untitled h1
untitled h2

Masonic Cancer Center University of Minnesota Nivolumab, Oral Cyclophosphamide, and N-803 for Relapsed/Refractory Acute Myeloid Leukemia (AML) and Higher-Risk Myelodysplastic Syndrome (MDS)
HM2017-33 CPRC \# 2017LS116 IND 138758 BMS protocol number CA209-9WK
Principal Investigator/IND Sponsor:
Fiona He, MD  
Co-Investigators:
Mukta Arora, MD
Veronika Bachanova, MD, PhD
Claudio Brunstein, MD, PhD
Craig Eckfeldt, MD, PhD
Najla El Jurdi, MD
Michael Linden, MD, PhD*
Joseph Maakaron, MD
Jeffrey Miller, MD
Armin Rashidi MD, PhD
Zohar Sachs, MD, PhD
Erica Warlick, MD
Daniel J. Weisdorf, MD
***will not consent study participants**
Biostatistician:
Qing Cao, MS
Version Date:
May 12, 2021 Confidential Revision History  
| Revision                                                                                                                                                           | Version                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             | Detail of Changes   | Consent                                                                                                                                                                                                                                                     |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| #                                                                                                                                                                  | Date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | change?  (Y/N)      |                                                                                                                                                                                                                                                             |
| 10/03/2017                                                                                                                                                         | Original version for CPRC and BMS (earlier version sent)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | n/a                 |                                                                                                                                                                                                                                                             |
| 11/01/2017                                                                                                                                                         | In response to CPRC stips:  Expand nivolumab background information in Section 2.3 and Section 2.4 (new)  Add wording to Section 6.2 regarding use of hydroxurea and  immunosuppression during the study treatment.  Other edits:  Cover page - update Co-I's  Section 4.2.1 - clarify negative pregnancy test with 7 days of study  administration  Section 13 and Section 14.2 - provide more detail pertaining to study  endpoints  Section 14.3 - expand definition of evaluable  Other minor edits and updates                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | n/a                 |                                                                                                                                                                                                                                                             |
| 02/23/2018                                                                                                                                                         | Original version to the IRB and FDA:  To align versions approved by CPRC and the older version approved by  BMS (no changes from BMS affecting the 11/01/2017 version approved by  the CPRC)  Update in protocol template language:  - Update Section 5 Patient Registration/Study Enrollment to current  template language  - Section 12.3 - delete wording about submitting copy of IRB continuing  review to CPRC  - Replace CTCAE v 4.03 with v 5.0  - Replace study coordinator with newer designation of Primary Clinical  Research Coordinator (PCRC)  - Add co-investigators Other minor edits and clarifications throughout.  n/a                                                                                                                                                                                                                                                                                                                                                                          |                     |                                                                                                                                                                                                                                                             |
| 03/20/2018                                                                                                                                                         | In response to FDA's potential hold and non-hold comments:  - Synopsis, schema, Section 3 and Section 6.3 - clarify and make  consistent that an increase in absolute blast count is ≥ 25% in  peripheral blood or bone marrow from baseline is criteria for stopping  treatment due to disease progression  - Synopsis, Section 4.1.2 and Appendix I - Add risk score of >4.5 to the  definition of higher risk MDS, separate relapsed AML and MDS  eligibility requirements  - Synopsis, Section 4.1.4 and Appendix I - add bilirubin ≤ 3 x ULN to  eligibility and require both AST and ALT results (previously or)  - Section 3, Section 11.2 and Section 14.4 - add selected Grade 3  nonhematologic events that result in the permanent discontinuation of  nivolumab (diarrhea, colitis, pneumonitis, transaminitis, myocarditis,  adrenal insufficiency)  - Section 6.1.1 - clarify nivolumab will be administered in the outpatient  setting, add monitoring language.  - Add IND number to the title page | yes                 |                                                                                                                                                                                                                                                             |
| 1                                                                                                                                                                  | 05/17/2018                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          | -                   | Per BMS for patient safety - Nivolumab may induce graft versus host  disease in patients who have had a prior allo-HSCT. To reduce this risk,  patients who have had a prior alloHSCT will receive a lower dose of  nivolumab (1 mg/kg instead of 3 mg/kg). |
| - Increase research sample blood volume as an insufficient amount was  originally written into the protocol  - Minor edits to match current protocol template  Yes |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |                     |                                                                                                                                                                                                                                                             |  
| 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | 09/13/2018                                                                            | - Updated Principal Investigator/IND Sponsor to Fiona He, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | Yes     |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------|
| Revision                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     | Version                                                                               | Detail of Changes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             | Consent |
| #                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | Date                                                                                  | change?  (Y/N)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |         |
| -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | Section 4.1.2 & Eligibility checklist: Updated eligibility criteria (disease  status) |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |         |
| - Minor clarification of research blood draw procedure  - Section 14.4 updated sample size  - Protocol synopsis: Updated for clarification including monthly peripheral  blood blast count disease evaluation  - Section 1.3 correlative objectives added neo-antigen identification on  blasts  - Section 8.1 bone marrow biopsy evaluations, changed screening bone  marrow biopsy to within 21 days of study registration, and that bone  marrow biopsies may be omitted if not medically safe to perform |                                                                                       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |         |
| 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | 03/26/2019                                                                            | - Removed bone marrow biopsy response assessment from final  treatment visit  - Cyclophosphamide will now be provided by BMS  - Updated study committee to remove Drs Cooley & Ustun                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          | Yes     |
| 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | 12/04/2019                                                                            | - Updated study committee to add Najla El Jurdi and Joseph Maakaron  - Schema, Synopsis, Section 1, , Section 3, Section 6.1, Section 7.3,  Section 10.3,Section 14.3, Appendix V, Appendix VI: Added SC N-803  once every 3 weeks in treatment schema, changed Nivolumab dosing  frequency to once every 3 weeks  - Schema, Section 3, Section 5.2, Section 6, Section 8.1, Section 8.2,  Section 14.1: Changed total number of cycles from 4 to 5 (each cycle defined as 3 weeks instead of 4 weeks)  - Synopsis, Section 1.1, Section 3, Section 6.4, Section 13, Section 14:  Changed bone marrow evaluation schedule from D30 and D90 to D21  and D42  - Section 2.6, Section 2.8: Added background information for N-803  - Section 8.2: Added research blood draw at C1D8, C1D15, C2D1, C2D8,  C2D15, C3D1, C4D1, C5D1, end of treatment visit  - Synopsis, Section 4.1, Section 8.2: Added disease eligibility criteria of  extramedullary leukemia that is biopsy-confirmed in absence of bone  marrow involvement; added CT or PET-scan for disease restaging  - Section 4.1: Added to inclusion criteria: Ability to be off prednisone and  other immunosuppressive drugs (>10 mg daily prednisone equivalent) for  at least 14 days prior to and while receiving N-803. Inhaled or topical  steroids, and adrenal replacement steroid doses < 10 mg daily  prednisone equivalent, are permitted in the absence of active  autoimmune disease  - Section 4.2: Added prior N-803 administration and cellular therapy  product within 30 days as exclusion  - Added Appendix V and Appendix VI - Section 6.1, Section 7, Section 11, and Section 14.4 reverted protocol  back to CTCAE v 4.03 in order to match protocol build in Oncore  - Section 1.1, Section 14.1: Changed timepoint for primary endpoint of  ORR to day 42  Yes |         |  
| 5                                                                                                                                                                                                                                                                                       | 06/08/2020                                             | Per FDA Stipulations:  - Synopsis, Schema, Section 3, Section 5.2, Section 6.1, Section  14.1: Clarified that original treatments as closed Arms 1 and 2,  treatment with N803 will be called Arms 3 and 4  - Synopsis, Section 3; Clarified that Day 42 BMBX will be used to  help determine additional cycles  - Synopsis, Section 1.3: added correlative objective to assess Tcell  infiltration through immunohistochemical testing in the bone  marrow  - Synopsis, Section 4.1: clarified eligibility for relapsed MDS  - Synopsis, section 4.2: added exclusion for allo HSCT receiving  calcineurin inhibitor within 4 weeks  - Section 6.1: updated eligibility for additional cycles (moved  information previously in section 6.1.5)  - Section 6.1.5: updated dose administration guidelines for N803  - Section 6.2: Updated GVHD management guidelines  No   |         |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------|
| Revision                                                                                                                                                                                                                                                                                | Version                                                | Detail of Changes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          | Consent |
| #                                                                                                                                                                                                                                                                                       | Date                                                   | change?  (Y/N)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |         |
| -                                                                                                                                                                                                                                                                                       | Section 6.3: updated definition of disease progression |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |         |
| -                                                                                                                                                                                                                                                                                       | Section 11.2, section 14.4: updated stopping rule      |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |         |
| events Per IRB Stipulation:  - Section 3 - Added N803 as part of endpoint Minor  edits and clarifications:  - Section 7.1, section 8.1 - added "N-803"  - Section 8.2: updated research tests performed on lab  samples  - Throughout protocol updated internal HTML and  section links |                                                        |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |         |
| 6                                                                                                                                                                                                                                                                                       | 9/18/2020                                              | Per FDA Stipulations:  Synopsis, Section 1.1, Section 3.0, Section 5.2, Section 14.1 - Removed  stage II from trial design  Synopsis, Section 1.2, Section 14.1 - defined response rate in secondary  objectives  Synopsis, Section 3.0, Section 14.1- updated accrual goal  Section 3.0, Section 11.2, Section 14.4- Updated stopping rules  Section 6.1 - clarified eligibility to begin additional treatment courses  Section 6.2 - Updated study management in the case of new onset GVHD  Yes  Additional Edits:  Section 7.1, Section 10.1, Section 10.3.6, Section 10.4 Updated the risk  language for N-803 and Nivolumab, based information from other trials  using study product and latest Investigator Brochures                                                                                                                                              |         |
| 7                                                                                                                                                                                                                                                                                       | 04/28/2021                                             | Synopsis, Schema, Section 3.0, Section 5.2, Section 14.3, Section 14.4,  number of patients changed from 24 to 20 - Rationale: improve feasibility  of recruitment while maintaining goals for statistical power  Synopsis, section 1.3, Section 8.2, added and clarified correlative studies  Rationale: add immune-related gene expression profiling of bone marrow  to evaluate other pathways that may confer sensitivity or resistance to  therapy  Section 8.2 added bone marrow sample. Rationale: for RNA gene  expression studies  Section 13.0, Section 14.1 changed primary endpoint to dose  determination, moved original primary endpoint to secondary. Rationale:  prior amendment removed stage II from study design. Primary endpoint  changed to reflect dose finding rather than efficacy.  Yes                                                         |         |  
| 05/12/2021                                                      |                                                                    |    |
|-----------------------------------------------------------------|--------------------------------------------------------------------|----|
| 7A                                                              | Synopsis, Schema - corrected number of patients. Rationale - error | No |
| correction (number of patients was amended in previous version) |                                                                    |    |
untitled h1
pi/ind sponsor contact information fiona

Assistant Professor of Medicine Division of Hematology, Oncology and Transplantation MMC 480, 420 Delaware Street S.E.  
Minneapolis, MN 55455
(612) 624-6982 (phone)
(612) 625-6919 (fax)
untitled h1
fionahe@umn.edu table of

Contents  
| Table of Key Abbreviations .                                                                                                                                                   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Protocol Synopsis                                                                                                                                                              |
| S STUDY SCHEMA                                                                                                                                                                 |
| 1 Objectives                                                                                                                                                                   |
| 12                                                                                                                                                                             |
| 1.2 Secondary Objectives                                                                                                                                                       |
| 1.3 Correlative Objectives .................................................................................................................................................12 |
| 2 Background and Rationale .                                                                                                                                                   |
| 2.1 High-risk AML and MDS                                                                                                                                                      |
| 2.2 Defective Leukemic Immunosurveillance in AML and MDS .............................................................................13                                       |
| 2.3  PD-1/PD-L1 Pathway in Malignancies ........................................................................................................................13             |
| 2.4  PD-1/PD-L1 Pathway in AML and MDS ...........................................................................................................................15           |
| 2.5  Low Dose Cyclophosphamide .....................................................................................................................................16         |
| 26 IL-15                                                                                                                                                                       |
| 2.7  Areas of Investigation                                                                                                                                                    |
| 2.8 Rationale                                                                                                                                                                  |
| 3 Study Design .                                                                                                                                                               |
| 4 Patient Selection.                                                                                                                                                           |
| 4.1 Inclusion Criteria                                                                                                                                                         |
| 4.2  Exclusion Criteria                                                                                                                                                        |
| 5 Screening and Study Enrollment .                                                                                                                                             |
| 5.1 Consent and Study Screening in OnCore                                                                                                                                      |
| 5.2  Study Enrollment and Treatment Assignment .                                                                                                                               |
| 5.3  Patients Who Do Not Begin Study Treatment....................................................................................................23                           |
| 6 Treatment Plan .                                                                                                                                                             |
| 6.1 Study Drug Administration                                                                                                                                                  |
| 6.2  GVHD Management Guidance in recipients of allogeneic HSCT ...........................................................................26                                   |
| 6.3  Supportive Care                                                                                                                                                           |
| 6.4  Duration of Study Treatment                                                                                                                                               |
| 6.5  Duration of Study Participation                                                                                                                                           |
| 7 Management of Selected Toxicity.                                                                                                                                             |
| 7.1  Nivolumab and N-803 .                                                                                                                                                     |
| 7.2  Oral Cyclophosphamide .                                                                                                                                                   |
untitled h1
hm2017-33 nivolumab oral ctx and

| 7.3  N-803 .                                                                                                                                                                |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 8 Schedule of Tests and Procedures ......................................................................................................................................39 |
| 8.1 Required Clinical Care Evaluations ...................................................................................................................40                |
| 8.2 Research Related Evaluations .............................................................................................................................41            |
| 9 Disease Assessment Criteria ..................................................................................................................................42          |
| 10 Drug Formulation, Availability and Preparation .....................................................................................................42                   |
| 10.1 Nivolumab................................................................................................................................................42            |
| 10.2 Low Dose Cyclophosphamide                                                                                                                                              |
| 10.3  N-803 Formulation, Supply, and Potential Toxicity ..........................................................................................4                         |
| 10.4  N-803 in Combination with Nivolumab                                                                                                                                   |
| 1 Adverse Event Monitoring, Documentation and Reporting .......................................................................................48                           |
| 1.1 Adverse Event Terminology ..............................................................................................................................49              |
| 1.2 Adverse Event Documentation                                                                                                                                             |
| 1.3 Required Reporting FDA, IRB, and Masonic Cancer Center's SAE Coordinator ............................................52                                                 |
| 1.4 Additional BMS Requirements for Nivolumab                                                                                                                               |
| 12 Study Data Collection and Monitoring                                                                                                                                     |
| 12.1 Data Management .                                                                                                                                                      |
| 12.2 Case Report Forms .                                                                                                                                                    |
| 12.3 Data and Safety Monitoring Plan (DSMP)                                                                                                                                 |
| 12.4 Monitoring                                                                                                                                                             |
| 12.5 Record Retention                                                                                                                                                       |
| 13 Endpoints .                                                                                                                                                              |
| 14 Statistical Considerations                                                                                                                                               |
| 14.1 Study Design                                                                                                                                                           |
| 14.2 Data Analysis Plan                                                                                                                                                     |
| 14.3 Sample Size Justification .                                                                                                                                            |
| 14.4  Early Study Stopping Rule for Safety .                                                                                                                                |
| 15 Ethical and Regulatory Considerations .                                                                                                                                  |
| 15.1 Good Clinical Practice                                                                                                                                                 |
| 15.2 Ethical Considerations                                                                                                                                                 |
| 15.3  Informed Consent .                                                                                                                                                    |
| 16 References                                                                                                                                                               |
| Appendix I - ECOG Performance Status ....................................................................................................................................67 |
| Appendix II - Revised International Prognostic Scoring System .................................................................................68                           |
| Appendix III - Response Criteria For MDS and AML .......................................................................................................69                  |
| Appendix IV - GVHD Grading Scales                                                                                                                                           |
| Appendix V - N-803 Targeted Toxicity Worksheet ..........................................................................................................73                 |
| Appendix VI - N-803 Injection Site Reactions Diary                                                                                                                          |  
| ALT      | alanine aminotransferase (aka SGPT)                         |
|----------|-------------------------------------------------------------|
| alloHSCT | allogeneic hematopoietic stem cell transplant               |
| AML      | acute myeloid leukemia                                      |
| AST      | aspartate aminotransferase (aka SGOT)                       |
| BM       | bone marrow                                                 |
| CNS      | central nervous system                                      |
| CR       | complete remission                                          |
| CRi      | complete remission with incomplete blood count  recovery    |
| CRp      | complete remission with incomplete platelet count  recovery |
| CTCAE    | Common Terminology Criteria for Adverse Events              |
| v4.03    | version 4.03                                                |
| CTX      | cyclophosphamide                                            |
| DC       | dendritic cell                                              |
| ECOG     | Eastern Cooperative Oncology Group                          |
| FDA      | Food and Drug Administration                                |
| HCT      | hematopoietic cell transplant                               |
| HI       | hematologic improvement                                     |
| IDO      | indolamine 2,3 dioxygenase                                  |
| IPSS     | International Prognostic Scoring System                     |
| irAE     | immune related adverse event                                |
| IV       | intravenous                                                 |
| MDS      | myelodysplastic syndrome                                    |
| MDSC     | myeloid derived suppressor cells                            |
| NK       | natural killer                                              |
| OR       | objective response                                          |
| ORR      | overall response rate                                       |
| OS       | overall survival                                            |
| PO       | per os                                                      |
| PR       | partial remission                                           |  
| PFS   | progression-free survival       |
|-------|---------------------------------|
| SOC   | standard of care                |
| WOCBP | women of childbearing potential |  
WOCBP women of childbearing potential
untitled h1
protocol synopsis

Nivolumab, Oral Cyclophosphamide and N-803 for Relapsed/Refractory Acute Myeloid Leukemia (AML) and Higher-Risk Myelodysplastic Syndrome (MDS)
Study Design:
This is a phase I trial of nivolumab, low dose cyclophosphamide (CTX) and N-803 when given in combination to patients with relapsed/refractory acute myeloid leukemia (AML) and higher-risk myelodysplastic syndrome (MDS) who are not eligible for or decline hematopoietic stem cell transplant. It includes a randomized pilot substudy during stage 1. Arm 1 and Arm 2 previously randomized patients in 1:1 ratio to IV nivolumab 3 mg/kg every 2 weeks and oral cyclophosphamide 50 mg daily or IV nivolumab 3 mg/kg every 2 weeks and oral cyclophosphamide 350 mg weekly. Arms 1 and 2 are now closed. 20 patients enrolled in the study are randomized to either Arm 3 (CTX
50mg PO daily + nivolumab IV and 10 ug/kg SC N-803 every 3 weeks) or Arm 4 (CTX 350 mg PO every 7 days + nivolumab IV **and 10 ug/kg** SC N-803 every 3 weeks) with 10 subjects in each arm. Nivolumab dosing is 360 mg unless the patient has had a prior allogeneic transplant, in which case the nivolumab dose is 180 mg. Disease will be assessed by bone marrow biopsy at 21 and 42 days after initiation of study drugs. If the increase in absolute blast count is <25% in peripheral blood or bone marrow from baseline at day 42 or later and there is perceived clinical benefit by the treating physician, the subject will proceed with further treatment with up to five 21-day courses. Continuous stopping rules are used to monitor excessive toxicity for each arm. If one arm is terminated by the toxicity stopping rule, all subsequent patients will be assigned to the other arm if it is not terminated by the toxicity stopping rule to continue enrollment of up to 20 patients. All patients receive nivolumab IV and SC N-803 every 3 weeks and oral cyclophosphamide (daily or weekly) as assigned for up to 5 treatment courses with each treatment course equal to 21 days. A final treatment visit occurs 30 days after the last dose of study drug with follow-up for response and survival continuing through 2 years from beginning of treatment. For patients with clinical benefit after the 5 treatment courses, additional therapy with the study drugs or other treatment may be offered.  
Primary **To identify the safety, immunological activity, and clinical benefit of**
Objective: **combination of nivolumab, N-803 and low-dose oral CTX when given in**
patients with relapsed/refractory AML and higher-risk MDS
Secondary - **To estimate objective response rate (ORR) at 42 days from**
Objectives: **treatment start. Response is defined as CR + CRi + CRp + PR in AML and**
CR/PR/hematologic improvement (HI) in MDS
- **To estimate progression-free survival (PFS) and overall survival**
(OS) at 6 months from treatment start Correlative - **To evaluate level of immune activation in blood and bone**
Objectives: **marrow microenvironment by measuring quantities and**
activation status of T-cells subsets, natural killer (NK) cells, myeloid derived suppressor cells (MDSC), and dendritic cells (DC) during treatment
- **To assess PD1/PD-L1 and TIM-3/galectin-9 interactions through**
quantified expression of PD-L1 and galectin-9 on leukemic blasts, galectin-9 in serum, PD-1 and TIM-3 on immune cells as biomarkers of response and potential mechanisms of resistance to treatment
- **To assess T-cell infiltration through immunohistochemical**
testing in the bone marrow
- **To evaluate immune and leukemia-related gene expression**
patterns in bone marrow aspirates at baseline and during treatment Eligible Diseases:
untitled h1
primary (de novo) aml or

CR after 2 or more induction attempts with high dose chemotherapy, hypomethylating agents, or other agents; No CR after 1 induction attempt and not eligible for a 2nd **induction. Higher risk MDS defined**
as risk score > 4.5 based on the by revised International Prognostic Scoring System (IPSS) criteria.  
Secondary AML (from antecedent hematologic malignancy or  
treatment-related): Not in CR after 1 or more cycles of chemotherapy  
Relapsed AML: **Blasts ≥5% in bone marrow or peripheral blood after**  
prior attainment of CR **or biopsy-proven extramedullary leukemia in** absence of bone marrow involvement; relapse at any time, but currently ≥100 days following allogeneic HCT Relapsed MDS: morphologic evidence of relapse or increase in blasts to ≥5% in bone marrow or peripheral blood after prior attainment of CR and not eligible for or decline intensive chemotherapy; relapse at any time but currently ≥100 days following allogeneic HCT  
Key Inclusion Criteria:  
|                                    |                                                                                                                                                                                                 |                              |
|------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------|
| Key  Inclusion  Criteria:          | -                                                                                                                                                                                               | ≥18 years of age             |
| -                                  | ECOG status ≤ 2                                                                                                                                                                                 |                              |
| -                                  | ineligible for or declines allogenic hematopoietic transplantation                                                                                                                              |                              |
| -                                  | voluntary written consent                                                                                                                                                                       |                              |
| -                                  | Adequate organ function as defined by ALC > 500 cells/m3 , serum  creatinine ≤2 mg/dL, AST and ALT ≤ 5x ULN, Bilirubin ≤3 x ULN,  no O2 requirements on room air or requiring ≤2L O2            |                              |
|                                    |                                                                                                                                                                                                 |                              |
| Key  Exclusion  Criteria:          | -                                                                                                                                                                                               | acute promyelocytic leukemia |
| -                                  | pregnant or breastfeeding                                                                                                                                                                       |                              |
| -                                  | prior allogeneic hematopoietic stem cell transplantation currently  within 100 days (note patients with prior alloHSCT receive a  reduced dose of nivolumab); they are eligible after that date |                              |
| -                                  | therapeutic immunosuppression within preceding 1 month                                                                                                                                          |                              |
| -                                  | signs or symptoms of graft versus host disease                                                                                                                                                  |                              |
| -                                  | active pneumonitis or uncontrolled infection                                                                                                                                                    |                              |
| -                                  | active, uncontrolled autoimmune disease                                                                                                                                                         |                              |
| -                                  | chemotherapy within the previous 2 weeks                                                                                                                                                        |                              |
| -                                  | estimated life expectancy less than 28 days                                                                                                                                                     |                              |
| -                                  | Previously treated with N-803 (or "ALT-803")                                                                                                                                                    |                              |
| -                                  | Cellular therapy product within 30 days                                                                                                                                                         |                              |
| -                                  | Allogeneic HSCT recipient receiving calcineurin inhibitor within 4  weeks                                                                                                                       |                              |
| Accrual                            | 20 patients randomized (50:50) to 1 of 2 treatment arms                                                                                                                                         |                              |
| Objective:                         |                                                                                                                                                                                                 |                              |
| Enrollment: 1-2 patients per month |                                                                                                                                                                                                 |                              |
untitled h1
study schema

Arm 1 and Arm 2 previously randomized patients in 1:1 ratio to nivolumab 3 mg/kg every 2 weeks and low dose cyclophosphamide 50 mg daily or 350 mg weekly and enrolled 12 patients. Due to low response rates (no complete responses and only 2 patients with partial response) and 4 patients receiving ≤1 cycle of treatment due to rapid disease progression, arms 1 and 2 are now closed. Arms 3 and 4 are open and will add N-803 to the platform of nivolumab and low dose cyclophosphamide daily or weekly. All patients without prior history of allogeneic stem cell transplantation receive nivolumab 360 mg every 3 weeks, low dose cyclophosphamide (CTX) at assigned dose/schedule (daily versus weekly), and N-803 subcutaneously at 10 ug/kg every 3 weeks for up to 5 treatment courses. Patients with prior allogeneic stem cell transplantation will receive reduced dose of 180 mg nivolumab every 3 weeks.  
One treatment course = 3 weeks Randomized Pilot of 20 patients randomized (1:1) to Arm 3 or Arm 4
untitled h1
1 objectives 1.1 primary objective

To identify the safety, immunological activity, and clinical benefit of combination of nivolumab, N-803 and low-dose oral CTX when given in patients with relapsed/refractory AML and higher-risk MDS
untitled h1
1.2 secondary objectives

- **To estimate the overall response rate (ORR) at 42 days from treatment start.**
Response is defined as CR + CRi + CRp + PR in AML and CR/PR/hematologic improvement (HI) in MDS
- **To estimate progression-free survival (PFS) and overall survival (OS) at 6**
months from treatment start
untitled h1
1.3 correlative objectives

- **To evaluate level of immune activation in blood and bone marrow**
microenvironment by measuring quantities and activation status of T-cells subsets and natural killer (NK) cells during treatment
- **To assess PD1/PD-L1 and TIM-3/galectin-9 interactions through quantified**
expression of PD-L1 and galectin-9 on leukemic blasts, PD-1 and TIM-3 on immune cells as biomarkers of response and potential mechanisms of resistance to treatment
- **To assess T-cell and NK cell infiltration through immunohistochemical**
testing in the bone marrow
- **To evaluate immune-related gene expression patterns in bone marrow**
aspirates at baseline and during treatment
untitled h1
2 background and rationale 2.1

Acute myeloid leukemia is a disease with high mortality rate that is predominantly diagnosed in the elderly with median age of diagnosis of 67. Elderly patients are more likely to present with more aggressive disease, as evidenced by higher rates of adverse molecular and cytogenetic features compared to younger patients.[1] Although 50-60% of patients with good performance status may achieve complete remission with cytotoxic chemotherapy (anthracycline and cytarabine in "7+3" regimen), 2**-year survival is poor at 15-20% due to high rates**
of relapse.[2] Salvage cytotoxic chemotherapy can induce objective response in 25 to 40% of patients, but these remissions are not durable, likely due to inability of chemotherapy to kill leukemic stem cells that persist. [3]
Higher-risk MDS, as defined by the revised International Prognostic Scoring System (R-IPSS) which evaluates cytogenetic risk, bone marrow blast count, hemoglobin, platelet count, and absolute neutrophil count, is associated with median overall survival of 0.8 to 1.6 years and 0.7 to 1.4 years for median time to 25% AML evolution. [4] Therapies are limited to hypomethylating agents and AML induction chemotherapy regimens in most cases.  
Current approved therapies for AML and high-risk MDS include cytotoxic chemotherapies, molecularly targeted therapies in a fraction of eligible patients with FLT3/ITD **or IDH2 mutations, and immunotherapy in the form of allogeneic** hematopoietic stem cell transplantation (HCT). There is a need for novel treatments that not only increase survival, but also can be well tolerated in this predominantly elderly population.
untitled h1
2.2 defective leukemic immunosurveillance in

Multiple mechanisms of immune evasion have been implicated in active AML and MDS. The tumor microenvironment is permissive towards preventing both innate and adaptive anti-leukemic immunity. Increased proportions of regulatory T-cells and myeloid-derived suppressor cells (MDSCs) have been identified in both AML and MDS patients as poor prognostic markers. [5][6][7] T-cells display aberrant gene expression activation patterns and form defective immune synapses in vitro.[8] Natural killer (NK) cell cytotoxicity is dampened by increased frequency of inhibitory KIR receptors on AML blasts.[9] Other pathways in AML and MDS
that may contribute to immune dysfunction include PD-1/PD-L1, TIM3/Galectin9, and IDO-1.
untitled h1
2.3 pd-1/pd-l1 pathway in malignancies

PD-1 is a member of the B7/CD28 family of  
  
co-stimulatory receptors that binds its ligands programmed death ligand-1 (PD-L1) and programmed death ligand-2 (PD-L2). PD-1 receptor is most highly expressed on activated mature T-cells, but also at low levels on NK cells, B-cells, and monocytes.[10] PD-1 binding of its ligand PD-L1 along with a co-stimulatory signal of T-cell receptor binding of the major histocompatibility complex (MHC) Figure 1. PD1/PD-L1 pathway **presenting an antigen results in reduced T-cell receptor**
signaling, activation, and cytotoxicity as a physiological termination of the immune response (Figure 1). PD-1 overexpression is a phenotype of
"exhausted," dysfunctional T-cells in states such as chronic viral infection and malignancy. PD-L1 is constitutively expressed at a low level in professional and non-professional antigen presenting cells (APCs), but can be overexpressed in malignant cells as a mechanism of immune escape. To exploit this overactive immunosuppressive pathway, PD-1 blockade through nivolumab, a monoclonal antibody to PD-1, has been used to unleash tumordirected cytotoxicity in multiple types of malignancy.  
The safety and efficacy of nivolumab has been established by multiple large trials in solid tumors. In melanoma, the randomized Checkmate-066 trial enrolled newly diagnosed metastatic melanoma patients to nivolumab or dacarbazine (n = 418) and reported higher ORR (34% vs. 9%) and median OS (not reached vs. 10.8 months, HR 0.42, p<0.0001) in the nivolumab arm.[11] Responses were durable with 43 of 63 responding patients achieving ongoing response of 6 months or longer. In patients with metastatic squamous non-small cell lung cancer who had progressed on a platinum-containing regimen, nivolumab was compared to docetaxel (n = 272) in the Checkmate-017 trial and was associated with significantly increased overall survival (median OS 9.2 months vs. 6 months, HR 0.59, p=0.0002).[12] In a similar study of metastatic non-squamous non-small cell lung cancer (n = 582) randomized to nivolumab or docetaxel, overall survival was 12.2 months for nivolumab vs. 9.2 months for docetaxel (HR 0.73, p=0.002).[13] Multiple other studies have solidified the role of PD-1 inhibitors in solid tumors including renal cell carcinoma, [14] squamous cell carcinoma of the head and neck, [15] and hepatocellular carcinoma. [16] Pooled safety analyses in melanoma trials (n=576) reported 71% (95% CI, 67% to 75%) with any-grade treatment-related adverse events (AEs) (most commonly fatigue [25%], pruritus [17%], diarrhea [13%], and rash [13%]), and 10% (95%CI, 8%to 13%) with grade 3 to 4 treatment-related AEs. Median time to onset of AEs ranged from 5 weeks for skin to 15 weeks for renal AEs. [17]
Within hematologic malignancies, PD-1 inhibitors have had efficacy in Hodgkin lymphoma, largely due to genetic alterations of the 9p24.1 locus leading to overexpression of PD-L1 and immune evasion. A phase II study of recurrent Hodgkin lymphoma relapsed post-autologous transplantation enrolled 80 patients and reported ORR of 66% (95% CI 54.8–**76.4) with acceptable safety**
profile. In the post-allogeneic transplantation setting of relapsed Hodgkin lymphoma, a multicenter retrospective review of 31 patients reported ORR of 77%, with 55% rate of acute graft-versus-host disease (9 of 17 with grade III-IV aGVHD or severe chronic GVHD) using standard 3 mg/kg nivolumab dosing. [18] A prospective phase I trial of nivolumab in relapsed hematologic malignancies reported dosing of 1 mg/kg (n = 6) and 0.5 mg/kg (n = 2). In the 1 mg/kg cohort, 1 patient had mild chronic GVHD and 2 patients had immune-related adverse events. [19]
Nivolumab has been shown to be safe and well tolerated up to a dose level of 10 mg/kg, and pharmacokinetic studies have not reported relationship between nivolumab exposure produced by 3 mg/kg and efficacy. This indicates that the safety and efficacy profile of 240 mg nivolumab is similar to that of 3 mg/kg nivolumab. Similarly, a flat dose of 360 mg corresponds to a dose of 4.5 mg/kg q3w, which is similar to the nivolumab doses evaluated in combination with chemotherapy in NCT01454012, ranging from 5-10 mg/kg q3w. The simulated steady state concentration at trough (Cminss), peak (Cmaxss), and average (C**avgss**)
with 360 mg are less than 10 mg/kg every 2 weeks. Thus, these regimens are expected to be safe and tolerable.
untitled h1
2.4 pd-1/pd-l1 pathway in aml

In AML, the PD-L1/PD-1 pathway is aberrantly upregulated in an estimated 4257% of AML patients,[20][21] with increased expression of PD-L1 on leukemic blasts at time of relapse [22] and increased expression of PD-1 on cytotoxic Tcells. Aberrant activity of this inhibitory immune checkpoint pathway is associated with defective recognition and cytotoxicity towards leukemic blasts. [23]
The immunosuppressive function of T-regs may be intimately connected to aberrant PD-L1/PD-1 pathways. T-regs were unable to suppress CD8+ proliferation or cytokine secretion in both a PD-1 knockout AML mouse model and PD-1 wild-type AML mouse treated with monoclonal antibody to PD-L1. Treg depletion through IL2-diptheria toxin in combination with PD-1/PD-L1 blockade showed synergistic activity in reducing AML blast burden. [24] Murine models have demonstrated that PD-L1 overexpressing antigen-presenting cells may convert naïve T-cells into a T-regulatory phenotype and aid in their expansion and proliferation, although this has not been tested in an AML model.[25]
Clinical trials of PD-1/PD-L1 blockade in AML are currently in early phase.  
CT011, a humanized IgG1 monoclonal PD-1 antibody, showed safety and tolerability in a phase 1 trial of advanced hematologic malignancies when given as a single dose of 0.2 to 6.0 mg/kg. [26] Seven of 8 patients with AML who were enrolled in this study had disease progression. One patient had blast reduction from 50% to 5% with two doses of CT-011 5 months apart, with disease control for 61 weeks.  
PD-L1 expression has also been widely detected in MDS, but may be more commonly expressed in non-leukemic immune cells than leukemic blasts (12% of CD34+ myeloid progenitor cells, 36% of CD34- myeloid progenitor cells, 26% of lymphocytes).[27] Another study showed increased PD-1 expression in two subtypes of T-regs as well as CD4+ effector memory T-cells in MDS patients compared to healthy controls.[28] PD-L1 expression may increase after failure of hypomethylating agents (HMA), suggesting PD-L1 upregulation as a mechanism of resistance to HMAs.  
Nivolumab has been studied as monotherapy and in combination with azacitadine in a phase II study of MDS patients after failure of hypomethylating agents. Although efficacy was seen with objective response rate of 69% in the combination arm (n = 13), there was no single agent activity noted in the Nivolumab monotherapy arm (n = 15). Pembrolizumab monotherapy was studied in 28 patients with MDS after HMA failure in the phase 1b KEYNOTE-013 study, which showed ORR of 4%, stable disease in 52%, and hematologic improvement in 11%. [29]
untitled h1
2.5 low dose cyclophosphamide

Cyclophosphamide (CTX) is an alkylating agent with differential effects at high and low doses. At maximal tolerated dose, it exerts broad anti-proliferative, cytotoxic effects in a variety of malignancies. At low, continuous dosing
("metronomic"), it has immunomodulatory and anti**-angiogenic properties as a**
monotherapy or in combination with other agents.  
Low dose CTX has been reported to decrease number of FOXP3+ regulatory Tcells, although this effect has not been sustained in most studies. [41] In vitro studies have additionally shown an attenuation of T-reg function and proliferative abilities.[42] Other immunomodulating effects of low dose CTX include polarization of CD4+ helper T-cells towards a Th1 profile that secrete type-1 IFNs and IL-2, favorable for conversion into a memory CD8+ T-cell phenotype,[43] and increased Th17+ population that secrete the pro-inflammatory cytokine IL-17.[44] In heavily pre-treated metastatic breast cancer patients, daily oral CTX at 50 mg daily was noted to increase percentage of tumor-specific T-cells and stabilize disease in 7 of 12 patients. Independent of effects on T-regs, studies have shown sustained increase in proliferative capacity of CD8+ effector T-cells. [45] Most studies of low dose CTX are in breast cancer, but efficacy has also been shown in hormone-resistant prostate cancer [46] and metastatic melanoma [47].  
The immunomodulatory properties of cyclophosphamide have been exploited by combining it with dendritic cell vaccines to prime the immune system in murine models. Preconditioning with low dose CTX in murine models of colon cancer and melanoma resulted in enhanced numbers of antigen-specific T-cells and increased tumor regression.[48] In addition to enhancing effector T-cells, CTX has been shown to increase number and activation status of dendritic cells in a murine model of colon cancer. [49] A combination of dendritic cell vaccine, low dose CTX, and anti-PD-1 therapy was effective in inducing an antigen-specific immune response leading to long-term tumor control in a murine model of glioma. [50]
Within hematologic malignancies, the use of continuous low dose CTX has been limited to non-Hodgkin lymphoma and multiple myeloma in combination with other agents. CTX and high-dose Celecoxib in a phase II trial had efficacy in a population of relapsed and refractory non-Hodgkin lymphoma patients, with 37% ORR and median PFS of 4.7 months.[51] To date, there are no published studies of low dose CTX for treatment of MDS or AML.  
Low dose CTX also has known anti-angiogenic effects, promoting normalization of the bone marrow vasculature through upregulation of thrombospondin-1 (TSP1), a glycoprotein with potent endogenous angiogenesis inhibiting properties. [52] [53] Endothelial cells have been reported to be very sensitive to low doses of CTX. Induction of hypoxia results in disruption of endothelial cell ability to form tubes and leads to apoptosis.[54] **In-vitro studies suggest a**
synergistic mechanism of CTX with other anti-angiogenic agents. Antiangiogenic effects of CTX have been mainly studied in solid tumor models. In AML, the role of angiogenesis in the vascular niche of leukemic blasts and stem cells has been investigated. Significantly increased microvascular density has been observed in the bone marrow of AML patients compared to healthy controls,[55] and may be a poor prognostic feature.[56] Induction of TSP-1 can directly induce apoptosis in AML cell lines, and is a potential therapeutic mechanism of low dose CTX in this setting. [57] While not proposed for direct testing, this may be a contributing therapeutic effect of the proposed therapy.  
2.6 IL-15 Interleukin-15 (IL-15) is a cytokine and growth factor capable of expanding activated T cells and NK cells. By broad consensus, the NCI Immunotherapy Workshop (2007) ranked IL-**15 as the \#1 agent with "high potential for** immunotherapy."[**58] Based on preclinical non-human primate and early phase**
clinical trial data, including those at the University of Minnesota, IL-15-containing regimens can be designed to prospectively and reproducibly increase T-cell and NK-cell counts.  
The NCI Biological Resource Branch has manufactured E. coli-expressed recombinant human IL-15 (rhIL-15); daily administration of rhIL-15 intravenously (IV) or subcutaneously (SC) has been shown to increase the number and activation status of circulating CD8+ T and NK cells, but the cytokine has a very short half-life. Furthermore, high levels of free rhIL-15 decrease circulating IL-15Rα, acting as a negative feedback signal to reduce further IL**-15**
transpresentation. Trans-presentation appears to be a dominant mechanism for IL- 15 action in vivo in response to immune stimuli.[59] N-803 (Nantcell Inc, Culver City, CA) is a soluble complex consisting of two protein subunits of a human IL-15 variant associated with high affinity to a dimeric human IL-15 receptor α (IL- 15Rα) sushi domain/h**uman IgG1 Fc fusion protein, that**
physiologically transpresents IL-15.[60][61] The IL-15 variant is a 114 aa polypeptide comprising the mature human IL-15 cytokine sequence with an Asn to Asp substitution at position 72 of helix C (N72D)12. The human IL-15**Rα sushi**
domain/human IgG1 Fc fusion protein comprises the sushi domain of the human IL-15 receptor α subunit (IL-15Rα) (aa 1-65 of the mature human IL-**15Rα**
protein) linked with the human IgG1 CH2-CH3 region containing the Fc domain (232 amino acids). Aside from the N72D substitution, all of the protein sequences are human. N-803 has a prolonged serum half-life in preclinical animal models and has a 4-fold increase in biologic activity greater than wild-type IL-15 (IL-15 wt). [60]
N-803 has been used in a Phase I study of relapsed AML patients post-alloHSCT
and found to have good tolerability and some clinical activity. [62] N-803 in combination with Nivolumab was safe and had clinical activity in a study of advanced non-small cell lung cancer patients with previous progression on single agent PD-1 inhibitor.[63] A summary of N-803 by route and dose is found in Section 6.1.4. The University of Minnesota's experience with N**-803 was that**
subcutaneous dosing was generally well tolerated with an injection site related skin rash as the most notable event, often quite widespread; however none were dose limiting. Typically, the rash resolved by 7 days post-injection. Other adverse events included fever, fatigue, and changes in blood pressure.  
In phase 1 studies that used weekly dosing of SC N-803, correlative data showed that highest level of immune stimulation, as measured by staining intensity of Ki67 in NK cells, increased concentration of circulating IFN-gamma was highest on day 4, and decreased with subsequent doses. [62] [63] This suggests that prolonged continuous treatment leads to immune anergy and reduced biological responsive. Thus subsequent studies using this agent have been amended to use less frequent dosing schedules for N-803 (NCT02989844). This study will use every 3 week dosing at 10 ug/kg given subcutaneously.
untitled h1
2.7 areas of investigation

The somatic mutational profile of AML (Cancer Genome Atlas Project) may be simpler than most solid tumors, with an average of only 13 mutations per gene, though it may be two-fold greater in secondary AML.[64] Cancers with high somatic mutation frequency have shown variable sensitivity to single agent PD1 blockade, from 50-60% clinical benefit with durable response in melanoma to low efficacy in squamous cell carcinoma of the lung, suggesting that other factors contribute to predicting response to checkpoint blockade. Within AML, Wilms Tumor (WT) has been identified as a potential neo-antigen targetable with a WTspecific cytotoxic T-cell response. Subgroups of AML with mutations including FLT3/ITD or NPM1 may also have neo-antigen targets and might benefit from PD-1 blockade. The relative importance of neo-antigen burden compared to factors such as PD-L1 expression on tumor cells and an immune environment that promotes immune activation is unknown.  
At cytotoxic doses, CTX may be able to alter the immunosuppressive microenvironment via downregulation of IDO. The effects of low dose continuous cyclophosphamide on IDO regulation have not been well studied. Since upregulation of IDO has been identified as a pathogenic feature of AML and may contribute to tolerogenic immune environment, the interaction of IDO and checkpoint blockade is of interest. [39]
The function and activity of dendritic cells to either induce antigen-directed cytotoxicity or anergy in T-cells in AML and MDS is an important variable in efficacy of PD-1/PD-L1 directed therapy. Dendritic cells have been classified into two groups, myeloid and plasmacytoid, based on expression of CD11c, both which can be derived from a malignant clone.[65] AML-derived DCs, particularly the plasmacytoid variant, have been reported to express tolerogenic cytokines such as IL-10 and secrete IDO, which induces an immunosuppressive Tregulatory response.[66] A study of MDS patients reported reduced numbers of peripheral blood DCs that were all clonally-derived.[67] In newly diagnosed AML patients, a small study showed a range of normal quantitative DC subsets, increased DC subsets, or no detectable DC subsets. Functional studies showed reduced ability to induce proliferative responses in naïve T-cells in DCs from AML patients compared to healthy controls. [68] Further understanding of the role of DCs in tumor evasion in the setting of relapsed/refractory AML and MDS may enhance delivery of effective immunotherapies.
untitled h1
2.8 rationale

Immunotherapy is a highly promising area of investigation in the treatment of AML and MDS. The ability of alloHCT to eliminate leukemic blasts and leukemiainitiating cells/leukemia stem cells highlights its curative potential. Many patients are not eligible for alloHCT due to pre-existing comorbidities, lack of donor graft availability, older age, and excessive leukemia burden. Immune checkpoint inhibitors of the PD-1/PD-L1 pathway have widespread efficacy across multiple cancer types and favorable tolerability. This research hypothesizes that PD-1 inhibitors in combination with immunomodulatory agents will induce leukemiadirected immune stimulation in AML and higher-risk MDS. Low dose cyclophosphamide is an immunomodulator which has not been reported to cause severe myelosuppression in a population that commonly has neutropenia and increased risk of infection due to active disease. N-803 is a promising immunotherapeutic agent that is safe, has known synergistic activity with PD-1 inhibitors, and is highly potent for increasing frequency and activation of T-cells and NK cells. Immune dysfunction induced by active AML may benefit from additional stimulation with an agent such as N-803 to induce T-cell cytotoxicity after PD-1 blockade.
untitled h1
3 study design

This phase I study consists of a randomized pilot sub-study of two dosage arms of CTX
in combination with nivolumab and N-803 in stage I. Arm 1 (CTX 50 mg PO daily + nivolumab IV) and Arm 2 (CTX 350 mg PO every 7 days+
nivolumab IV) previously enrolled randomized patients in a 1:1 ratio. Due to low response rates (no complete responses and only 2 patients with partial response) and 4 patients receiving ≤1 cycle of treatment due to rapid **disease progression, arms 1 and**
2 are now closed. In the amended protocol, the first 20 patients enrolled in the study are randomized to either Arm 3 (CTX 50 mg PO daily + nivolumab IV + SC N-803 every 3 weeks) or Arm 4 (CTX 350 mg PO every 7 days+ nivolumab IV + SC N-803 every 3 weeks) with 10 subjects in each arm. Nivolumab is dosed at 360 mg, unless the patient has had a prior allogeneic hematopoietic stem cell transplant (alloHSCT), in which case nivolumab is given at 180 mg IV every 3 weeks. N-803 is dosed at 10 ug/kg every 3 weeks and given subcutaneously. Continuous stopping rules, defined as selected Grade 3 non-hematologic events, graftversus-host disease, and any Grade 4 or 5 non-hematologic event, will be used to monitor excessive toxicity for each arm. Efficacy will be assessed with pooled total from both arms 3 and 4 with up to 20 patients available for assessment of OR at 42 days. All patients receive nivolumab IV over 30 minutes every 3 weeks, N-803 SC every 3 weeks and oral cyclophosphamide as assigned for up to 5 treatment courses with each treatment course equal to 21 days. Nivolumab is dosed at 360 mg, unless the patient has had a prior allogeneic hematopoietic stem cell transplant (alloHSCT), in which case nivolumab is given at 180 mg IV every 3 weeks. **N-803 is dosed at 10 ug/kg every 3** weeks and given subcutaneously. Disease will be assessed by bone marrow biopsy at 21 and 42 days after initiation of study drugs. If the increase in absolute blast count is <25% in peripheral blood or bone marrow from baseline at day 42 or later and there is perceived clinical benefit by the treating physician, the subject will proceed with further cycles of treatment with up to 5 courses of treatment on study. A final treatment visit occurs 30 days after the last dose of study drug with follow-up for response and survival continuing through 2 years from beginning of treatment. For patients with clinical benefit after the 5 treatment courses, additional therapy with the study drugs or other treatment may be offered.
untitled h1
4 patient selection

Study entry is open to patients 18 years of age and older regardless of gender, race, or ethnic background. While there will be every effort to seek out and include minority patients, the patient population is expected to be no different than that of other relapsed/refractory acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome studies at the University of Minnesota.
untitled h1
4.1 inclusion criteria

4.1.1 **≥18 years of age**
4.1.2 **Meets one of the following disease criteria:**
- **Primary (de novo) AML or higher-risk MDS with induction failure: No**
CR after 2 or more induction attempts with chemotherapy, hypomethylating, agents or other agents; no CR after 1 induction attempt and not eligible for a 2nd induction. Higher risk MDS defined as risk score > 4.5 based on the revised IPSS criteria (refer to Appendix II).  
- **Secondary AML (from antecedent hematologic malignancy or**
treatment-related): Not in CR after 1 or more cycles of chemotherapy.  
- Relapsed AML: Blasts ≥5% in bone marrow **or peripheral blood after**
prior attainment of CR or biopsy-proven extramedullary leukemia in absence of bone marrow involvement; relapse at any time but currently ≥100 days following allogeneic HCT.  
- **Relapsed MDS: Morphologic evidence of relapse or increase in blasts**
to ≥5% in bone marrow or peripheral blood after prior hematologic improvement or partial or complete response and not eligible for or decline intensive chemotherapy; relapse at any time but currently ≥100 days following allogeneic HCT.  
4.1.3 ECOG Performance Status ≤ 2 - **refer to Appendix I**
4.1.4 **Adequate organ function within 14 days of study registration defined as:**
- Absolute Lymphocyte Count: **≥ 500 cells/mm**3
- Hepatic: **total bilirubin ≤ 3 x upper limit of institutional normal (ULN);**
ALT **and AST ≤ 5 x ULN**
- Renal: **Serum creatinine ≤ 2 mg/dL**
- Pulmonary: **No oxygen requirement on room air or requiring ≤ 2L**
supplemental O2 4.1.5 **Ability to be off prednisone and other immunosuppressive drugs (>10 mg**
daily prednisone equivalent) for at least 14 days prior to and while receiving N-803. Inhaled or topical steroids, and adrenal replacement steroid doses < 10 mg daily prednisone equivalent, are permitted in the absence of active autoimmune disease 4.1.6 **Sexually active females of child bearing potential and males with partners**
of child bearing potential must agree to use effective contraception during therapy and continuing (23 weeks for females, 31 weeks for males) after the last dose of nivolumab 4.1.7 **Voluntary written consent**
untitled h1
4.2 exclusion criteria

4.2.1 Pregnant or breastfeeding –**The agents used in this study fall under**
Pregnancy Category D - Drugs which have caused, are suspected to have caused or may be expected to cause, an increased incidence of human fetal malformations or irreversible damage. Women of childbearing potential must have a negative pregnancy test (urine or serum) within 7 days of study drug administration.  
4.2.2 **Prior allogeneic hematopoietic stem cell transplantation currently within**
previous 100 days (note patients with a prior alloHSCT receive nivolumab at the reduced dose of 180 mg); they are eligible after that date 4.2.3 **Signs or symptoms of active graft versus host disease** 4.2.4 **Active pneumonitis or uncontrolled infection** 4.2.5 **Received chemotherapy drugs within previous 2 weeks** 4.2.6 **Estimated life expectancy <28 days in the opinion of the enrolling**
investigator 4.2.7 Previously treated with N-803 (or "ALT-**803")**
4.2.8 **Received cellular therapy product within 30 days** 4.2.9 **Allogeneic HSCT recipient receiving calcineurin inhibitor within 4 weeks**
untitled h1
5 screening and study enrollment

Written consent must be obtained prior to the performance of any research related tests or procedures. Consent is usually obtained before final eligibility is determined.
untitled h1
5.1 consent and study screening

Any patient who has been consented is to be entered in OnCore by the Primary Clinical Research Coordinator (PCRC) or designee. If a patient is consented, but not enrolled, the patient's record is updated in OnCore as a screen failure and reason for exclusion recorded.
untitled h1
5.2 study enrollment and treatment

To be eligible for study enrollment, the patient must sign the treatment consent and meet each of the inclusion criteria and none of the exclusion on the eligibility checklist based on the eligibility assessment documented in the patient's medical record.  
The Primary Clinical Research Coordinator (PCRC) or designee will complete the enrollment process in OnCore by assigning the treatment arm and entering the on treatment date.  
Up to 20 patients enrolled in the study are randomized via OnCore at the time of study registration to either:
Arm 3: CTX 50 mg PO daily + nivolumab 360 mg (or if prior alloHSCT, 180 mg)
IV every 3 weeks + SC N-803 10 ug/kg every 3 weeks or Arm 4: CTX 350 mg PO every 7 days + nivolumab 360 mg (or if prior alloHSCT,
180 mg) IV every 3 weeks + SC N-803 10 ug/kg every 3 weeks  
No additional patients will be enrolled to Arm 1 or 2 (closed). If Arm 3 or Arm 4 is terminated by the toxicity stopping rule, all subsequent patients will be assigned to the other arm if it is not terminated by the toxicity stopping rule to continue enrollment of up to 20 patients.
untitled h1
5.3 patients who do not

If a patient is enrolled to the study, and is later found not able to begin the first dose of study drug, for whatever reason, the patient will be removed from study and treated at the physician's discretion. The study staff will update OnCore of the patient's non**-treatment status (off study). The reason for removal from study**
prior to starting study treatment will be clearly indicated in OnCore. The patient will be replaced to fulfill study enrollment requirements.  
6 Treatment Plan In order to provide optimal patient care and to account for individual medical conditions, investigator discretion may be used in the prescribing of all supportive care drug therapy
(i.e. acetaminophen, diphenhydramine, antimicrobials, etc.).
untitled h1
6.1 study drug administration

Participants will receive one of the two following treatment plans based on assignment at enrollment:  
Arm 3: CTX 50 mg PO daily + nivolumab 360 mg (or if prior alloHSCT, 180 mg)
IV every 3 weeks + SC N-803 10 ug/kg every 3 weeks or Arm 4: CTX 350 mg PO every 7 days + nivolumab 360 mg (or if prior alloHSCT,
180 mg) IV every 3 weeks + SC N-803 10 ug/kg every 3 weeks  
Each treatment course consists of 3 weeks with up to 5 treatment courses permitted. A window of ±3 days is permitted for the nivolumab infusion to accommodate scheduling difficulties (i.e. holidays, inclement weather).  
To begin a new treatment course (Day 1) the following criteria must be met:
- **Cyclophosphamide**
o **No grade 3-4 oral mucositis or grade 3-4**
cystitis o **No signs or symptoms of new**
infection
- Nivolumab o **No contraindication for continuation based on immunerelated adverse events (see Section 7.1)**
o **No signs or symptoms of new infection** o **No**
active GVHD
- N-803 o **Previous injection site reaction is not showing signs of resolving**
(improving) based on measurement or intensity o **No**
hypotension (systolic blood pressure <90 mmHg) not resolving with intravenous fluids o **No contraindication for continuation based on**
immune-related adverse events (see Section 7.1)
o **No signs or symptoms of new infection** o **No**
active GVHD  
Patients who have delay of nivolumab and/or N-803 greater than 3 weeks for toxicities that are at least possibly related despite supportive treatment should be considered to have study treatment discontinued, unless the treating physician considers that the patient may benefit from continued study treatment after resolution of AEs.  
If nivolumab is delayed, N-803 and/or cyclophosphamide should continue if no contraindication is present.  
If N-803 is delayed, nivolumab and/or cyclophosphamide should continue if no contraindication present.  
If cyclophosphamide is delayed, nivolumab and/or N-803 should continue if no contraindication present.  
If nivolumab and N-803 are both permanently discontinued, cyclophosphamide should be discontinued and patient should be taken off study.
untitled h1
6.1.1 nivolumab (all participants)

Nivolumab will be given at a fixed dose of 360 mg (or if prior alloHSCT, 180 mg)
IV over 30 minutes every 21 days on Days 1 of each cycle for up to five 21-day courses.  
Nivolumab will be administered in the outpatient setting; however, inpatient administration is permitted as medically appropriate if a patient is hospitalized. No premedication is required. Monitoring will be according to institutional guidelines with interruption or slowing of rate of infusion with grade 1 to 2 infusional toxicities and discontinuation of nivolumab with grade 3 to 4 infusional toxicities.  
No dose modifications are permitted for nivolumab but dose may be withheld based on occurrence of significant immune-related AE Grade 2 or higher based on NCI Common Terminology Criteria for Adverse Events (CTCAE) v4.03, as described in Section 7.1.
untitled h1
6.1.2 oral cyclophosphamide (ctx) administered

The patient should be instructed to take CTX once a day, every day, by mouth at approximately the same time each day. The tablet must be swallowed whole, with a full glassful of water. Cyclophosphamide tablets are best taken early in the day about an hour before a meal. However, to avoid queasiness, it may be taken with food. The patient should be encouraged to drink plenty of liquids.  
If a dose is missed and it is more than 12 hours before the next dose is due, the patient should take the missed dose and retain the previous schedule. If the next dose is due in less than 12 hours, the patient must skip the missed dose, recording the dose as missed on the daily drug log.  
6.1.3 Oral Cyclophosphamide (CTX) Administered Weekly (Arm 4)
The patient should be instructed to take CTX once weekly at approximately the same time each week. The tablet must be swallowed whole, with a full glassful of water. Cyclophosphamide tablets are best taken early in the day about an hour before a meal. However, to avoid queasiness, it may be taken with food. The patient should be encouraged to drink plenty of liquids.  
If a dose is missed, it may be taken if less than 48 hours from missed dose. If greater than 48 hours from missed dose, the patient must skip the missed dose and resume at next scheduled dose if clinically appropriate.
untitled h1
6.1.4 n-803 (all participants)

N-803 at 10 ug/kg is administered subcutaneously on D1 of a 21-day cycle for a maximum of 5 doses, or until stopping rules are met or patient refusal. A window of +/- 1 week if permitted for each N-803 injection in the event of scheduling issues (i.e. holiday, bad weather, or other scheduling issues). N-803 will be administered in the outpatient setting; however, inpatient administration is permitted as medically appropriate if a patient is hospitalized.  
N-803 dosing is calculated using a weight obtained within 3 days prior to the first dose. For patients > 100 kilograms weight, the N-803 dose is calculated using a weight capped at 100 kg. The patient's wei**ght is re-checked prior to each dose** (within 7 days) and the dose re-**calculated if ≥ 10% change from the weight used**
for the previous dose calculation. Rounding of a dose is permitted per institutional policy.  
If the total subcutaneous dose is greater than 1.5 mL volume, the dose will be divided by the pharmacist into 2-3 subcutaneous injections as needed. Injections are given in the abdominal area. The injection site should be rotated per institutional guidelines and each injection site separated by at least 1 inch.
untitled h1
pre-medication

Use of pre-medications is at the discretion of the treating physician on an individual patient basis. Acetaminophen may be given prior to the injection to reduce the intensity of the fever that often occurs a few hours later.
untitled h1
required post n-803 dose monitoring

Patients will be observed for a minimum of 2 hours after the 1st dose of N-803 for immediate adverse events. Vital signs (heart rate, blood pressure, respiration, temperature, and oxygen saturation) will be documented prior to the N-803 injection and then at 30, 60 and 120 minutes with a ± 20 minute window for each time point.  
If the 1st dose of N-803 is well tolerated, subsequent doses may be administered with a 30-minute post dosing observation period. Vital signs (heart rate, blood pressure, respiration, temperature, and oxygen saturation) will be documented prior to each N-803 injection and then at 30 minutes ± 10 minutes.
untitled h1
6.1.5 dose reduction

A one-time dose decrease to 6 mcg/kg is allowed for recurrent N-803 related constitutional symptoms (e.g. fever, fatigue, muscle aches) interfering with activities of daily living (ADL) despite pre-medication. Patients unable to tolerate the reduced dose will be discontinued from further N-803. Re-escalation of the dose is not permitted.
untitled h1
6.2 gvhd management guidance in

New or worsening skin rash outside of injection site area and other GVHD
manifestations should be managed per institutional guidelines. Refer to Section 7.3 for management of skin rash/injection site reaction within the vicinity of the injection.  
GVHD will be graded using the University of Minnesota aGVHD Grading Scale
(Appendix IV).  
N-803 and Nivolumab will be permanently discontinued with diagnosis of new onset of GVHD.
untitled h1
6.3 supportive care

Concurrent Hydroxyurea use will be permitted for high blast count leukemia for up to 1 month after enrollment in study.  
Steroids or other immune modulatory medications should be avoided unless required for treating a grade 3-4 Nivolumab or N-803-related adverse event.  
Supportive Care will be provided per University of Minnesota institutional guidelines.
untitled h1
6.4 duration of study treatment

Patients will receive five 21-day treatment courses unless any one of the following occurs:
- **Unacceptable toxicity**
- **Progression as defined by increase in absolute blast count of ≥25% in**
peripheral blood or bone marrow by day 42 or later
- **A different anti-cancer treatment is indicated**
- **Patient is non-compliant or refuses treatment** - **In the opinion of the treating investigator, continuation of study therapy is**
not of benefit to the patient  
A final treatment visit occurs 30 days after the last dose of study drug (maximum of 5 courses).  
Any patient unable to receive at least 1 cycle of study therapy will be replaced.  
If follow-up ends before Day 42 for a reason other than death or progression, the patient will be considered unevaluable and will be replaced per Section 14.
untitled h1
6.5 duration of study participation

Follow-up for disease status and survival for study end points occurs at 6 months by clinic visit, review of the medical record or contact with a local medical doctor unless the patient is:
- **Unevaluable (e.g. unable to receive at least 1 cycle of study therapy)**
- **enters hospice care** - refuses follow-up  
After 6 months, follow-up for survival only by record review will continue until 2 years from study enrollment.  
The date and cause of death should be entered into the follow-up tab in OnCore upon knowledge.
untitled h1
7 management of selected toxicity

The NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 will be used to grade adverse events. A copy of the CTCAE v 4.03 can be downloaded: (https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03/CTCAE_4.03_20100614_QuickReference_8.5x11.pdf).
untitled h1
7.1 nivolumab and n-803 immune-related

Immune-related adverse events (irAEs) from nivolumab and N-803 will be managed depending on severity (NCI CTCAE 4.03 grade) as outlined below.  
Grade 1 to 2: Treat symptomatically or with moderate dose steroids, more frequent monitoring.  
Grade 1 to 2 (persistent): Manage similar to Grade 3 to 4 irAE Grade 3 to 4: Treat with high dose corticosteroids Any Grade 4 irAEs require treatment discontinuation with nivolumab and N-803 **except for single laboratory values out of normal range that are unlikely** related to study treatment as assessed by the Investigator, do not have any clinical correlate, and resolve within 7 days with adequate medical management
untitled h1
any grade 3 iraes require

of the following: Transient (≤ 6 hours) Grade 3 flu**-like symptoms or fever, which**
is controlled with medical management, transient (≤ 24 hours) Grade 3 fatigue, local reactions, headache, nausea, emesis that resolves to Grade ≤ 1 and **single**
laboratory values out of normal range (excluding Grade ≥ 3 liver function test increase) that are unlikely related to study treatment according to the Investigator, do not have any clinical correlate, and resolve **to Grade ≤ 1 within 7**
days with adequate medical management
untitled h1
any grade 2 iraes should

If a Grade 2 irAE resolves to Grade ≤ 1 by the next planned cycle, treatment may continue.  
If a Grade 2 irAE does not resolve to Grade ≤ 1 by the **next planned cycle,**
treatment should be withheld at next cycle. If at the end of the following cycle the event has not resolved to < Grade 1, the subject should permanently discontinue treatment with nivolumab and N-803 (except for hormone insufficiencies, that can be managed by replacement therapy).  
Upon the recurrence of the same Grade 2 irAE (except for hormone insufficiencies that can be managed by replacement therapy) in the same subject, treatment with nivolumab and N-803 should be permanently discontinued. Treatment of gastrointestinal, dermatological, pulmonary, hepatic, renal, cardiac, neurological and endocrine irAEs should follow guidelines set forth in the table below.  
| Gastrointestinal irAEs                                                   |            |                                                                                                                                             |
|--------------------------------------------------------------------------|------------|---------------------------------------------------------------------------------------------------------------------------------------------|
| Severity of  Diarrhea/Colitis                                            | Management | Follow-up  Close monitoring for worsening  symptoms  Educate subject to  report worsening  immediately If worsens:  Treat as Grade 2 or 3/4 |
| Grade 1  Diarrhea: < 4  stools/day over  baseline  Colitis: asymptomatic | Continue nivolumab and N803 therapy  Symptomatic treatment (for  example, loperamide)  If improves to Grade <1:  Resume nivolumab and N-803  therapy  If persists > 5-7 days or recur  - 0.5-1.0 mg/kg/day  methylprednisolone or oral  equivalent  - When symptoms improve to  grade 1, taper steroids at least 1  month, consider prophylactic  antibiotics for opportunistic  infections, and resume I-O  therapy per protocol    If worsens or persists > 3-5 with  oral steroids, then treat as Grade  3 to 4            |                                                                                                                                             |
| Grade 2  Diarrhea: 4 to 6  stools per day over  baseline; IV fluids  indicated < 24 hours;  not interfering with  ADL  Colitis: abdominal  pain; blood in stool  Withhold nivolumab and N803  Symptomatic treatment                                                                          |            |                                                                                                                                             |  
| Grade 3 to 4  Diarrhea (Grade 3): ≥  7 stools per day over  Baseline;  incontinence; IV fluids  ≥ 24 hrs.; interfering  with ADL  Colitis (Grade 3):  severe abdominal  pain, medical  intervention indicated,  peritoneal signs  Grade 4:  lifethreatening,  perforation  Permanently discontinue  nivolumab and N-803 for  Grade 4    Withhold nivolumab and  N803 for Grade 3    1.0 to 2.0 mg/kg/day  methylprednisolone IV or  equivalent Add  prophylactic  antibiotics for opportunistic  infections  Consider colonoscopy if  needed   | If improves, continue steroids  until Grade < 1, then taper over at  least 1 month  If worsens, persists > 3 to 5 days,  or recurs after improvement, add  infliximab 5 mg/kg (if no  contraindication), Note: Infliximab  should not be used in cases of  perforation or sepsis    Grade 3: If improves to Grade  ≤1: Resume nivolumab and N803  therapy   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                                                                                                                                                                                             |
untitled h1
dermatological iraes

| Grade of Rash                                                                                                                                                                                                                                                                                                                                          | Management   | Follow-up   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------|-------------|
| If persists > 1 to 2 weeks or  recurs:  Consider skin biopsy  Delay nivolumab and N-803.  Consider 0.5 to 1.0 mg/kg/day  methylprednisolone IV or oral  equivalent. Once improving, taper  steroids over at least 1 month,  consider prophylactic antibiotics  for opportunistic infections, and  resume nivolumab. If worsens.  treat as Grade 3 or 4 |              |             |
| Symptomatic therapy (for  example, antihistamines,  topical steroids)  Hold nivolumab and N803,  may resume if resolving  after 1 week                                                                                                                                                                                                                 |              |             |
| Grade 1 to 2  Covering ≤ 30% body  surface area                                                                                                                                                                                                                                                                                                        |              |             |  
| Grade 3 to 4  Covering > 30%  Grade 4: body surface  area; life threatening  consequences  Withhold nivolumab and N803 for Grade 3  Permanently discontinue  nivolumab and N-803 for  Grade 4 or recurrent  Grade 3  Consider skin biopsy,  Dermatology consult 1.0  to 2.0 mg/kg/day  methylprednisolone IV or  IV equivalent                                                                        | If improves to <Grade 1, taper  steroids over at least 1 month and  add prophylactic antibiotics for  opportunistic infections  Resume nivolumab and N-803  therapy   |                                                                                                                                                                                                                                            |
|------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Pulmonary irAEs                                                        |                                                                                                                                                                       |                                                                                                                                                                                                                                            |
| Grade of                                                               |                                                                                                                                                                       |                                                                                                                                                                                                                                            |
| Pneumonitis                                                            | Management                                                                                                                                                            | Follow-up                                                                                                                                                                                                                                  |
| Grade 1 Radiographic  Consider delay of                                | If improves or resolves, continue                                                                                                                                     |                                                                                                                                                                                                                                            |
| changes only                                                           | nivolumab and N-803                                                                                                                                                   | planned therapy.                                                                                                                                                                                                                           |
| therapy                                                                | Re-image at least every 3 weeks                                                                                                                                       |                                                                                                                                                                                                                                            |
| Monitor for symptoms                                                   | If worsens, treat as Grade 2 or 34                                                                                                                                    |                                                                                                                                                                                                                                            |
| every 2 to 3 days  Consider pulmonary and  Infectious disease consults |                                                                                                                                                                       |                                                                                                                                                                                                                                            |
| Grade 2  Mild to moderate new  symptoms                                | Delay nivolumab and N803 therapy  Pulmonary and Infectious  Disease consults  Monitor symptoms daily,  consider hospitalization  1.0 mg/kg/day  methylprednisolone IV or  oral equivalent  Consider bronchoscopy,  lung biopsy                                                                                                                                                                       | Re-image every 1-3 days  When symptoms improve to  Grade < 1, taper steroids over at  least 1 month and then resume  nivolumab and consider  prophylactic antibiotics  If not improving after 2 weeks or  worsening, treat as Grade 3 to 4 |  
| Grade 3 to 4  Severe new  symptoms; New /  worsening hypoxia;  life-threatening                                                                                          | Permanently discontinue  nivolumab and N-803  Hospitalize  Pulmonary and Infectious  Disease consults  2 to 4 mg/kg/day  methylprednisolone IV or  IV equivalent  Add prophylactic  antibiotics for opportunistic  infections  Consider bronchoscopy,  lung biopsy                                                                                               | When symptoms improve to  Grade < 1, taper steroids over at  least 6 weeks  If not improving after 48 hours or  worsening:, add additional  immunosuppression (for example,  infliximab, cyclophosphamide, IV  immunoglobulin, or  mycophenolate mofetil)   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Hepatic irAEs                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                             |
| Grade of Liver Test  Elevation                                                                                                                                           | Management                                                                                                                                                                                                                                                                                                                                                       | Follow-up                                                                                                                                                                                                                                                   |
| Grade 1  Grade 1 AST or ALT  > ULN to 3.0 x ULN  and / or total bilirubin  > ULN to 1.5 x ULN                                                                            | Continue liver function monitoring  If worsens, treat as Grade 2 or 3 to  4                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                                                                             |
| Continue nivolumab and  N-803                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                             |
| Grade 2  AST or ALT > 3.0 to ≤  5 x ULN and / or total  bilirubin > 1.5 to ≤ 3 x  ULN  Withhold nivolumab and  N-803  Increase frequency of  monitoring to every 3  days | If returns Grade < 1, resume  routine monitoring, resume  nivolumab and N-803  If elevations persist > 5-7 days or  worsens, 0.5 to 1 mg/kg/day  methylprednisolone or oral  equivalent and when LFT returns to  Grade < 1, taper steroids over at  least 1 month, consider prophylactic  antibiotics for  opportunistic infections, resume  nivolumab and N-803 |                                                                                                                                                                                                                                                             |  
| Grade 3 to 4  AST or ALT > 5 x ULN  and / or total bilirubin  > 3 x ULN  Permanently discontinue  nivolumab and N-803  Increase frequency of  monitoring to every 1 to  2 days  1.0 to 2.0 mg/kg/day  methylprednisolone IV or  IV equivalent Add  prophylactic  antibiotics for  opportunistic infections,  Consult  gastroenterologist  Consider obtaining  MRI/CT scan of liver and  liver biopsy if clinically  warranted   | If returns to Grade < 1, taper  steroids over at least 1 month If  does not improve in >3 - 5 days,  worsens or rebounds, add  mycophenolate mofetil 1 gram (g)  twice daily  If no response within an additional  3 to 5 days, consider other  immunosuppressants per local  guidelines   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                                                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                                                                                                                            |  
| Renal irAEs                                                                                                              |                                                                                                                                     |                                                                                                                                                                                                                                                                                          |
|--------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade of Creatinine  Elevation                                                                                           | Management                                                                                                                          | Follow-up                                                                                                                                                                                                                                                                                |
| If returns to baseline:  •Resume routine creatinine                                                                      |                                                                                                                                     |                                                                                                                                                                                                                                                                                          |
| Continue nivolumab and  N-803                                                                                            | monitoring per protocol If                                                                                                          |                                                                                                                                                                                                                                                                                          |
| Monitor creatinine weekly  worsens:  •Treat as Grade 2 or 3/4                                                            |                                                                                                                                     |                                                                                                                                                                                                                                                                                          |
| Grade 1  Creatinine > ULN and  > than baseline but ≤  1.5x baseline  Grade 2-3  Creatinine >  1.5x baseline to  ≤ 6x ULN | Delay nivolumab and N803  Monitor creatinine every  2-3 days  0.5 to 1.0 mg/kg/day  methylprednisolone IV or  oral equivalent Consider  renal biopsy with  nephrology consult                                                                                                                                     | If returns to Grade 1:  •Taper steroids over at least 1  month, consider prophylactic  antibiotics for opportunistic  infections, and resume nivolumab  and N-803 therapy and routine  creatinine monitoring per protocol If  elevations persist > 7 days or  worsen:  •Treat as Grade 4 |
| Grade 4                                                                                                                  | Permanently discontinue  nivolumab and N-803                                                                                        |                                                                                                                                                                                                                                                                                          |
| Creatinine > 6x ULN                                                                                                      | Monitor creatinine daily    1.0-2.0 mg/kg/day  methylprednisolone IV or  IV equivalent  Consult nephrologist  Consider renal biopsy | If returns to Grade 1 : Taper  steroids over at least 1 month and  add prophylactic antibiotics for  opportunistic infections                                                                                                                                                            |
|                                                                                                                          | Neurological irAEs                                                                                                                  |                                                                                                                                                                                                                                                                                          |
| Grade of                                                                                                                 |                                                                                                                                     |                                                                                                                                                                                                                                                                                          |
| Neurological                                                                                                             | Management                                                                                                                          | Follow-up                                                                                                                                                                                                                                                                                |
| Toxicity                                                                                                                 |                                                                                                                                     |                                                                                                                                                                                                                                                                                          |
| Grade 1  Asymptomatic or  mild symptoms;  Intervention not  indicated                                                    | If returns to baseline:  •Resume routine monitoring per  protocol If worsens:  •Treat as Grade 2 or 3/4                             |                                                                                                                                                                                                                                                                                          |
| Continue nivolumab and  N-803                                                                                            |                                                                                                                                     |                                                                                                                                                                                                                                                                                          |  
| Grade 2  Moderate symptoms;  Limiting instrumental  ADL                 | Delay nivolumab and N803  Treat symptoms per local  guidelines Consider 0.5  to 1.0 mg/kg/day  methylprednisolone IV or  PO equivalent  If returns to baseline:  - resume nivolumab and N-803  therapy when returned to baseline  If worsen:  •Treat as Grade 3-4                                                                                                                                                                                                                                                                                                                                                                                                                           |
|-------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 3-4  Severe symptoms;  Limiting self-care  ADL;  Life-threatening | Permanently discontinue  nivolumab and N-803  Obtain neurology consult  Treat symptoms per local  guidelines  1.0-2.0 mg/kg/day IV  methylprednisolone IV or  IV equivalent Add  prophylactic antibiotics  for opportunistic  infections  If improves to Grade 2:  Taper steroids over at least 1  month  If worsens or atypical presentation:  Consider IVIG or other  immunosuppressive therapies per  local guidelines |  
| Cardiac irAEs   |            |           |
|-----------------|------------|-----------|
| Myocarditis     | Management | Follow-up |  
| Grade 2  Symptoms with mild  to  moderate activity or  exertion   | Withhold nivolumab and N803  Hospitalize.  Urgent Cardiology consult  to establish etiology and  rule-out immune-mediated  myocarditis, consider  myocardial biopsy;  management o  Troponin and BNP o  ECG +/- continuous  cardiac monitoring o  Echocardiogram  o Cardiac MRI    Prompt initiation of 2  mg/kg/day  methylprednisolone IV or  equivalent                                                                                                                                                                                                                                                                                                                                                                                        | If symptoms improve and  immune-mediated etiology is  ruled out, resume nivolumab and  N-803.    If worsens, intensify treatment  according to grade  - Upon recovery, taper steroids  over at least 1 month with  close monitoring of troponin  and BNP as well as for new  symptoms  - Repeat cardiac MRI for post  treatment assessment and  cardiology follow-up  - Retreatment may be  considered after recovery and  completion of steroid taper   |
|-------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 3 or Grade 4                                                | Permanently discontinue  nivolumab and N-803  Hospitalize to intensive  cardiac monitoring  Cardiac evaluation to  include:  - Troponin and BNP  monitoring  - ECG +/- continuous  cardiac monitoring  - Echocardiogram  - Cardiac MRI  - Myocardial biopsy if  feasible    - Immediate initiation of  2 mg/kg/day  methylprednisolone IV or  1 g IV bolus  - Consider adding a second | Once improving, taper steroids  over at least 1 month with close  monitoring of troponin and BNP  as well as for new symptoms    If no improvement or worsening,  consider additional  immunosuppressants (e.g.  azathioprine, cyclosporine A)    Repeat cardiac MRI for post  treatment assessments and  cardiology follow-up                                                                                                                           |  
| immunosuppressive                                            |                                                     |                              |
|--------------------------------------------------------------|-----------------------------------------------------|------------------------------|
| agent                                                        |                                                     |                              |
| Additionally, for Grade 4:                                   |                                                     |                              |
| .                                                            | 🙂 Hospitalize/transfer to                          |                              |
| institution with expertise                                   |                                                     |                              |
| in intensive cardiac                                         |                                                     |                              |
| monitoring                                                   |                                                     |                              |
| Consider ATG as second                                       |                                                     |                              |
| .                                                            | agent given its immediate                           |                              |
| effect                                                       | Endocrine irAEs                                     |                              |
| Endocrine Disorder                                           | Management                                          | Follow-up                    |
| Continue nivolumab and N-803                                 |                                                     |                              |
| If TSH < 0.5 x LLN, or TSH > 2 x ULN, or consistently out of |                                                     |                              |
| Asymptomatic TSH                                             | range in 2 subsequent measurements: include T4 at   |                              |
| anormality                                                   | subsequent cycles as clinically indicated; consider |                              |
| endocrinology consult                                        |                                                     |                              |
| Symptomatic                                                  | Evaluate endocrine function                         | lf improves (with or without |
| endocrinopathy                                               | Consider pituitary scan                             | hormone replacement):        |
| Withhold nivolumab and N-803                                 | Taper steroids over at least                        |                              |
| 1 month and consider                                         |                                                     |                              |
| 1 mg/day prednisone                                          | prophylactic                                        |                              |
| equivalents                                                  | antibiotics for  opportunistic                      |                              |
| Initiate appropriate hormone                                 | infections                                          |                              |
| therapy as indicated                                         | Resume nivolumab and                                |                              |
| Consider Endocrinology consult                               | N803                                                |                              |
| No abnormal lab/pituitary MRI                                | Patients with adrenal                               |                              |
| scan but symptoms persist:                                   | insufficiency may need to                           |                              |
| Repeat labs in 1-3 weeks / MRI                               | continue steroids with                              |                              |
| in 1 month                                                   | mineralocorticoid                                   |                              |
| component                                                    |                                                     |                              |  
| Suspicion of  adrenal crisis (e.g.  severe dehydration,  hypotension, shock  out of proportion to  current illness   | Delay or Permanently  discontinue nivolumab and N803  Rule out sepsis  Stress dose of IV steroids  with mineralocorticoid activity  IV fluids  Consult endocrinologist  If adrenal crisis ruled out, then  treat as above for  symptomatic endocrinopathy   |
|----------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                                                      |                                                                                                                                                                                                                                                             |
|                                                                                                                      |                                                                                                                                                                                                                                                             |  
Nivolumab may induce graft versus host disease in patients who have had a prior allogeneic hematopoietic stem cell transplant. To reduce this risk, patients who have undergone a prior alloHSCT will receive a lower dose of nivolumab (180 mg instead of 360 mg).  
Complications of allogeneic hematopoietic stem cell transplantation after nivolumab have been seen including severe or refractory graft versus host disease, hyper-acute GVHD, steroid requiring febrile syndrome without an identified infectious cause, encephalitis, and hepatic veno-occlusive disease.  
The consent contains language instructing the participant to inform the transplant team of previous nivolumab treatment if he/she undergoes a HSCT at any time in the future.
untitled h1
7.2 oral cyclophosphamide

Management of toxicities from oral cyclophosphamide will be per the package insert and standard institutional guidelines.  
For Grade 2 or greater GI toxicities assessed as likely attributable to CTX, drug may be held for up to 2 weeks and restarted after improvement of symptoms.  
For neutropenic fever with ANC <500 cells/mm3**, drug may be held for up to 2**
weeks and restarted as assessed as clinically appropriate by the treating physician.
untitled h1
7.3 n-803

Hypotension (systolic blood pressure < 90 mm Hg) N-803 dosing should be held for hypotension (defined as systolic blood pressure less than 90 mm Hg) if in the presence of any clinically significant symptoms (in the opinion of the treating physician), until the systolic blood pressure reading is stable. If mild dehydration is suspected, an IV fluid bolus may be used per standard of care.  
Based on current experience, localized skin rashes are common with subcutaneous administration. If a rash occurs and the rash area surrounding the N-803 injection site is > 6 cm and symptomatic (painful and/or itchy), it may be treated (at the discretion of the treating physician) with topical 0.05% clobetasol propionate (i.e. 0.05% Cormax) or 0.1% triamcinolone (i.e., Kenalog) cream. Diphenhydramine may be administered pre- (25-50 mg TID orally) and postdosing (25-50 mg TID orally x 2 days) of N-803 at the discretion of the treating physician. Diphenhydramine should be eliminated if not tolerated.
untitled h1
8 schedule of tests and

Scheduled evaluations through during treatment may be performed ±3 days from the targeted date. The end of treatment visit may be performed ±7 days of the targeted date. Follow-up for disease status and survival for study end points occurs at 6 months by clinic visit, review of the medical record or contact with a local medical doctor. Followup for survival only will continue until 2 years from study enrollment. Collection of research samples are linked with the standard of care testing as no visit is done solely for research. Targeted days may be altered as clinically appropriate.
untitled h1
8.1 required clinical care evaluations

| During each treatment cycle (up to 5 cycles)                                                                                                                                                                                                                          | Final Treatment                                   | from C1D1               |                     |           |    |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------|-------------------------|---------------------|-----------|----|
| Day 11                                                                                                                                                                                                                                                                | Day 8                                             | Day 15                  | Visit (30 days post | Follow-up |    |
| treatment)                                                                                                                                                                                                                                                            |                                                   |                         |                     |           |    |
| Consent                                                                                                                                                                                                                                                               | X                                                 |                         |                     |           |    |
| Medical History                                                                                                                                                                                                                                                       | X                                                 |                         |                     |           |    |
| Physical Exam                                                                                                                                                                                                                                                         | X                                                 | X                       | X                   |           |    |
| Weight                                                                                                                                                                                                                                                                | X                                                 | X                       | X                   |           |    |
| Brief Provider                                                                                                                                                                                                                                                        | X                                                 | X                       | X                   |           |    |
| Assessment1                                                                                                                                                                                                                                                           | Baseline (within  14 days of study  registration) |                         |                     |           |    |
| Evaluations/Tests  and Procedures  ECOG PS                                                                                                                                                                                                                            | X                                                 |                         |                     |           |    |
| Adverse Event  Assessment                                                                                                                                                                                                                                             | X                                                 | X                       | X                   | X         |    |
| including targeted  toxicities  CBC, diff, plt                                                                                                                                                                                                                        | X                                                 | X                       | X                   | X         | X  |
| Complete metabolic                                                                                                                                                                                                                                                    | X                                                 | X                       | X                   | X         | X  |
| panel (CMP)  Pregnancy test for                                                                                                                                                                                                                                       | X                                                 |                         |                     |           |    |
| WOCBP2                                                                                                                                                                                                                                                                | 4                                                 | Prior to cycle          |                     |           |    |
| X                                                                                                                                                                                                                                                                     | 2 and 3                                           |                         |                     |           |    |
| Bone Marrow  Biopsy and  Aspirate  Response                                                                                                                                                                                                                           | Prior to cycle                                    |                         |                     |           |    |
| assessment in BM                                                                                                                                                                                                                                                      | 2 and 3                                           |                         |                     |           |    |
| Response  assessment in  peripheral blood                                                                                                                                                                                                                             | Prior to cycle  2, 3, 4, 5                        |                         |                     |           |    |
| CT or PET-CT scan  (extramedullary  disease only)                                                                                                                                                                                                                     | X                                                 | Prior to cycle  3 and 5 |                     |           |    |
| Survival (PFS and  OS) by record  review                                                                                                                                                                                                                              | X (through 2  years)                              |                         |                     |           |    |
| Nivolumab IV  (charge to                                                                                                                                                                                                                                              | X                                                 |                         |                     |           |    |
| research)  Cyclophosphamide  PO (charge to                                                                                                                                                                                                                            | X                                                 | X                       | X                   |           |    |
| research)3  Cyclophosphamide  drug diary and                                                                                                                                                                                                                          | X                                                 | X                       |                     |           |    |
| reconciliation  N-803 SC (charge                                                                                                                                                                                                                                      | X                                                 |                         |                     |           |    |
| to research)  N-803 Skin Rash                                                                                                                                                                                                                                         | X                                                 | X                       | X                   |           |    |
| Diary                                                                                                                                                                                                                                                                 |                                                   |                         |                     |           |    |
| 1 - include assessment for infection and bleeding  2 - women of child bearing potential must have a negative pregnancy test (serum or urine) within 7 days of each cycle day 1 3  -- cyclophosphamide administration per patient's assigned regimen (daily vs weekly) |                                                   |                         |                     |           |    |  
| Screen                                                                                                                                                                        | Weekly   | Cycle 1   | Cycle 2          | Cycle 3   | Cycle 4   | Cycle 5   | Final   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------|-----------|------------------|-----------|-----------|-----------|---------|
| D1                                                                                                                                                                            | D1       | D1        | Treatment  Visit |           |           |           |         |
| D1                                                                                                                                                                            | D8       | D15       | D1               | D8        | D15       |           |         |
| Assessment of  immune related  AEs                                                                                                                                            | X        | X6        |                  |           |           |           |         |
| TSH (to FV lab)                                                                                                                                                               | X        | X         | X                |           |           |           |         |
| Bone Marrow  Aspirate (20  mL  heparinized  sample syringe  or divided into  4 green top  tubes, 2 x 2  mL tubes (4  mL) in  Qiagen  Paxgene  syringe) at time  of SOC BM bx5 | X        | X         | X                | X         |           |           |         |
| Peripheral  Blood (40 mL  heparinized  serum divided  into 3 heparin  green top  tubes and 1  red top tube)                                                                   | X        | X         | X                | X         | X         | X         |         |
| X                                                                                                                                                                             | X        | X         | X                | X         |           |           |         |
untitled h1
8.2 research related evaluations

4 - **Bone Marrow Biopsies may be omitted if not medically safe to perform. If so, peripheral blood counts will be used for**
disease assessment. Baseline bone marrow biopsy may be within 21 days of study registration.  
5 If additional bone marrow biopsies performed as standard of care, research aspirates may be obtained 6 - **BMS requires SAE reporting for 3 months after last dose of nivolumab per Section 11.4.**
All research samples are submitted to TTL unless otherwise noted.  
Note: if a patient is not abiding by the required clinical care calendar (Section 8.1), the collection schedule of the toxicity data and research related samples may be altered or discontinued on an individual patient basis, as appropriate.  
Research related testing on the bone marrow aspirate includes analysis of immune checkpoint receptor expression on T-cell and NK cell subsets by flow cytometry and bone marrow infiltration by immunohistochemistry. AML blast immune checkpoint ligand expression will be evaluated by flow cytometry. Gene expression analysis of genes will be performed by Nanostring Ncounter to evaluate T-cell immune activation  
Research related testing on the peripheral blood includes analysis of T-cell and NK cell subsets, and myeloid blast immune checkpoint ligand expression by flow cytometry.
untitled h1
10 drug formulation availability and

Qualified personnel who are familiar with procedures that minimize undue exposure to themselves and to the environment should undertake the preparation, handling, and safe disposal of chemotherapeutic agents in a self-contained, protective environment. Discard unused portions of injectable chemotherapeutic agents that do not contain a bacteriostatic agent or are prepared with un-preserved diluents (i.e., Sterile Water for Injection USP or 0.9% Sodium Chloride for Injection USP) within eight hours of vial entry to minimize the risk of bacterial contamination. The total administered dose of study drug may be rounded up or down within a range of 5% of the actual calculated dose. Drug dosages need not be changed unless the calculated dose changes by at least 10%.
untitled h1
10.1 nivolumab

Nivolumab (Opdivo) is a humanized IgG4 monoclonal antibody to PD-1. Its mechanism of action is to block an inhibitory signal that decreases cytotoxicity towards malignant cells. Nivolumab was initially FDA-approved in 2014 for treatment of unresectable or metastatic melanoma, and since has received approvals for treatment of metastatic non-small cell lung cancer, metastatic renal cell carcinoma, metastatic squamous cell carcinoma of the head and neck, relapsed classical Hodgkin lymphoma, and metastatic urothelial carcinoma. FDA-approved dosing is 240 mg every 2 weeks or 480 mg every 4 weeks for Hodgkin Lymphoma and squamous cell carcinoma of the head and neck. For NSCLC, renal cell carcinoma, and urothelial carcinoma, FDA-approved dosing is 240 mg every 2 weeks or 480 mg every 4 weeks. There have not been any observed differences in safety and efficacy between nivolumab dose of 3 mg/kg and 240 mg every 2 weeks in patients with melanoma, NSCLC, and RCC.
untitled h1
availability

Cartons containing 5 vials of 100 mg, 10 mg/mL Nivolumab will be provided for the study.
untitled h1
storage and stability

Nivolumab must be dispensed only from official study sites and to eligible patients under the supervision of the site investigator. Nivolumab should be stored in a secure area according to local regulations. It is the responsibility of the site investigator to ensure that study drug is only dispensed to patients on this study.  
Store Nivolumab under refrigeration at 2°C to 8°C (36°F to 46°F). Protect nivolumab from light by storing in the original package until time of use. Do not freeze.  
The product does not contain a preservative. After preparation, store the nivolumab infusion either:
- **at room temperature for no more than 8 hours from the time of preparation.**
This includes room temperature storage of the infusion in the IV container and time for administration of the infusion or
- **under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours**
from the time of infusion preparation.
untitled h1
administration

Refer to the current Investigator's Brochure for the most up to date information. Nivolumab is to be administered as an intravenous infusion over 30 minutes according to institutional practice.
untitled h1
toxicities

Refer to the current Investigator's Brochure for the most up to date information.  
The most common (>10%) adverse events reported in patients treated with nivolumab are: fatigue, rash, pruritus, diarrhea, nausea, hypothyroidism, loss of appetite, constipation, musculoskeletal pain, **peripheral neuropathy, and pyrexia.** Events reported in 5-10% of subjects included pneumonia, vomiting, abdominal pain, hyperthyroidism, headache, dyspnea, ventricular arrhythmia, **nephritis,** cough, dry mouth, colitis, autoimmune hypothyroidism, **thyroiditis upper**
respiratory tract infection and peripheral edema. Laboratory abnormalities reported in >10% of patients include hypertransaminasaemia (including ALT increased, AST increased, Transaminases increased), increased alkaline phosphatase, **increased lipase, increased amylase, hyponatremia, and** hyperkalemia.  
As of the most recent Nivolumab Investigator Brochure, (v19) Fulminant type 1 diabetes mellitus is included as a SAR based on a comprehensive evaluation. Fulminant type 1 diabetes mellitus is characterized by rapid-onset diabetic ketoacidosis, low glycated hemoglobin (HbA1c) value, undetectable serum Cpeptide, and negative islet-related autoantibodies. Fulminant type 1 diabetes mellitus is generally believed to be a sub-type of non-autoimmune diabetes, but some reports show evidence of involvement of autoimmune mechanism in the onset of fulminant type 1 diabetes. In cases observed in nivolumab clinical trials, most patients received insulin therapy and were able to control the event of diabetes mellitus. It has been established that nivolumab and other check point inhibitors may cause immune-related endocrinopathies, including diabetes. Clinical experts do not alter treatment or management strategies for onset of type 1 diabetes in patients on immunotherapy and do not recommend discontinuation of therapy in response to diabetes-related event.
untitled h1
10.2 low dose cyclophosphamide

Cyclophosphamide is a synthetic alkylating agent chemically related to the nitrogen mustards. CTX received initial approval by the FDA in 1959. Leukemias are among the approved indications. Dosing can be oral or intravenous. CTX is activated by cytochrome P450, mainly CYP 2B6 and 3A4, to its active metabolite, phosphoramide mustard which forms cross links in DNA. The active dosing for malignant diseases is generally 1 mg/kg to 5 mg/kg PO per day for cytotoxic effect. For immunomodulatory effect, CTX has been given most commonly at 50 mg PO daily.[69]
Refer to the FDA-approved package insert for oral cyclophosphamide for product information, extensive instructions, and a comprehensive list of adverse events.
untitled h1
availability

Oral cyclophosphamide in 25 mg and 50 mg tablets **will be provided for the study.**
untitled h1
storage and stability

Store at room temperature at or below 77 degrees F (25 degrees C) away from light and moisture. Brief storage not exceeding 86 degrees F (30 degrees C) is permitted.  
Unopened vials of cyclophosphamide are stable until the date indicated on the package when stored at or below 25°C (77°F).
untitled h1
10.3 n-803 formulation supply and

N-803 (previously known as ALT-803), a recombinant human superagonist IL-15 complex, is the working name of the drug under investigation. Its active ingredient is N-803 and its pharmacologic class is an anti-cancer and anti-viral immunotherapeutic.  
N-803 has been referred to as IL-15N72D:IL-**15RαSu/IgG1 Fc complex in various**
preclinical study reports, publications, and other related documents.
untitled h1
10.3.1 formulation and composition

The biological drug product, N-803, is formulated in a phosphate buffered saline
(PBS) solution. The solution appears as a clear and colorless liquid. The drug substance is produced by a recombinant mammalian cell line and is manufactured using a protein free media. The vialed quantitative composition of N-803 is listed in the table below.  
| Quantitative Composition of N-803   |               |             |
|-------------------------------------|---------------|-------------|
| Componenta                          | Concentration | Amount/Vial |
| N-803                               | 1.0 mg/mL     | 0.6 mg      |
| N-803                               | 2.0 mg/mL     | 1.2 mg      |
| PBSb                                | QS            | 0.6 mLc     |  
```
a - N-803 is available in 2 different concentrations. The volume of PBS used is the same for both.
b- PBS Formulation: Sodium Chloride (USP) 8.18 g/L; Sodium Phosphate Dibasic (USP) 2.68
g/L; Potassium Phosphate Monobasic (NF) 1.36 g/L pH 7.4. c- Fill volume is 0.6 mL, extractable
volume is 0.5mL.

```
untitled h1
10.3.2 structural formula

N-803 is a soluble complex consisting of 2 protein subunits of a human IL-15 variant associated with high affinity to a dimeric IL-15R sushi domain/human IgG1 Fc fusion protein. The IL-15 variant is a 114 aa polypeptide comprising the mature human IL-15 cytokine sequence with an Asn to Asp substitution at position 72 of helix C (N72D).6. The human IL-15R sushi domain/human IgG1 Fc fusion protein comprises the sushi domain of the IL-15R subunit (aa 1-65 of the mature human IL-15Rα protein) linked with the human IgG1 CH2**-CH3 region**
containing the Fc domain (232 amino acids). Aside from the N72D substitution, all of the protein sequences are human. Based on the amino acid sequence of the subunits, calculated molecular weight of the complex comprising 2 IL15N72D
polypeptides and a disulfide linked homodimeric IL-**15RαSu/IgG1 Fc protein is**
92.4 kDa. Each IL-15N72D polypeptide has a calculated molecular weight of approximately 12.8 kDa and the IL-15RαSu/IgG1 Fc fusion pro**tein has a**
calculated molecular weight of approximately 33.4 kDa. Both the IL-15N72D and IL-**15RαSu/IgG1 Fc proteins are glycosylated resulting in an apparent molecular**
weight of N-803 as approximately 114 kDa by size exclusion chromatography. The isoelectric point (pI) determined for N-803 range from approximately 5.6 to 6.5. Thus, the fusion protein is negatively charged at pH 7. The calculated molar extinction coefficient at A280 for N-803 is 116,540 M-1, or 1.26 OD280 for a 1 mg/mL solution of N-803, or one OD280 is equivalent to 0.79 mg/mL solution of N-803.
untitled h1
10.3.3 storage and handling

N-803 is supplied in a 2-mL single-dose/single-use vial containing 0.6 mL of N803
(extractable volume is 0.5 mL) at a concentration of 1 mg/mL or 2 mg/mL. Vials are packaged in cartons and shipped to the clinical site. Study medication must be maintained at a temperature between 2°C and 8°C.
untitled h1
10.3.4 study drug preparation and

N-803 dose calculation will be based on actual body weight; however for patients
> 100 kilograms weight, the N-803 dose will be calculated using a weight capped at 100 kg. Refer to Section 6.1.4 for additional details.  
The calculated amount of N-803 will be drawn into a syringe for subcutaneous injection. The current IDS stock concentration is 1 mg/ml. Doses will be drawn directly into the syringe for injection. If the total subcutaneous dose is greater than 1.5 mL, the dose will be divided into 2-3 subcutaneous injections as needed.
untitled h1
10.3.5 agent inventory records

The investigator, or a responsible party designated by the investigator (e.g.  
institutional investigational pharmacy), must maintain a record of the inventory and disposition of study product using the Study Agent Drug Accountability Record.
untitled h1
10.3.6 toxicity

The most common side effects seen in studies with subcutaneous (under the skin) injections have been, fever, chills, hypoalbuminemia, and injection site reaction, and skin rash, which at times has been widespread. These localized skins reactions are common (occurring in more than 50% of patients).  
In June 2020 an SAE was filed on a study participant who developed atrial fibrillation (a-fib) with no prior history resulting in a hospitalization. We identified a previous case of a patient who developed a-fib while on treatment from a different clinical trial that used N-803 weekly to treat relapse. In both cases of afib, there were other potential explanations that could have triggered the arrhythmia. While we cannot directly attribute causality between N-803 and a-fib, it is at least possible that they are related, directly or indirectly. A-fib may be indirectly triggered in susceptible patients by fevers and/or use of diuretics for fluid retention that can be observed with some N803 regimens. Based on this information, we decided to add the development of a-fib as a possible rare side effect from N-803 in the consent form.  
Very common Common Rare  
| -   | injection site reaction (skin  rash), which may be large (>  2 inches), itchy, and/or  painful                                                                                   |                                                                |                        |
|-----|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------|------------------------|
| -   | fever                                                                                                                                                                            |                                                                |                        |
| -   | chills - anemia                                                                                                                                                                  |                                                                |                        |
| -   | change in blood pressure                                                                                                                                                         |                                                                |                        |
| -   | nausea                                                                                                                                                                           |                                                                |                        |
| -   | swelling of hands or feet                                                                                                                                                        |                                                                |                        |
| -   | temporary changes in  routine lab results including  decreased albumin and  decreased lymphocytes                                                                                |                                                                |                        |
|     | -                                                                                                                                                                                | flu-like symptoms, including  headache, muscle, or joint  pain |                        |
| -   | fatigue                                                                                                                                                                          |                                                                |                        |
| -   | decreased appetite                                                                                                                                                               |                                                                |                        |
| -   | diarrhea, vomiting                                                                                                                                                               |                                                                |                        |
| -   | abdominal pain                                                                                                                                                                   |                                                                |                        |
| -   | itchy skin and/or skin  irritation                                                                                                                                               |                                                                |                        |
| -   | shortness of breath - high  blood sugar  (hyperglycemia)                                                                                                                         |                                                                |                        |
| -   | changes in electrolytes on  routine lab work                                                                                                                                     | -                                                              | inflammatory  reaction |
| -   | infection including  upper respiratory  infection                                                                                                                                |                                                                |                        |
| -   | atrial fibrillation  (a-fib) - may be  asymptomatic,  but when  symptoms do  appear they may  include irregular  and often rapid  heartbeat,  shortness of  breath, and  fatigue |                                                                |                        |  
Tuberculosis is a potential risk of N-803. One instance of tuberculosis has been reported in a participant receiving N-803 in combination with BCG (a live, attenuated strain of Mycobacterium bovis) administered into the bladder by a urinary catheter. A causal relationship between N-803, in combination with BCG, and tuberculosis infection cannot be definitely ruled out.  
Anti-N-803 antibodies have been detected in subjects receiving N-803. The impact of anti-N-803 antibody formation on clinical efficacy and safety of N-803 is unknown.  
Previous editions of the N-**803 Investigator's Brochure prior to 2019 relied heavily**
on clinical experience with the related cytokine therapeutic Proleukin® Interleukin-2 to anticipate potential risks associated with (N-803 administration.  
This approach was based on the fact that N-803 and IL-**2 are both γ chain**
cytokines and thus could reasonably be predicted to have similar immunostimulatory properties. However, the substantial accumulated information on N-803 effects in humans presented the most recent IB indicates that many side effects of IL-2 are not observed in patients treated with N-803 at the doses being used clinically. For this reason, side effects observed in subjects treated with IL-2 but not N-803, such as capillary leak syndrome, pulmonary dysfunction, acidosis, and gastritis, have been removed from the IB and are reflected in this protocol and its consent form.  
Refer to the current Investigator Brochure (version 7) for additional information.
untitled h1
10.4 n-803 in combination with

The combination of N-803 + nivolumab has been associated with AEs of injection site reaction, flu-like symptoms, fever, fatigue, nausea, pain, chills, dizziness, hypotension, cough, dyspnea, anorexia, constipation, and vomiting.
untitled h1
11 adverse event monitoring documentation

Toxicity and adverse events will be classified and graded according to NCI's Common Terminology Criteria for Adverse Events version 4.03 (CTCAE) and reported on the schedule below. A copy of the CTCAE v4.03 can be downloaded from the CTEP home page
(https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03/CTCAE_4.03_2010-0614_QuickReference_8.5x11.pdf) The following definitions of adverse events (AEs) and serious adverse events (SAEs) will determine whether the event requires expedited reporting via the OnCore SAE Report Form in addition to routine documentation in the OnCore AE case report form (CRF). SAE Email Address: **Worldwide.Safety@BMS.com**
SAE Facsimile Number: **+1 609-818-3804**
If only limited information is initially available, follow-up reports are required. (Note:
Follow-up SAE reports should include the same investigator term(s) initially reported.) If an ongoing SAE changes in its intensity or relationship to study drug or if new information becomes available, a follow-up SAE report should be sent within 24 hours to BMS (or designee) using the same procedure used for transmitting the initial SAE report. All SAEs should be followed to resolution or stabilization. SAEs should be reported on MedWatch Form 3500A, which can be accessed at:
http://www.accessdata.fda.gov/scripts/medwatch/. The website will instruct you where to send the SAE forms. The reporting timeframes for SAEs and other reportable events are located in Section 11.3.  
Note: throu**ghout this section the generic term "study drug" refers to the study**
related treatment (nivolumab, N-803, and cyclophosphamide). Adverse event monitoring will begin with the 1st dose of study drug.
untitled h1
11.1 adverse event terminology

Adverse Event: Any untoward medical occurrence associated with the use of a drug in humans, whether or not considered drug related.  
Serious Adverse Event: **An adverse event is considered "serious" if, in the view**
of either the investigator or sponsor, it results in any of the following outcomes:
- **Death**
- **A life-threatening adverse event**
- **Inpatient hospitalization or prolongation of existing hospitalization**
- **A persistent or significant incapacity or substantial disruption of the ability to**
conduct normal life functions
- **A congenital anomaly/birth defect**
- **Important medical events 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 or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.  
Unexpected Event: An adverse event or suspected adverse reaction is considered "unexpected" if it is not listed in the investigator brochure or is not listed at the specificity or severity that has been observed; or, if an investigator brochure is not required or available, is not consistent with the risk information described in the general investigational plan or elsewhere in the current application, as amended.
untitled h1
attribution of event

- 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.**  
The following **definitions are from the Masonic Cancer Center's Standard**
Operating Procedure (SOP) Deviation Reporting:  
Major Deviation: A deviation or violation that impacts the risks and benefits of the research; may impact subject safety, affect the integrity of research data and/or affect a subject's willingness to participate in the research. Deviations that place a subject at risk, but do not result in harm are considered to be major deviations.  
Minor Deviation: A deviation or violation that does not impact subject safety, compromise the integrity of research data and/or affect a subject's willingness to participate in the research.
untitled h1
11.2 adverse event documentation

Adverse event monitoring and documentation begins with the 1st **dose of the**
study drug through the final treatment visit. For the purposes of this study, adverse event documentation will focus on immune related adverse events (irAEs). Most commonly affected are the skin (rash/vitiligo/pruritis); the liver (hepatitis/rise in liver enzymes); the bowel (diarrhea/colitis), and the endocrine system (hypophysitis, thyroiditis, adrenal insufficiency). More rarely, uveitis, conjunctivitis, neuropathy, myopathy, and nephritis may occur. In addition, any unexpected grade 3 or greater toxicity at least possibility related to study treatment will be documented.  
Patients self-administering oral cyclophosphamide will complete a drug diary to document administration and side effects.  
At visits through the End of Treatment visit a targeted toxicity worksheet
(Appendix V) will be completed to document select expected toxicities associated with N-803 as follows:
- **Prior to each planned N-803 injection** - **At the end of dose monitoring period (as described in Section 6.1.4) with**
±20 minute window for 2 hour monitoring or ±10 minute window for 30 minute monitoring
- **At the End of Treatment visit**