.  
| REGIMEN DESCRIPTION                 |                                                |                           |                                                                                                                                                           |                                                                                         |         |
|-------------------------------------|------------------------------------------------|---------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------|---------|
| Premedications;                     | Cycle                                          |                           |                                                                                                                                                           |                                                                                         |         |
| Agent                               | Precautions                                    | Dose                      | Route                                                                                                                                                     | Schedule                                                                                | Length  |
| ESK981                              | n/a                                            | 160 mg                    | PO                                                                                                                                                        | Once daily for  5 consecutive  days of every  week (5 days  on followed by  2 days off) | 28 days |
| Nivolumab (solution for  injection) | Per institutional  guidelines, none  mandated. | 480 mg/dose               | IV infusion over 30-60 minutes with  a sterile,  nonpyrogenic,  low protein  binding 0.2 to  1.2  micrometer  in-line filter.  Follow with  saline flush. | Day 1                                                                                   | 28 days |
| Dose Level                          | Dose of ESK981                                 | Dose of Nivolumab         |                                                                                                                                                           |                                                                                         |         |
| Level 0                             | 160 mg                                         | Fixed at 480 mg flat dose |                                                                                                                                                           |                                                                                         |         |
| Level -1                            | 120 mg                                         | Fixed at 480 mg flat dose |                                                                                                                                                           |                                                                                         |         |
| Level -2                            | 80 mg                                          | Fixed at 480 mg flat dose |                                                                                                                                                           |                                                                                         |         |
| Dose-Limiting Toxicity (DLT)        |                                                |                           |                                                                                                                                                           |                                                                                         |         |  
Dose-Limiting Toxicity (DLT) Dose limiting toxicity (DLT) will be defined as any Grade 3 or higher toxicity (as defined by CTCAE 4.03) that occurs during the DLT evaluation period (Cycle 1 i.e. 28 days) EXCEPT laboratory abnormalities that are not clinically relevant or significant. Subjects will be given a pill diary and instructed to complete it every cycle. Doses missed by 6 or more hours or vomited will be skipped and not made up but will be recorded on the diary as missed or vomited. The subject will be advised not to take any additional doses, but to wait for the next scheduled dose.
untitled h1
5.2 toxicities and dosing delays/dose

Any patient who receives treatment on this protocol will be evaluable for toxicity. Each patient will be assessed for the development of toxicity according to the Time and Events Table (Section 6.1). Toxicity will be assessed according to the NCI Common Terminology Criteria for Adverse Events
(CTCAE), version 4.03. Dose adjustments should be made according to the system showing the greatest degree of toxicity.  
| Table 5.2.1 Hematological Toxicities Hematological Toxicity Dose Reductions for ESK981                                                                                       |                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| ANC1                                                                                                                                                                         | Platelets        | Action                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
| ≥ 1,500/L or                                                                                                                                                                | >100,000/L      | None. -1st Occurrence: Hold current dose until ANC ≥                                                                                                                                                                                                                                                                                                                                                                                                              |
| 1000-1499/L or                                                                                                                                                              | 75,000-99,000/L | 1,500/L and platelets ≥ 100,000/L. Do not  replace missed doses. Restart next treatment at  1 dose lower.  -2nd Occurrence: Hold current dose until ANC ≥  1,500/L and platelets ≥ 100,000/L. Do not  replace missed doses. Restart next treatment at  1 dose lower if available or discontinue if not  available -3rd Occurrence: Discontinue protocol therapy. -1st Occurrence: Hold current dose until ANC ≥                                               |
| 500-999/L or                                                                                                                                                                | 50,000-74,000/L | 1,500/L and platelets ≥ 100,000/L. Do not  replace missed doses. Restart next treatment at  1 dose lower if available or discontinue if not  available. -2nd Occurrence: Hold current dose until ANC ≥  1,500/L and platelets ≥ 100,000/L. Do not  replace missed doses. Restart next treatment at 1  dose lower if available or discontinue if not  available. -3rd Occurrence: Discontinue protocol therapy. -1st Occurrence: Hold current dose until ANC ≥ |
| <500/L or                                                                                                                                                                   | <50,000/L       | 1,500/L and platelets ≥ 100,000/L. Restart  next treatment at 1 dose lower if available or  discontinue if not available. -2nd Occurrence: Discontinue protocol therapy.                                                                                                                                                                                                                                                                                        |
| 1Note: G-CSF (Filgrastim) may be added for low ANC on day of treatment BEFORE a dose reduction  is instituted at treating physician's discretions. Neulasta® is NOT allowed. |                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |  
Table 5.2.1 Hematological Toxicities Treatment-Emergent Non-hematological Toxicities: (EXCEPT non-clinically relevant/significant laboratory abnormalities):  
| NCI CTCAE Grade                                                  | ESK981                                                                                                        | Nivolumab                                                                                |
|------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------|
| 1                                                                | No change from original starting                                                                              | No change from original starting                                                         |
| dose                                                             | dose, supportive care as required                                                                             |                                                                                          |
| 2                                                                | Hold until resolved to ≤ Grade 1,  then reduce by 1 dose level if  available or discontinue if not  available | Hold until resolved to ≤ Grade 1, supportive care as required and  then resume treatment |
| Second episode of  grade 2 or 1st episode of  ≥ grade 3 toxicity | Hold until resolved to ≤ Grade 1,  then reduce by 1 dose level if  available or discontinue if not  available | Discontinue treatment                                                                    |
| Third episode of grade 2 or 2nd episode of ≥ grade 3 toxicity    | Discontinue treatment                                                                                         |                                                                                          |  
Note: The drug modifications for toxicity only apply to the drug the toxicity is attributed to (i.e. the offending drug), and the other drug could be continued without modification.  
Note: Any drug holds for toxicity can continue for a maximum duration of 12 weeks. Beyond that, the offending drug shall be permanently discontinued. The other drug can be continued.  
5.3 **Concomitant Medications/Treatments**
Systemic corticosteroids greater than the equivalent of 10 mg of prednisone or equivalent alternative steroid (except physiologic dose for adrenal replacement therapy) or other immunosuppressive agents (such as cyclosporine or methotrexate) and any other medications that could potentially impact the efficacy or safety of the study as judged by the treating investigator are NOT permitted from time of registration to subjects completing protocol therapy unless clinically indicated to manage adverse events or life threatening or serious conditions as determined by the treating investigator.  
Subjects are prohibited from receiving the following therapies during the Screening and Treatment Phase of this trial:
Immunotherapy not specified in this protocol Chemotherapy not specified in this protocol Investigational agents other than ESK981 or checkpoint inhibitor immunotherapy Neulasta®
Live vaccines within 30 days prior to the initial study treatment administration through the last dose of study treatment. Examples of live vaccines include, but are not limited to, the following: measles, mumps, rubella, varicella/zoster, yellow fever, intranasal influenza, rabies, BCG (tuberculosis vaccine), and typhoid vaccine.  
If precluded by local regulations, live vaccines should not be given for 120 days after the last dose of checkpoint inhibitor immunotherapy is administered.  
Systemic glucocorticoids or other immunosuppressive drugs for any purpose other than to modulate symptoms from a drug-related AE of immunologic etiology (refer to Section 5.2 - Dose Modification). The use of physiologic doses of corticosteroids may be approved after consultation with the Study PI.  
o Use of prophylactic corticosteroids to avoid allergic and other adverse reactions
(e.g., to IV contrast dye or transfusions) is permitted.  
o Use of intermittent inhaled steroids or local injection of corticosteroids is permitted upon consultation with the Principal Investigator.  
o Physiologic doses of prednisone ≤10 mg (or equivalent) per day.  
5.4 **Other Modalities or Procedures**
No other modalities or procedures will be used in this protocol.  
5.5 **Duration of Therapy**
In the absence of treatment delays due to adverse events, treatment may continue until one of the criteria listed in Section 5.6 apply. Patients will be followed for up to 24 months after removal from treatment or until death, whichever occurs first. Patients removed from treatment for unacceptable adverse events will be followed by phone call or clinic visit until resolution or stabilization of the adverse events.  
5.6 **Off Treatment Criteria**
Patients can be taken off study treatment at any time at their own request with a withdrawal of informed consent, or they may be withdrawn at the discretion of the investigator for safety, behavioral or administrative reasons. The reason(s) for discontinuation from study treatment will be documented and may include:
Disease progression as defined in Section 7.0 or evidence of clinical progression as determined by treating investigator; Subject has intolerable toxicity from study therapy despite supportive measures and maximum permitted dose modifications and holds per protocol; Patient withdraws informed consent (termination of treatment and follow-up for any reason);
Loss of ability to freely provide informed consent through imprisonment or involuntary incarceration for treatment; Patient is unable to comply with protocol requirements;  
Treating physician determines continuation on the study would not be in the patient's best interest; Development of second malignancy (except for basal cell carcinoma or squamous cell carcinoma of the skin or Gleason ≤ 6 prostate cancer) that requires treatment, which would interfere with this study; Lost to Follow-up. If a research subject cannot be located to document survival after a period of 2 years, the subject may be considered "lost to follow-up." All attempts to contact the subject during the two years must be documented; Termination of the study by the University of Michigan; Patient completes protocol treatment and follow-up.
5.7 **Patient Replacement**
Patients who are not evaluable for objective response (as defined in Section 7.1.1) will be replaced.
untitled h1
6.0 schedule of assessments 6.1

| 1 cycle (C) = 28 days (D).                                                                                                            |                                                                                                                               |                                     |      |      |      |            |      |            |
|---------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------|-------------------------------------|------|------|------|------------|------|------------|
| Trial Period                                                                                                                          | Screening (-28 to -1  days)                                                                                                   | C1D1                                | C2D1 | C3D1 | C4D1 | Additional | EOT7 | Follow-Up8 |
| Cycles…                                                                                                                               | Every 12  weeks (+/-14  business  days) for up  to 24  months/death                                                           |                                     |      |      |      |            |      |            |
| Informed Consent                                                                                                                      | X                                                                                                                             |                                     |      |      |      |            |      |            |
| Tumor tissue  specimen (15 FFPE  slides required;  blocks preferred)  identified                                                      | 30 days  from last  dose  (+/- 7  business  days)                                                                             |                                     |      |      |      |            |      |            |
| X                                                                                                                                     |                                                                                                                               |                                     |      |      |      |            |      |            |
| Blood for banking                                                                                                                     | X                                                                                                                             |                                     |      |      |      |            |      |            |
| History, PE,  Concomitant Meds, Vital Signs1                                                                                          | X                                                                                                                             | X                                   | X    | X    | X    | X          | X    |            |
| PT/INR, aPTT                                                                                                                          | X                                                                                                                             |                                     |      |      |      |            |      |            |
| Karnofsky                                                                                                                             | X                                                                                                                             | X                                   | X    | X    | X    | X          | X    |            |
| Performance Status Pregnancy Test for                                                                                                 | X                                                                                                                             |                                     |      |      |      |            |      |            |
| WOBCP2 Toxicity (include DLT)                                                                                                         | X                                                                                                                             | X                                   | X    | X    | X    | X          | X    |            |
| Evaluations12 CBC with differential,                                                                                                  | X                                                                                                                             | X13                                 | X13  | X    | X    | X          | X    |            |
| platelets3 COMP4                                                                                                                      | X                                                                                                                             | X                                   | X    | X    | X    | X          | X    |            |
| TSH                                                                                                                                   | X                                                                                                                             | Every 12 weeks from Cycle 1 Day 1 5 |      |      |      |            |      |            |
| QoL (EQ-5D-5L)                                                                                                                        | X                                                                                                                             | X                                   | X    | X14  | X    |            |      |            |
| Pill Diary                                                                                                                            | X                                                                                                                             | X                                   | X    | X    | X    |            |      |            |
| collection/handing out Tumor response  assessment 6 (CT  chest, CT or MRI  abdomen/pelvis; CT  or MRI brain if  clinically indicated) | X                                                                                                                             | X                                   | X 6  | X    |      |            |      |            |
| Treatment ESK9819, 10                                                                                                                 | X                                                                                                                             | X                                   | X    | X    | X    |            |      |            |
| (Cohort A and B) Nivolumab11                                                                                                          | X                                                                                                                             | X                                   | X    | X    | X    |            |      |            |
| (Cohort B only) Survival Status                                                                                                       | X                                                                                                                             |                                     |      |      |      |            |      |            |
| 1.                                                                                                                                    | Vital signs will include weight, temperature, pulse, respirations, blood pressure; height will be obtained at screening only. |                                     |      |      |      |            |      |            |  
1. Vital signs will include weight, temperature, pulse, respirations, blood pressure; height will be obtained at screening only. 2. WOCBP: Women of child bearing potential; either urine or serum pregnancy test. 3. CBC with diff includes total WBC, hemoglobin, hematocrit and differential of the WBC including absolute counts. Other checks are at discretion of treating investigator.  
4. COMP or Comprehensive metabolic profile includes sodium, potassium, chloride, bicarbonate, BUN, creatinine, AST, ALT,
alkaline phosphatase, total bilirubin.  
5. TSH: Every 12 weeks from Cycle 1 Day 1 (i.e. Cycle 4 Day 1; Cycle 7 Day 1, etc.). 6. Window of +/- 7 business days. Imaging will be with or without intravenous contrast, before or on associated visit. CT or MRI
brain with (preferred) or without IV contrast if suspected or known brain metastases. Frequency of tumor assessments will be q2 cycles (i.e. q 8 weeks) for first 4 assessments beyond baseline and then q 3 cycles (i.e. 12 weeks) subsequently until withdrawal of consent/death/2 years from C1 D1 whichever is later. If CR/PD, should be confirmed with repeat imaging after an interval of at least 4 weeks. In follow-up, if subjects are on alternative therapies, no mandated imaging but data from routine imaging will be captured at least every 12 weeks if available (+/- 7 business days).  
7. End of treatment visit may or may not be the same day as a planned study visit. If it is not on a planned study visit, the minimum assessments listed in the schedule must be completed.  
8. Follow-up may be conducted by phone call or a clinic visit. 9. Study drug(s) must be started within 14 business days from time of enrollment. 10. ESK981 will only be given on days 1-5 of each week of each treatment cycle followed by 2 days off. 11. Nivolumab will be administered on Day 1 of each treatment cycle in Cohort B. 12. All Serious Adverse Events (SAEs) occurring from the initial study treatment administration through 60 days following the last dose of the study treatment should be reported to the Coordinating Center. Any SAEs occurring after 60 days following the last dose of the study treatment that are believed to be related to study drug should also be reported to the Coordinating Center.  
13. CBC with diff must be obtained weekly during Cycles 1 and 2. For patients who experience no ≥ Grade 3 hematological toxicity during Cycles 1 and 2, monthly blood counts will be obtained during subsequent cycles.  
14. QOL obtained Cycles 1-3, 5, 7 and 9 then q 3 cycles (12 weeks) subsequently NOTE: All assessments have a window of ± 3 business days unless otherwise mentioned.
untitled h1
7.0 measurement of effect 7.1

Immunotherapy drugs such as nivolumab can initially cause inflammation in the early stages of treatment. Immune-related RECIST (irRECIST) utilizes RECISTv1.1 but considers an inflammatory response (or "pseudo-progression") as normal. The main difference between RECISTv1.1 and irRECIST is that patients can stay on trial after the first progressive disease (PD) assessment (as per RECISTv1.1) if using immune-related RECIST criteria. This PD per RECISTv1.1 is then relabeled as immune related stable disease (irSD) per irRECIST and requires addition of unidimensional measurements of all new lesions (that meet the definition of target lesion) to be added to the sum of longest diameters (SLD) calculation for response assessment. Importantly, immune-related progression (irPD) must be confirmed by a follow-up scan at least 4 weeks (within 48 weeks) following the initial PD/irSD assessment in order to take the patient off the trial.  
Subjects that are deemed to have clinical progression and/or unstable should not be continued on therapy after PD (per RECISTv1.1) and are therefore not required to have repeat tumor imaging for confirmation as per irPD definition. It is at the discretion of the treating investigator whether to continue a subject on study treatment until repeat confirmatory imaging is obtained. This clinical judgment decision by the site investigator should be based on the subject's overall clinical condition, including performance status, clinical symptoms, and laboratory data.  
7.1.1 **Definitions**
Evaluable for toxicity. All patients will be evaluable for toxicity if they have received at least 1 dose of ESK981.  
Evaluable for objective response. Only those patients who have measurable disease present at baseline, have received at least 2 cycle(s) of therapy, and have had their disease re-evaluated will be considered evaluable for response. These patients will have their response classified according to the definitions stated below. (Note: Patients who exhibit objective disease progression prior to the end of cycle 2 will also be considered evaluable.)
7.1.2 **Disease Parameters**
Measurable disease. Measurable lesions are defined as 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:  
10mm by CT scan (irrespective of scanner type) for studies with a slice thickness of
<5mm or twice the slice thickness or MRI
10mm caliper measurement by clinical exam (lesions which cannot be accurately measured with calipers should be recorded as non-measurable)
20mm by chest X-ray (if clearly defined and surrounded by aerated lung)  
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters).
Malignant lymph nodes: To be considered pathologically enlarged and measurable, a lymph node must be ≥15mm in short axis when assessed by CT scan (CT scan slice thickness recommended to be no greater than 5 mm). At baseline and in follow-up, only the short axis will be measured and followed. Note: Tumor lesions that are situated in a previously irradiated area will only be considered measurable, if they have had subsequent progression by at least 5 mm.  
Non-measurable disease. All other lesions (or sites of disease), including small lesions (<10 mm using CT scan), are considered non-measurable disease. Bone lesions without measurable soft tissue component, leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonis, inflammatory breast disease, abdominal masses (not followed by CT or MRI), and cystic lesions are all non-measurable.  
Target lesions. All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total should be identified as **target lesions** and recorded and measured at baseline.  
Target lesions should be selected on the basis of their size (lesions with the longest diameter), be representative of all involved organ, but in addition should be those that lend themselves to reproducible repeated measurements.  
For Cohort B only: If a non-nodal lesion is either not present or is initially measured with longest diameter <10mm as a non-target then grows to >10mm after baseline, this lesion then becomes a new target lesion as per irRECIST criteria. The nonnodal longest diameter is then added to the sum of diameters, and patient response is calculated with the new lesion.  
Lymph nodes merit special mention since they are normal anatomical structures which may be visible by imaging even if not involved by tumor. Pathological nodes which are defined as measurable and may be identified as target lesions must meet the criterion of a short axis of
≥15mm by CT scan. Only the short axis of these nodes will contribute to the baseline sum.  
The short axis of the node is the diameter normally used by radiologists to judge if a node is involved by solid tumor. Nodal size is normally reported as two dimensions in the plane in which the image is obtained (for CT scan this is almost always the axial plane; for MRI the plane of acquisition may be axial, sagittal or coronal). The smaller of these measures is the short axis. For example, an abdominal node which is reported as being 20mm x 30mm has a short axis of 20mm and qualifies as a malignant, measurable node. In this example, 20mm should be recorded as the node measurement. All other pathological nodes (those with short 32 axis ≥10mm but <15 mm) should be considered non-target lesions. Nodes that have a short axis <10mm are considered nonpathological and should not be recorded or followed. A sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated and reported as the baseline sum diameters. If lymph nodes are to be included in the sum, then as noted above, only the short axis is added into the sum. The baseline sum diameters will be used as reference to further characterize any objective tumor regression in the measurable dimension of the disease.  
For Cohort B only: If a non-target lymph node grows to >15mm after baseline, this node then becomes a new target lesion as per irRECIST. The nodal short axis is then added to the sum of diameters, and patient response is calculated with the new lesion.  
Non-target lesions. All other lesions (or sites of disease) including pathological lymph nodes should be identified as non-target lesions and should also be recorded at baseline.  
Measurements are not required and these lesions should be followed as 'present', 'absent',
or in rare cases 'unequivocal progression' (more details to follow). In addition, it is possible to record multiple non-target lesions involving the same organ as a single item on the case record form (e.g. 'multiple enlarged pelvic lymph nodes' or 'multiple liver metastases').
untitled h1
7.1.3 guidelines for evaluation of

All measurements should be recorded in metric notation, using calipers if clinically assessed. All baseline evaluations should be performed as close as possible to the treatment start and never more than 4 weeks before the beginning of the treatment. The same method of assessment and the same technique should be used to characterize each identified and reported lesion at baseline and during follow-up. Imaging based evaluation should always be done rather than clinical examination unless the lesion(s) being followed cannot be imaged but are assessable by clinical exam.  
Clinical lesions: Clinical lesions will only be considered measurable when they are superficial and >10mm diameter as assessed using calipers (e.g. skin nodules). For the case of skin lesions, documentation by color photography including a ruler to estimate the size of the lesion is suggested. As noted above, when lesions can be evaluated by both clinical exam and imaging, imaging evaluation should be undertaken since it is more objective and may also be reviewed at the end of the study. Chest X-ray: Chest CT is preferred over chest X-ray, particularly when progression is an important endpoint, since CT is more sensitive than X-ray, particularly in identifying new lesions. However, lesions on chest X-ray may be considered measurable if they are clearly defined and surrounded by aerated lung. CT, MRI: CT is the best currently available and reproducible method to measure lesions selected for response assessment. This guideline has defined measurability of lesions on CT scan based on the assumption that CT slice thickness is 5mm or less. When CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. MRI is also acceptable in certain situations (e.g. for body scans).  
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.  
Endoscopy, laparoscopy: The utilization of these techniques for objective tumor evaluation is not advised. However, they can be useful to confirm complete pathological response when biopsies are obtained or to determine relapse in trials where recurrence following complete response or surgical resection is an endpoint. Tumor markers: Tumor markers alone cannot be used to assess objective tumor response.
untitled h1
7.1.4 response criteria 7.1.4.1 evaluation

Patients will be evaluated according the following RECISTv1.1 response: Complete Response (CR): Disappearance of all target lesions, determined by two separate observations conducted not less than 4 weeks apart. There can be no appearance of new lesions.  
Partial Response (PR): At least a 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline sum LD. There can be no appearance of new lesions.  
Progressive Disease (PD): At least a 20% increase in the sum of the LD of target lesions (with a minimum absolute increase of 5 mm), taking as reference the smallest sum LD recorded since the treatment started, or the appearance of one or more new lesions.  
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR (taking as reference the baseline sum LD) nor sufficient increase to qualify for PD (taking as reference the smallest sum LD since the treatment started). For Cohort B only:
After the first PD assessment per RECISTv1.1 (=irSD per irRECIST), patients will be evaluated for irPD at least 4 weeks apart according to the following definition:
Immune-related Progressive Disease (irPD): At least a 20% increase in the sum of the LD of target lesions (with a minimum absolute increase of 5 mm), taking as reference the smallest sum LD recorded since the treatment started, or appearance of new lesions since the last evaluation.
untitled h1
7.1.4.2 evaluation of non-target lesions

Complete Response (CR): Disappearance of all non-target lesions. All lymph nodes should be non-pathological in size (<10 mm short axis)
Non-CR/Non-OD: Persistence of one or more non-target lesion(s). Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions.  
Although a clear progression on non-target lesions in absence of stable target lesions is exceptional, *the opinion of the treating physician should prevail in such* circumstances.
untitled h1
7.1.4.3 evaluation of best overall

The best overall response is the best response recorded from the start of the treatment until disease progression/recurrence (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.  
| Overall  Response  per  irRECIST (Cohort B  only)   |                                                                                                                           |         |                     |      |                                   |
|-----------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------|---------|---------------------|------|-----------------------------------|
| Overall  Response  per  RECISTv1.1                  | Confirmed Response  for this Category  Requires:                                                                          |         |                     |      |                                   |
| Target                                              | Non-Target                                                                                                                | New     |                     |      |                                   |
| Lesions                                             | Lesions                                                                                                                   | Lesions |                     |      |                                   |
| CR                                                  | CR                                                                                                                        | No      | CR                  | NA   | >4 wks. confirmation              |
| CR                                                  | CR Non-CR/PD                                                                                                              | No      | PR                  | NA   | >4 wks. confirmation              |
| PR                                                  | CR Non-CR/PD                                                                                                              | No      | Documented at least |      |                                   |
| SD                                                  | CR Non-CR/PD                                                                                                              | No      | SD                  | NA   | once >4 wks. from  baseline       |
| PD                                                  | Any                                                                                                                       | Any     |                     |      |                                   |
| Any                                                 | PD*                                                                                                                       | Any     | PD                  | irSD | >4 wks. confirmation              |
| Any                                                 | Any                                                                                                                       | Yes     |                     |      |                                   |
| PD                                                  | Any                                                                                                                       | Any     | NA                  | irPD | No further confirmation  required |
| Any                                                 | PD*                                                                                                                       | Any     |                     |      |                                   |
| Any                                                 | Any                                                                                                                       | Yes     |                     |      |                                   |
| *                                                   | Only in exceptional circumstances, unequivocal progression in non-target lesions may be  accepted as disease progression. |         |                     |      |                                   |  
Evaluation as per combined RECISTv1.1/irRECIST
Note: 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.  
NA=not applicable Note: If subjects respond to treatment and are able to have their disease resected, the patient's response will be assessed prior to the surgery.
untitled h1
7.1.4.4 treatment beyond progression -

Accumulating evidence indicates a minority of subjects treated with immunotherapy may derive clinical benefit despite initial evidence of PD.  
Subjects treated on Arm B will be permitted to continue study treatment beyond initial RECISTv1.1 defined PD, assessed by the investigator, as long as they meet the following criteria:
Investigator determined clinical benefit Tolerance of study drug Stable performance status  
Treatment beyond progression will not delay an imminent intervention to prevent serious complications of disease progression (e.g., CNS
metastases)
A radiographic assessment/ scan should be performed within 4-8 weeks of initial investigator-assessed progression to determine whether there has been a decrease in the tumor size or continued PD (termed irPD). The assessment of clinical benefit should be balanced by clinical judgment as to whether the subject is clinically deteriorating and unlikely to receive any benefit from continued treatment.  
If the investigator feels that the subject continues to achieve clinical benefit by continuing treatment, the subject should remain on the trial and continue to receive monitoring according to the Time and Events Table (Section 6.1).  
Immune-related Progressive Disease (irPD): For the subjects who continue study therapy beyond progression, further progression is defined as an additional 10% increase in tumor burden with a minimum 5 mm absolute increase from time of initial PD, unequivocal worsening of NT lesions, or appearance of new lesions since the last evaluation. This includes an increase in the sum of diameters of all target lesions and/ or the diameters of new measurable lesions compared to the time of initial PD. Study treatment should be discontinued permanently upon documentation of further progression (i.e. irPD).  
7.1.5 **Duration of Response**
Duration of overall response: The duration of overall response is measured from the time measurement criteria are met for CR or PR (whichever is first recorded) until the first date that recurrent or progressive disease is objectively documented (taking as reference for progressive disease the smallest measurements recorded since the treatment started).  
Duration of stable disease: Stable disease is measured from the start of the treatment until the criteria for progression are met, taking as reference the smallest measurements recorded since the treatment started.  
7.1.6 **Progression-Free Survival**
Progression-free survival (PFS) is defined as the duration of time from start of treatment to time of progression or death, the event that occurs first.
untitled h1
7.2 safety/tolerability

Analyses will be performed for all patients having received at least one dose of study drug. The study will use the CTCAE version 4.03 for reporting of non-hematologic adverse events (https://www.eortc.be/services/doc/ctc/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf) and modified criteria for hematologic adverse events.
untitled h1
8.0 adverse events 8.1 esk981

8.1.1 Contraindications Because of the potential for drug-drug interaction, the concurrent use of all other drugs, over-the-counter medications, and alternative therapies must be documented in the patient's record.  
8.1.2 Special Warnings and Precautions for Use ESK981 is metabolized via CYP1A2, CYP2C8, and CYP3A4. Inhibitors of CYP1A2, CYP2C8, and CYP3A4 have the potential to increase plasma concentration of ESK981.  
Inducers of CYP1A2, CYP2C8, and CYP3A4 have the potential to decrease plasma concentrations of ESK981. Concomitant use of a medication known to be a potent inhibitor of CYP1A2, CYP2C8, or CYP3A4, or a potent inducer of CYP1A2, CYP2C8, or CYP3A4 should be avoided unless deemed to be medically necessary by the investigator. In addition, nonclinical studies have identified the potential for ESK981 to inhibit CYP3A4/5 (Ki 2.2μM). ESK981 has the potential to increase plasma concentration of concomitant mediations that are CYP3A4/5 substrates. Caution should be used, or alternative treatments considered, if concomitant treatment with CYP3A4/5 substrates that have a narrow therapeutic range is needed (see Appendix 2).
untitled h1
adverse reactions

**Side effects:** The most frequently reported AE of any grade was fatigue (51%).  
Other frequently reported AEs (≥ 20% of patients) were nausea (47%), diarrhea (33%), decreased appetite (33%), abdominal pain (30%), back pain (28%), vomiting (28%), constipation (28%), headache (28%), dizziness (28%), and dyspnea (23%). These AEs were reported at a similar frequency between dosage cohorts, and no relationship with dose was evident.
untitled h1
treatment-emergent adverse events of grades

Grade 3 or Grade 4 AEs occurred in 37% of patients across dosing cohorts ([32.6%] Grade 3 and [4.7%] Grade 4). Treatment-related Grade 3 or Grade 4 AEs were most frequent in the 97.4 mg/m2 cohort. Grade 3 or Grade 4 laboratory hematologic toxicities were reported in 18.6 % of patients across dosage cohorts. The most common Grade 3 or Grade 4 laboratory hematologic toxicity was lymphopenia, which occurred across dosage cohorts (5.9, 29.6, 55.0, 97.4, and 126.6 mg/m2). Grade 4 leukopenia occurred in a single patient in the 126.6 mg/m2 cohort. Grade 3 or Grade 4 neutropenia also occurred in two patients in the 97.4 mg/m2 cohort (Grade 3) and in one patient in the 126.6 mg/m2 cohort (Grade 4). No Grade 5 AEs occurred.  
**Serious Adverse Events**
Serious adverse events (SAEs) occurred were deemed unlikely or not related to ESK981. Three patients (1 patient in the 97.4 mg/m2 cohort and two patients in the 126.6 mg/m2 cohort) experienced SAEs that were categorized as possibly or definitely related to ESK981: pyrexia, hemolytic anemia, hyperbilirubinemia, dyspnea, neutropenia, ECG change, and chest discomfort. There were no deaths occurred during the study.
untitled h1
procedure in case of pregnancy

The effect of ESK981 in pregnant and lactating women is not known, and the exposure of a fetus or nursing infant is considered a potential risk. ESK981 can cause fetal harm when administered to a pregnant woman based on its mechanism of action. Subjects receiving ESK981 are advised to use two acceptable methods of birth control (one of which must include a condom as a barrier method of contraception) starting at the time of screening for an ESK981 study and continuing throughout the course of treatment and for at least six months after ESK981 is discontinued. If during the conduct of the clinical trial, a male subject impregnates his partner, the subject should report the pregnancy to the investigator. The investigator should report the pregnancy to the Coordinating Center as an SAE within 24 hours of awareness of the event. The expected date of delivery or expected date of the end 37 of the pregnancy, last menstruation, estimated fertility date, pregnancy result and neonatal data etc., should be included in this information.  
The investigator should report the outcome of the pregnancy (independent of outcome, e.g., full term delivery, pre-term delivery, spontaneous abortion, induced abortion, stillbirth, death of newborn, congenital anomaly [including anomaly in a miscarried fetus, etc.] in accordance with the same reporting procedure as for SAEs. The date of outcome of the pregnancy, gestational age, date of birth and neonatal data etc., should be included in this information.  
8.2 **Nivolumab**
Refer to the current package insert for nivolumab contraindications and adverse reactions.  
8.3 Adverse Event **Reporting Requirements**
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial and is done to ensure the safety of subjects enrolled in the studies as well as those who will enroll in future studies using similar agents. Data on adverse events will be collected from the time of the initial study treatment administration through 60 days after the last dose of study treatment.  
In addition to new events, any increase in the frequency or severity (i.e., toxicity grade) of a preexisting condition that occurs after the patient begins study treatment is also considered an adverse event.
untitled h1
8.4 definitions

8.4.1 **Adverse Event**
An adverse event (AE) is any untoward medical occurrence in a patient receiving study treatment and which does not necessarily have a causal relationship with this treatment. An AE can be any unfavorable and unintended sign (including an abnormal laboratory finding),
symptom, or disease temporally associated with the use of an experimental intervention, whether or not related to the intervention.  
Diagnostic and therapeutic non-invasive and invasive (i.e., surgical) procedures will not be reported as adverse events. However, the medical condition for which the procedure was performed must be reported if it meets the definition of an adverse event unless it is a pre-existing (prior to protocol treatment) condition.  
*Abnormal laboratory values or test results constitute adverse events if they induce* clinical signs or symptoms or require therapy. They are to be captured under the signs, symptoms or diagnoses associated with them.
8.4.2 **Serious Adverse Event**
An adverse event is considered "serious" if, in the view of either the investigator, it results in any of the following outcomes:
o Death If death results from (progression of) the disease, the disease should be reported as event (SAE) itself.  
o A life-threatening adverse event An adverse even is considered 'life-threatening' if, in the view of either the investigator [or sponsor], its occurrence places the patient or subject at immediate risk of death. It
does not include an adverse event that, had it occurred in a more severe form, might have caused death.  
o Inpatient hospitalization or prolongation of existing hospitalization for > 24 hours.  
o A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions o A congenital anomaly/birth defect
o Important medical event Any event that may not result in death, be life-threatening, or require hospitalization may be considered serious when, based upon appropriate medical judgment, they may jeopardize the patient and may require medical or surgical intervention to prevent one of the outcomes listed in this definition of "Serious Adverse Event". Examples of such medical events include allergic bronchospasm requiring intensive treatment in an emergency room or at home; convulsions that do not result in inpatient hospitalization or the development of drug dependency or drug abuse.  
Previously planned (prior to signing the informed consent form) surgeries should not be reported as SAEs unless the underlying medical condition has worsened during the course of the study. Preplanned hospitalizations or procedures for preexisting conditions that are already recorded in the patient's medical history at the time of study enrollment should not be considered SAEs. Hospitalization or prolongation of hospitalization without a precipitating clinical AE (for example, for the administration of study therapy or other protocol-required procedure) should not be considered SAEs. However, if the preexisting condition worsened during the course of the study, it should be reported as an SAE.  
8.4.3 **Expected Adverse Events**
An adverse event (AE) is considered "expected" if:  
For approved and marketed drugs or devices, those adverse events are described in the approved Package Insert (Label).  
For investigational new drugs or devices, those adverse events are described in the FDA Investigator's Brochure.  
In clinical research studies, information on expected adverse events is also summarized in the protocol and in the consent document.
8.4.4 **Unexpected Adverse Event**
An adverse event (AE) is considered "unexpected" if it is not described in the Package Insert, Investigator's Brochure, in published medical literature, in the protocol, or in the informed consent document.
untitled h1
8.5 adverse event characteristics

8.5.1 **CTCAE Term**
(AE description) and grade: The descriptions and grading scales found in the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 will be utilized for AE
reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 4.03. A copy of the CTCAE version 4.03 can be down loaded from the CTEP web site. (https://www.eortc.be/services/doc/ctc/CTCAE_4.03_2010-0614_QuickReference_5x7.pdf 8.5.2 **Attribution of the AE**
The investigator or co-investigator is responsible for assignment of attribution.  
Definite - The AE *is clearly related* to the study treatment.  
Probable - The AE *is likely related* to the study treatment.  
Possible - The AE *may be related* to the study treatment.  
Unlikely - The AE *is doubtfully related* to the study treatment. Unrelated - The AE *is clearly NOT related* to the study treatment.
untitled h1
8.6 serious adverse event reporting

All serious adverse events (SAEs) and unanticipated problems (UPs), regardless of causality to study drug, will be reported to the Principal Investigator and also to the Coordinating Center. All SAEs and UPs must be reported to the Coordinating Center within 24 hours of first awareness of the event. Events should be reported using the Coordinating Center SAE form as available in the study database. A copy of the Coordinating Center SAE form as available in the study database should be sent to the Coordinating Center via fax at 734-232-0744 or via email to CTSU-OncologyMultisite@med.umich.edu within 24 hours of the site's knowledge of the event.  
Follow-up information should also be reported within 24 hours of receipt of the information by the investigator.  
All SAEs and UPs will be reported to the IRB per current institutional standards. The Coordinating Center will disseminate information regarding SAEs and UPs to the participating sites within 5 days of review of the information by the Coordinating Center's Principal Investigator (or designee in the event of extended absence) only in the case that the event(s) is believed to be related (i.e., possibly, probably, or definitely) to the study drug. The Coordinating Center will be responsible for reporting of events to the FDA and supporters, as appropriate (outlined below).
untitled h1
8.6.1 reporting procedures to esanik

All Serious Adverse Events (SAEs) occurring from the initial study treatment administration through 60 days following the last dose of the study treatment will be reported by the Coordinating Center to Esanik. Any SAEs occurring after 60 days following the last dose of the study treatment that are believed to be related to study drug will also be reported to Esanik.  
The Coordinating Center will send the initial completed SAE Form within 24 hours of receipt via email to Esanik:
Email: drugsafety@esanik.com. The Coordinating Center will confirm receipt of the email by calling 858-693-9158 If only limited information is initially available or an ongoing SAE changes in its intensity or relationship to the study drug, or if new information becomes available, a follow-up report will be generated and sent to Esanik within 24 hours of receipt.
untitled h1
8.6.2 reporting procedures to the

In this trial, serious unexpected adverse events believed to be definitely, probably or possibly related to the study treatment will be reported to the Food and Drug Administration via the MedWatch 3500A. The Michigan IND/IDE Assistance Program (MIAP) (University of Michigan) will assist the IND Sponsor in reporting SAEs to the FDA that meet the reporting requirements in 21 CFR 312.32. This reporting could include the initial report and follow-up reports when appropriate for the event.  
All correspondence to the FDA by sponsor-investigator should be provided to Esanik.  
8.7 **Routine Reporting**
All other adverse events- such as those that are expected, or are unlikely or definitely not related to the study participation- are to be reported annually as part of regular data submission.  
8.8 **Reporting of Unanticipated Problems**
There are types of incidents, experiences and outcomes that occur during the conduct of human subjects research that represent unanticipated problems but are not considered adverse events. For example, some unanticipated problems involve social or economic harm instead of the physical or psychological harm associated with adverse events. In other cases, unanticipated problems place subjects or others at increased risk of harm, but no harm occurs. Upon becoming aware of any incident, experience, or outcome (not related to an adverse event) that may represent an unanticipated problem, the investigator should assess whether the incident, experience, or outcome represents an unanticipated problem. The incident, experience or outcomes is considered unanticipated if it meets all of the following criteria:  
1. Unexpected (in terms of nature, severity, or frequency); 2. Related or possibly related to participation in the research; and 3. Suggests that the research places subjects or others at a greater risk of harm than was previously known or recognized.
If the investigator determines that the incident, experience, or outcome represents an unanticipated problem, the investigator must report it to the Coordinating Center within 2 calendar days of the study team becoming aware of the problem and report to their local IRB as per institutional guidelines.  
8.9 Early **Stopping Rules**
See section 11.3 for Early Stopping Due to Toxicity.