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9.3 response criteria for primary

9.3.1 Measurable Soft‐tissue *Lesions* When evaluating soft-tissue lesions, the definitions in Table 4 apply.  
| Table 4. RECIST 1.1 Response Criteria for Target Lesions Response Evaluation of Target Lesions Complete response  Disappearance of all target lesions. Any pathological lymph  (CR)  nodes (whether target or non-target) must have reduction in  short axis to < 10 mm.  Partial response (PR) At least a 30% decrease in the sum of diameters of target  lesions, taking as reference the baseline sum diameters.  Progressive disease  At least a 20% increase in the sum of diameters of target  (PD)  lesions, taking as reference the smallest sum on study (this  includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also  demonstrate an absolute increase of ≥ 5 mm. (Note: the  appearance of one or more new lesions is also considered  progression).   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| Stable disease (SD)   | Neither sufficient shrinkage to qualify for PR nor sufficient  increase to qualify for PD, taking as reference the smallest  sum diameters while on study.   |
|-----------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| normal tissue. When the evaluation of complete response depends on this  determination, it is recommended that the residual lesion be investigated (e.g. fine  needle aspirate or biopsy) before confirming the complete response status.  Changes in nodal and visceral sites should be recorded and reported separately, and  lymph nodes in the pelvis must measure ≥ 15 mm in shortest diameter to be  considered target lesions. Complete elimination of disease at a particular site  should be recorded separately. Any favorable change should be confirmed using a  second follow-up scan.  For each patient, use a waterfall plot to report the percent change in PSA from  baseline to 12 weeks (or earlier for those who discontinue therapy) and the  maximum decline in PSA that occurs at any point after treatment. We will also  report the proportion of patients to achieve a 50% of greater decrease in PSA from  baseline (i.e. PSA50 response rate).  Record post-treatment changes as either "no new lesions" or "new lesions."   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
In the absence of clearly worsening soft-tissue (nodal and visceral) disease or disease-related symptoms, progression at the first scheduled assessment should be confirmed on a second scan performed ≥ 6 weeks later. In the rare case where visible lesions disappear, this too should be confirmed.  
9.3.4 Nontarget *Lesions* When assessing nontarget lesions, the definitions in Table 5 will apply.  
| Response            | Evaluation of Nontarget Lesions                                                                                       |
|---------------------|-----------------------------------------------------------------------------------------------------------------------|
| Complete response   | The disappearance of all nontarget lesions and                                                                        |
| (CR)                | normalization of tumor marker levels. All lymph nodes must  be non-pathological in size (< 10 mm short axis).         |
| Non-CR/non-PD       | The persistence of one or more nontarget lesions and/or  maintenance of tumor marker levels above the normal  limits. |
| Progressive disease | The appearance of one or more new lesions and/or                                                                      |
| (PD)                | unequivocal progression of existing nontarget lesions.                                                                |  
Table 5. RECIST 1.1 Response Criteria for Nontarget *Lesions*
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9.4 criteria for progressive disease.

9.4.1 Measurable Soft‐tissue *Lesions* When evaluating soft-tissue lesions, the definitions in Table 4 apply. In some circumstances, it may be difficult to distinguish residual disease from normal tissue. When the evaluation of complete response depends on this determination, it is recommended that the residual lesion be investigated (e.g. fine needle aspirate or biopsy) before confirming the complete response status. Progression in a nodal or visceral site should be defined using RECIST 1.1 Criteria (Table 4).  
9.4.2 PSA
Per the PCWG3, PSA progression is defined as the date that a 25% or greater increase and an absolute increase of 2 ng/mL or more from the nadir is documented and confirmed by a second value obtained 3 or more weeks later. Where no decline from baseline is documented, PSA progression is defined as a 25% increase from the baseline value along with an increase in absolute value of 2 ng/mL or more after 12 weeks of treatment.  
9.4.3 *Bone* Progressing disease on bone scan is considered when at least 2 new lesions are observed. Yet, progression remains unconfirmed unless at least 2 *additional* new lesions appear at a subsequent time point. Unless clinically indicated, there is no need to perform a follow-up bone scan before 12 weeks of treatment. To define disease progression requires a confirmatory scan (which shows additional new lesions compared with the first follow-up scan) performed ≥ 6 weeks later. When further progression is documented on the confirmatory scan, the date of progression recorded for the trial is the date of the first scan that shows the change.  
9.4.4 Nontarget *Lesions* When assessing nontarget lesions, the definitions in Table 5 apply.
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10. data reporting and regulatory

The Protocol Chair, Dr. Mark Markowski is responsible for performing the following tasks:
Coordinating, developing, submitting, and obtaining approval for the protocol as well as its subsequent amendments.  
Assuring that all participating institutions are using the correct version of the protocol.  
Taking responsibility for the overall conduct of the study at all participating institutions and for monitoring the progress of the study.  
Reviewing and ensuring reporting of Serious Adverse Events (SAEs). Reviewing data from all sites.
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lead center

The Lead Center (Johns Hopkins University) is responsible for performing the following tasks:
Ensuring that IRB approval has been obtained at each participating site prior to the first patient registration at that site, and maintaining copies of IRB approvals from each site.  
Managing central patient registration. Collecting and compiling data from each site. Establishing procedures for documentation, reporting and submitting of AEs and SAEs to the Protocol Chair and all other applicable parties.  
Facilitating audits by securing selected source documents and research records from participating sites for audit, or by auditing at participating sites.
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participating pcctc sites

Participating sites are responsible for performing the following tasks:
10.1 Data **Entry**
Data collected during this study will be entered into a secure database. Staff at Johns Hopkins University will be responsible for the initial study configuration and setup in the CRMS database and for any future changes.
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10.1.1 case report forms completion

Electronic Case report forms will be generated by the coordinating center for the collection of all study data. Investigators will be responsible for ensuring that the CRFs are kept up-to-date.  
The paper Eligibility Checklist CRF must be completed using black ink. Any errors must be crossed out so that the original entry is still visible, the correction clearly indicated and then initialed and dated by the individual making the correction.  
eCRFs will be completed within 2 weeks of the patient coming to the clinic and all relevant supporting documentation such as scans, progress notes, nursing notes, blood work, pathology reports, etc., will be submitted via email to the SKCCC Coordinating Center Study Manager. All patient names or other identifying information will be removed prior to being sent to the Coordinating Center (SKCCC)
Following the protocol as written, and the guidelines of Good Clinical Practice (GCP). Submitting data to the Lead Center. Registering all patients with the Lead Center by submitting patient registration form and signed informed consent promptly.  
Providing sufficient experienced clinical and administrative staff and adequate facilities and equipment to conduct a collaborative trial according to the protocol.  
Maintaining regulatory binders on site and providing copies of all required documents to the Lead Center.  
Collecting and submitting data according to the schedule specified by the protocol.  
or non-redacted source documents can be sent via a password-protected/secured document transfer based on each institution's guidelines. Authorized representatives of the Coordinating Center (SKCCC) may visit the satellite sites to perform audits or inspections, including source data verification. The purpose of these audits or inspections is to systematically and independently examine all trial-related activities and documents to determine whether these activities were conducted and data were recorded, analyzed, and accurately reported according to the protocol, Good Clinical Practice (GCP), and any applicable regulatory requirements.  
10.1.2 Source *Documents* Study personnel will record clinical data in each patient's source documents (i.e. the patient's medical record). Source documentation will be made available to support the patient research record. Study monitors will review entries on the CRFs at regular intervals, comparing the content with source documents.  
10.1.3 Record *Retention* The Investigator will maintain adequate and accurate records to enable the conduct of the study to be fully documented and the study data to be subsequently verified.  
After study closure, the Investigator will maintain all source documents, studyrelated documents, and the CRFs. Because the length of time required for retaining records depends upon a number of regulatory and legal factors, documents should be stored until the Investigator is notified that the documents may be destroyed. In this study, records are to be retained and securely stored for a minimum of 5 years after the completion of all study activities.
investigator approval of protocol
10.2 data management

10.2.1 Lead Research Program *Coordinators* A Lead research program coordinator at the coordinating center will be assigned to the study. A Lead Research Program Coordinator will manage the study activities at each of the participating sites. The responsibilities of the Lead Research Program Coordinator include project compliance, data collection, data entry, data reporting, regulatory monitoring, problem resolution and prioritization, and coordination of the activities of the protocol team.
investigator approval of protocol
10.3 study monitoring and quality

Regularly scheduled registration reports will be generated to monitor patient accruals and the completeness of registration data. Routine data quality reports will be generated to assess missing data and inconsistencies. Accrual rates and the extent and accuracy of evaluations and follow-up will be monitored periodically throughout the study period, and potential problems will be brought to the attention of the principal investigator for discussion and action. Random-sample data quality and protocol compliance audits will be conducted by the study team at least once a year, more frequently if indicated. Audits by the coordinating center may entail (1) shipping source documents and research records for selected patients from participating sites to the coordinating center for audit, or (2) on-site auditing of selected patient records at participating sites.  
All clinical work conducted under this protocol is subject to Good Clinical Practice (GCP) guidelines. This includes inspection of study-related records by the lead site, sponsor, its designee, or health authority representatives at any time. Data and Safety *Monitoring:* This is a DSMP Medium Risk study under the SKCCC Data and Safety Monitoring Plan (6/5/2020). Data Monitoring of this protocol will occur annually. The protocol will be monitored internally at SKCCC by the Principal Investigator. The SKCCC Compliance Monitoring Program will provide external monitoring for JHU affiliated sites in accordance with SKCCC DSMP (Version 6.0, 02/21/2019). The SMC Subcommittee will determine the level of patient safety risk and level/frequency of monitoring. Additionally, scheduled meetings will take place monthly and will include the protocol Principal Investigator, research nurse, data manager, and, when appropriate, the collaborators, subinvestigators, and biostatistician involved with the conduct of the protocol. During these meetings the investigators will discuss matters related to: the safety of protocol participants, validity and integrity of the data, enrollment rate relative to expectation, characteristics of participants, retention of participants, adherence to protocol (potential or real protocol violations), data completeness, and progress of data for secondary objectives.  
10.4 Clinical Trial **Agreement**
This trial is being conducted under one or more clinical trial agreements that contain, among other terms, the publication policy, indemnity agreements, and financial arrangements for the study.
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11. statistical considerations

The primary endpoint will be the proportion of subjects who achieve a PSA response, defined as a 50% or greater decline in PSA from baseline, confirmed on a subsequent measurement at least 4 weeks apart. The treatment regimen would be considered of insufficient activity for further study in this population if the PSA response rate is 25% or less. The sample size is calculated to detect an improved PSA response rate from 25% (null hypothesis) to 45% (alternative). A minimax Simon two stage design is planned. A total of 23 patients will be entered in the first stage. A planned analysis will be performed 12 weeks after the last patient in the first stage receives the first dose of nivolumab. If ≤ 5 subjects have a PSA response, the study will be terminated and we will conclude the regimen is ineffective. If ≥ 6 subjects respond, then an additional 16 patients will be studied, for a total of 39 patients. If a total of ≤ 13 subjects respond in stage one and two combined, we consider this regimen ineffective. If a total of ≥ 14 respond, we conclude the regimen is promising and warrants further study. The maximum sample size will be increased to 44 patients to account for 10% possible dropouts and unevaluable patients. This design provides 90% power to detect an absolute 20% increase in PSA response rate with a one-sided type I error of 0.1. The probability of early stopping is 0.49 under the null hypothesis that the PSA50 response rate is 25%.
investigator approval of protocol
11.1 study endpoints

11.1.1 Analysis of the Primary *Endpoint* The primary endpoint of this study is PSA50 response, defined as a decrease in the PSA to 50% less than the baseline PSA upon enrollment in the trial. The decrease must be confirmed by a second measurement at least 4 weeks apart. For purposes of meeting the primary endpoint, patients will be considered to have done so if they have a PSA50 response only while on therapy with Testosterone +/- Nivolumab. PSA
values will be measured each cycle during the trial. All patients who are administered at least one dose of Testosterone will be considered evaluable for the primary endpoint. If patients do not have follow-up PSAs after initiation of Testosterone therapy due to withdrawing consent or being lost to follow-up for example, then they will be replaced.  
We will estimate the PSA50 response rate, along with the exact 95% confidence interval, for the population of patients.  
11.1.2 Analysis of Secondary Endpoints
investigator approval of protocol
11.1.2.1 safety

Patients will be assessed for toxicities at each clinical evaluation. Toxicities will graded according to the most current CTCAE standardized grading scales. The incidence of grade 3-5 toxicities will be reported. Patients will be assessed for toxicity as long as they are taking Testosterone +/- Nivolumab, and patients will continue to be followed if treatment is discontinued for toxicity until the toxicities improve to grade 1 or resolve. Toxicities will be reported as a tabulated table by type and grade.  
11.1.2.2 PSA Progression‐free Survival *(PSA‐PFS)*
A standard definition of PSA progression per PCWG3 will be used. PSA-PFS will be defined as an increase in 25% over a nadir value, confirmed by a follow-up PSA at least 4 weeks apart. If patients are removed from study prior to PSA progression, then they will be censored at that time.  
We will use the Kaplan-Meier method to summarize the median PSA PFS. 11.1.2.3 Progression‐free Survival *(PFS)*
Progression-free survival will be measured from the time of first dose to objective tumor progression as defined by RECIST 1.1 for progressive disease or death and summarized using a Kaplan-Meier curve. Progression will be assigned to the earliest observed time. Patients whose disease has not progressed at follow-up will be censored at the date when the last tumor assessment determined a lack of progression.  
We will use the Kaplan-Meier method to summarize the median PFS.  
11.1.2.4 Objective Response Rate (ORR)
The objective response rate is defined as the percentage of patients who achieve an objective response by RECIST 1.1 criteria (i.e. Complete response or Partial Response) to Testosterone +/- Nivolumab. We will estimate the objective response rate, along with the exact 95% confidence interval, for the population of patients with RECIST 1.1 evaluable disease.  
11.1.2.5 Durable Progression‐free *Survival* Durable PFS will be defined as the proportion of patients without clinical or radiographic progression or death at 24 weeks from start of treatment. 11.1.2.6 Overall Survival *(OS)*
Overall survival will be defined as the time from study enrollment to death or up to 2 years after the last dose of study treatment. This will be analyzed as a Kaplan-Meier plot.  
11.1.3 Analysis of Exploratory Endpoints 11.1.3.1 Estimate the Percentage of Patients with a Pathogenic Somatic or *Germline*
Mutation in a HR or MMR Gene *Mutation* The somatic DNA mutations present in the tumor will be identified through Foundation Medicine sequencing. Germline DNA mutation testing per standard of care practice will be done using clinical-grade testing in a CLIAcertified laboratory (i.e. COLOR genomics) for consenting subjects only.  
Patients with a germline or somatic deleterious mutation or deletion in the pre-specified gene list (BRCA1, BRCA2, ATM, CHEK2, NBN, RAD50, RAD51C, RAD51D, PALB2, MRE11, FANCA, FANCB, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCI, FANCL, FANCM, MLH1, MLH3, MSH2, MSH3, MSH6, PMS1 and PMS2) will be considered biomarker positive. For biomarker positive and biomarker negative subjects, we will calculate PSA50 response rates with confidence intervals for hypothesis generation.  
11.1.3.2 PD‐1, PD‐L1, CD4, CD8, FOXP3,γH2AX, RAD51, 53BP1 Protein *Levels:*
Subjects will have pre-treatment, on-treatment (and at progression) tumor biopsy specimens analyzed. IHC staining for PD-1 and PD-L1 will be performed on the pre-treatment samples and scored as <1%, 1-5%, 5-10%, >10% and the results will be associated with responses for both proteins, separately, using descriptive statistics and Fisher's Exact Tests. Immunofluorescence will be used to quantify the median intensity of each gamma-H2AX, RAD51m and 53BP1 foci per cell as well determine the median number of foci per cell on the pretreatment biopsies. Using analytical microscopy, Drs. Meeker and Heaphy have developed imaging software which can isolate single nuclei and quantify both the intensity and number of immunofluorescent foci per nucleus (i.e. per cell). Using FFPE
tissue obtained at biopsy, we will examine the change in DNA damage foci number and intensity (reported as median percent change) induced by BAT
+/- Nivolumab in PSA50 responders versus non-responders using a T-test.  
Using imaging software, we will count the number of CD4+ and CD8+ lymphocytes in pre-treatment and on-treatment biopsies. We will correlate PSA50 responses with CD4+ and CD8+ lymphocyte tumor infiltration.
investigator approval of protocol
11.1.3.3 manas/taas assay

Whole-exome sequencing will be performed on pre-treatment samples, after 12 weeks of BAT lead-in therapy, and post-progression tumor and matched normal samples. Exome data will be applied in a neoantigen prediction pipeline that evaluates antigen processing, MHC binding, and gene expression to generate neoantigens specific to the patient's HLA haplotype. Truncal neoantigens will be identified by correcting for tumor purity and ploidy. Putative neoantigens will then be used to generate peptides and stimulate autologous T cells, followed by TCR next-generation sequencing.  
11.1.3.4Cytokines and Chemokines *Analysis* Milliplex human cytokine/chemokine Immunology Multiplex Assay (Millipore-Sigma) will be used to assay acute effects of BAT on production of cytokines and chemokines. Plasma samples are obtained at prior to the first BAT injection on C1D1, 3 hours after the first BAT injection (C1D1), 3 days after the first BAT injection (C1D4), prior to C2D1, and prior to C7D1. Samples will be processed and stored in the Denmeade Laboratory and analyzed by the Immune Processing Core Lab at Johns Hopkins.
investigator approval of protocol
11.2 analysis populations

11.2.1 Intent‐to‐treat/Response‐to‐treatment/Evaluable *Population* All patients who meet eligibility criteria and receive at least 1 dose of testosterone will be included in the main analysis of the response rate, even if there are major protocol deviations (e.g. incorrect treatment schedule or drug administration). Each patient will be assigned to one of the following categories:  
| Category                                                                 | Response                                   |
|--------------------------------------------------------------------------|--------------------------------------------|
| 1                                                                        | Complete response                          |
| 2                                                                        | Partial response                           |
| 3                                                                        | Stable disease                             |
| 4                                                                        | Progressive disease                        |
| 5                                                                        | Early death from malignant disease         |
| 6                                                                        | Early death from toxicity                  |
| 7                                                                        | Early death from other causes              |
| 8                                                                        | Unknown (not assessable/insufficient data) |
| NOTE: By arbitrary convention, category 8 designates unknown status in a |                                            |  
Conclusions are to be based on the population of all eligible patients. Subanalyses may be performed on various subsets of patients, such as those with no major protocol deviations or those who continued in the study for the entire treatment period (i.e. did not withdraw prematurely). Subanalysis will not serve as the basis for drawing conclusions concerning treatment efficacy.
investigator approval of protocol
11.2.2 safety population

All patients enrolled in the study will be included in the safety analysis population and considered evaluable for toxicity and safety from the time of their first dose. Demographic and baseline characteristics for the safety population will be summarized by number and percent for categorical data (e.g. sex, race/ethnicity) and by descriptive statistics for continuous data (e.g. weight, vital signs, EKG readings, disease status).
investigator approval of protocol
11.3 safety analysis

11.3.1 Evaluation of Adverse *Events* Treatment-emergent adverse events will be translated from investigator terms to MedDRA v.20.1 terminology and summarized (number and percentage of patients)
for all patients who receive at least 1 dose. Adverse event summaries will be organized by body system, frequency of occurrence, intensity (i.e. severity grade),
and causality or attribution. Patients who experience an adverse event more than once will be counted only once. The occurrence with the maximum severity will be used to calculate intensity.  
11.3.2 Evaluation of Serious Adverse Events and Premature *Withdrawals* Adverse events deemed serious and those resulting in treatment withdrawal or death will be summarized separately. Narrative paragraphs will be generated to describe the circumstances surrounding each SAE and death.  
11.3.3 Evaluation of Laboratory Parameters and *Assays* Selected clinical laboratory parameters will be summarized and clinically significant changes from baseline will be discussed.
investigator approval of protocol
11.3.4 extent of exposure

Treatment exposure will be summarized for all patients, including dose administration, number of cycles, dose modifications or delays, and duration of therapy.
investigator approval of protocol
12. protection of human subjects

12.1  Ethical *Considerations* This study will be conducted in compliance with the protocol, GCP guidelines established by the International Conference on Harmonization, and the ethical standards set forth in the Declaration of Helsinki 2004 (available at: www.laakariliitto.fi/e/ethics/helsinki.html).  
12.2  Protocol *Amendments* Before starting the study, the protocol must be approved by each institution's IRB or Independent Ethics Committee (IEC). Amendments to the protocol may be made only with consent of the lead site/sponsor and principal investigator and are subject to IRB approval before instituting.  
12.3  Written Informed *Consent* Before obtaining consent, members of the study team will review the rationale for the treatment program with the patient. The discussion will review the alternatives available (including hormonal therapy, chemotherapy, or supportive care as appropriate), the potential benefits of this program, the risks and the probability of their occurrence, and the procedures to minimize these risks. Should an adverse event occur, the provisions available to ensure medical intervention will also be reviewed. Why the risks are reasonable in relation to the anticipated benefits, incentives, or costs that will or may be incurred as a result of participating in the study, as well as the efforts to maintain confidentiality, will also be discussed with the patient. Patients will be required to sign and date (in duplicate) a statement of informed consent that meets the requirements of the Code of Federal Regulations (Federal Register Vol. 46, No. 17, January 27, 1981, part 50) and the IRB. The medical record will include a statement that written informed consent was obtained (and document the date that it was obtained) before the patient is enrolled in the study. The original signed document will become part of the patient's medical record, a copy will be forwarded to the lead site/sponsor pursuant to sponsor registration, and a copy will be sent home with each patient. The consent form will include the following:
The nature and objectives, potential toxicities, and benefits of the intended study.  
The length of therapy and likely follow-up required. Alternatives to the proposed therapy (including available standard and investigational therapies).  
The name of the investigator(s) responsible for the protocol. The right of the patient to accept or refuse treatment and to withdraw from participation in this study.  
Text regarding the coordinating center should be added to all institutional informed consent documents.  
12.4  Protection of *Privacy* Patients will be informed of the extent to which their confidential health information generated from this study may be used for research purposes. After this discussion, they will be asked to sign a Notice of Privacy Practice research authorization/HIPAA form. The original signed documents will become part of the patient's medical records, and each patient will receive a copy of the signed documents. The use and disclosure of protected health information will be limited to the individuals described in the research authorization form. The research authorization form must be completed by the principal investigator and approved by the IRB.  
12.5  Terminating or Modifying the *Study* Adverse event and laboratory data from this trial will be assessed by the medical monitor (Dr. Mark Markowski) on an ongoing basis. At least quarterly, data from the clinical database will be reviewed. The results of this review will be shared with all investigators either in writing or as part of a teleconference. SAEs will be reviewed as they are reported to the lead site/sponsor, and the medical monitor will make an assessment regarding the safety of continuing or modifying the study. This assessment will be shared with the investigators either in writing or as part of a teleconference as well as with BMS. Should the assessment of either the lead site/sponsor or the principal investigator be that the study should be terminated, the study will be closed to further accrual. Patients who are receiving Testosterone +/- Nivolumab will be assessed individually by the investigator to see if it is in the patients' best interest to continue, which might be the case for a patient that is responding to the intervention. Follow-up safety assessments will be performed for all patients who are terminated from the study prematurely. Any planned data disclosures will also be discussed with BMS.
investigator approval of protocol
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Topalian SL, Chen L. Colocalization of inflammatory response with B7-h1 expression in human melanocytic lesions supports an adaptive resistance mechanism of immune escape. Science translational medicine 2012;4(127):127ra137.  
24. Iwai Y, Terawaki S, Honjo T. PD-1 blockade inhibits hematogenous spread of poorly immunogenic tumor cells by enhanced recruitment of effector T cells. International immunology 2005;17(2):133-144.  
25. Hirano F, Kaneko K, Tamura H, Dong H, Wang S, Ichikawa M, Rietz C, Flies DB, Lau JS, Zhu G,
Tamada K, Chen L. Blockade of B7-H1 and PD-1 by monoclonal antibodies potentiates cancer therapeutic immunity. Cancer research 2005;65(3):1089-1096.  
26. Li B, VanRoey M, Wang C, Chen TH, Korman A, Jooss K. Anti-programmed death-1 synergizes with granulocyte macrophage colony-stimulating factor--secreting tumor cell immunotherapy providing therapeutic benefit to mice with established tumors. Clinical cancer research : an official journal of the American Association for Cancer Research 2009;15(5):1623-1634.  
27. Curran MA, Montalvo W, Yagita H, Allison JP. PD-1 and CTLA-4 combination blockade expands infiltrating T cells and reduces regulatory T and myeloid cells within B16 melanoma tumors. Proceedings of the National Academy of Sciences of the United States of America 2010;107(9):4275-4280.  
28. Brendler H CW, Scott WW. Prostatic Cancer: Further investigation of hormone relationships.  
Arch Surg 1949:433-440.  
29. Prout GR, Jr., Brewer WR. Response of men with advanced prostatic carcinoma to exogenous administration of testosterone. Cancer 1967;20(11):1871-1878.  
30. Donati RM, Ellis H, Gallagher NI. Testosterone potentiated 32P therapy in prostatic carcinoma. Cancer 1966;19(8):1088-1090.  
31. Johnson DE, Haynie TP. Phosphorus-32 for intractable pain in carcinoma of prostate.  
Analysis of androgen priming, parathormone rebound, and combination therapy. Urology 1977;9(2):137-139.  
32. Manni A, Bartholomew M, Caplan R, Boucher A, Santen R, Lipton A, Harvey H, Simmonds M,
White-Hershey D, Gordon R, et al. Androgen priming and chemotherapy in advanced prostate cancer: evaluation of determinants of clinical outcome. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 1988;6(9):1456-1466.  
33. Szmulewitz R, Mohile S, Posadas E, Kunnavakkam R, Karrison T, Manchen E, Stadler WM. A
randomized phase 1 study of testosterone replacement for patients with low-risk castration-resistant prostate cancer. European urology 2009;56(1):97-103.  
34. Morris MJ, Huang D, Kelly WK, Slovin SF, Stephenson RD, Eicher C, Delacruz A, Curley T,
Schwartz LH, Scher HI. Phase 1 trial of high-dose exogenous testosterone in patients with castration-resistant metastatic prostate cancer. European urology 2009;56(2):237-244.  
35. Behre HM, Nieschlag E. Testosterone preparations for clinical use in males. In:
Testosterone: Action,Deficiency. Cambridge University Press 2012;4th edition:309-335.  
36. Schweizer MT, Antonarakis ES, Wang H, Ajiboye AS, Spitz A, Cao H, Luo J, Haffner MC,
Yegnasubramanian S, Carducci MA, Eisenberger MA, Isaacs JT, Denmeade SR. Effect of bipolar androgen therapy for asymptomatic men with castration-resistant prostate cancer: results from a pilot clinical study. Science translational medicine 2015;7(269):269ra262.  
37. Hussain MH, Pienta KJ, Redman BG, Cummings GD, Flaherty LE. Oral etoposide in the treatment of hormone-refractory prostate cancer. Cancer 1994;74(1):100-103.  
38. Teply BA, Kachhap S, Eisenberger MA, Denmeade SR. Extreme Response to High-dose Testosterone in BRCA2- and ATM-mutated Prostate Cancer. European urology 2017;71(3):499.  
39. Beer TM, Kwon ED, Drake CG, Fizazi K, Logothetis C, Gravis G, Ganju V, Polikoff J, Saad F,
Humanski P, Piulats JM, Gonzalez Mella P, Ng SS, Jaeger D, Parnis FX, Franke FA, Puente J, Carvajal R, Sengelov L, McHenry MB, Varma A, van den Eertwegh AJ, Gerritsen W. Randomized, Double-Blind, Phase III Trial of Ipilimumab Versus Placebo in Asymptomatic or Minimally Symptomatic Patients With Metastatic Chemotherapy-Naive CastrationResistant Prostate Cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2017;35(1):40-47.  
40. Kwon ED, Drake CG, Scher HI, Fizazi K, Bossi A, van den Eertwegh AJ, Krainer M, Houede N,
Santos R, Mahammedi H, Ng S, Maio M, Franke FA, Sundar S, Agarwal N, Bergman AM, Ciuleanu TE, Korbenfeld E, Sengelov L, Hansen S, Logothetis C, Beer TM, McHenry MB, Gagnier P, Liu D, Gerritsen WR, Investigators CA. Ipilimumab versus placebo after radiotherapy in patients with metastatic castration-resistant prostate cancer that had progressed after docetaxel chemotherapy (CA184-043): a multicentre, randomised, doubleblind, phase 3 trial. The lancet oncology 2014;15(7):700-712.  
41. McCarthy EF. CT-guided needle biopsies of bone and soft tissue tumors: a pathologist's perspective. Skeletal radiology 2007;36(3):181-182.  
42. Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, Verweij J, Van Glabbeke M, van Oosterom AT, Christian MC, Gwyther SG. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. Journal of the National Cancer Institute 2000;92(3):205-216.  
43. Morris MJ, Scher HI, Stadler WM, Higano C, Basch E, Fizazi K, Antonarakis ES, Beer TM,
Carducci MA, Chi KN, Corn PG, de Bono JS, Dreicer R, George DJ, Heath EI, Hussain M, Kelly WK, Liu G, Logothetis C, Nanus D, Stein MN, Rathkopf DE, Slovin SF, Ryan CJ, Sartor O, Small EJ, Smith MR, Sternberg CN, Taplin ME, Wilding G, Nelson PS, Schwartz LH, Halabi S, Kantoff PW, Armstrong AJ, Prostate Cancer Clinical Trials Working G. Trial Design and Objectives for Castration-Resistant Prostate Cancer: Updated Recommendations From the Prostate Cancer Clinical Trials Working Group 3. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2016;34(12):1402-1418.
investigator approval of protocol
appendix a management algorithm for

These general guidelines constitute guidance to the Investigator. The guidance applies to all immuno-oncology agents and regimens. A general principle is that differential diagnoses should be diligently evaluated according to standard medical practice. Non-inflammatory etiologies should be considered and appropriately treated. Corticosteroids are a primary therapy for immuno-oncology drug-related adverse events. The oral equivalent of the recommended IV doses may be considered for ambulatory patients with low-grade toxicity. The lower bioavailability of oral corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids. For subjects expected who require more than 4 weeks of corticosteroids or other immunosuppressants to manage an adverse event, consider the following recommendations:
Antimicrobial/antifungal prophylaxis per institutional guidelines to prevent opportunistic infections such as Pneumocystis jiroveci (PJP) and fungal infections.  
Early consultation with an infectious disease specialist should be considered.  
Depending on the presentation, consultation with a pulmonologist for bronchoscopy or a gastroenterologist for endoscopy may also be appropriate.  
In patients who develop recurrent adverse events in the setting of ongoing or prior immunosuppressant use, an opportunistic infection should be considered in the differential diagnosis.  
Consultation with a medical or surgical specialist, especially prior to an invasive diagnostic or therapeutic procedure, is recommended.
The frequency and severity of the related adverse events covered by these algorithms will depend on the immuno-oncology agent or regimen being used.  
Johns Hopkins University
investigator approval of protocol
gi adverse event management algorithm

Rule out non-inflammatory causes. If non-inflammatory cause is identified, treat accordingly and continue I-O therapy. Opiates/narcotics may mask symptoms of perforation. Infliximab should not be used in cases of perforation or sepsis.  
  
improvement is observed.  Lower bioavailability of oral corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.  
Johns Hopkins University
renal adverse event management algorithm
gi adverse event management algorithm

Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O therapy Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, once sustained clinical improvement is observed.  Lower bioavailability of oral corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.  
Bipolar Androgen Therapy and Nivolumab in mCRPC Johns Hopkins University
renal adverse event management algorithm
pulmonary adverse event management algorithm

Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O therapy. Evaluate with imaging  
  
corticosteroids.  
Johns Hopkins University
renal adverse event management algorithm
hepatic adverse event management algorithm

Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O therapy. Consider imaging for obstruction.  
  
improvement is observed.  Lower bioavailability of oral corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.  
*I-O therapy may be delayed rather than discontinued if AST/ALT ≤ 8 x ULN and T.bili ≤ 5 x ULN. *The recommended starting dose for grade 4 hepatitis is 2 mg/kg/day methylprednisolone  IV.  
Johns Hopkins University
renal adverse event management algorithm
endocrinopathy management algorithm

Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O therapy. Consider visual field testing, endocrinology consultation, and imaging.  
  
once sustained clinical improvement is observed.  Lower bioavailability of oral corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.  
Bipolar Androgen Therapy and Nivolumab in mCRPC
Johns Hopkins University
skin adverse event management algorithm
endocrinopathy management algorithm

Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O therapy.  
Grade of Rash
(NCI CTCAE v4)
Management Follow-up  
  
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, once sustained clinical improvement is observed.  Lower bioavailability of oral corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.  
*Refer to NCI CTCAE v4 for term-specific grading criteria.  
Johns Hopkins University
neurological adverse event management algorithm
endocrinopathy management algorithm

Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O therapy.  
  
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, oce sustained clinical improvement is observed.  Lower bioavailability of oral corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.  
| APPENDIX B: PERFORMANCE STATUS CRITERIA                                                                                                                                                  |                                                                          |                                                                           |                                                                        |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------|---------------------------------------------------------------------------|------------------------------------------------------------------------|
| ECOG Performance Status Scale                                                                                                                                                            | Karnofsky Performance Scale                                              |                                                                           |                                                                        |
| Grade                                                                                                                                                                                    | Description                                                              | %                                                                         | Description                                                            |
| 100                                                                                                                                                                                      | Normal, no complaints, no evidence  of disease.                          |                                                                           |                                                                        |
| Normal activity. Fully active, able to                                                                                                                                                   |                                                                          |                                                                           |                                                                        |
| 0                                                                                                                                                                                        | continue all predisease performance  without restriction.                | 90                                                                        | Able to carry on normal activity,  minor signs or symptoms of disease. |
| Symptoms, but ambulatory.  Restricted in physically strenuous  activity but ambulatory and able to  carry out work of a light or sedentary  nature (e.g. light housework, office  work). | 80                                                                       | Normal activity with effort, some  signs or symptoms of disease.          |                                                                        |
| 1                                                                                                                                                                                        | 70                                                                       | Cares for self, unable to carry on  normal activity or to do active work. |                                                                        |
| In bed < 50% of the time. Ambulatory  and capable of all self-care but unable  to carry out any work activities. Up  and about more than 50% of waking  hours.                           | 60                                                                       | Requires occasional assistance but is  able to care for most needs.       |                                                                        |
| 2                                                                                                                                                                                        | Requires considerable assistance and                                     |                                                                           |                                                                        |
| 50                                                                                                                                                                                       | frequent medical care.                                                   |                                                                           |                                                                        |
| 40                                                                                                                                                                                       | Disabled, requires special care and  assistance.                         |                                                                           |                                                                        |
| In bed > 50% of the time. Capable of                                                                                                                                                     |                                                                          |                                                                           |                                                                        |
| 3                                                                                                                                                                                        | only limited self-care, confined to bed  or chair > 50% of waking hours. | 30                                                                        | Severely disabled, hospitalization  indicated. Death not imminent.     |
| 20                                                                                                                                                                                       | Very sick, hospitalization indicated.  Death not imminent.               |                                                                           |                                                                        |
| 100% bedridden. Completely                                                                                                                                                               |                                                                          |                                                                           |                                                                        |
| 4                                                                                                                                                                                        | disabled, cannot carry on any selfcare, totally confined to bed or chair.                                                                          | 10                                                                        | Moribund, fatal processes  progressing rapidly.                        |
| 5                                                                                                                                                                                        | Dead.                                                                    | 0                                                                         | Dead.                                                                  |
neurological adverse event management algorithm
appendix c laboratory manual

Pathology will be reviewed and processed centrally at Johns Hopkins. Biopsy specimens will be handled and sampled in a uniform fashion. The lead pathologist at Johns Hopkins University, Dr. Angelo De Marzo, will perform the central review and prepare tissue for correlative analysis. For Outside Sites ONLY: Tumor tissue cores for FFPE will each be prepared into separate blocks (≥2 cores) and the cores for flash freezing will be combined *into* 1 block (≥2 cores). Specimens will be sent for prior review to the De Marzo *Laboratory* on dry ice to the following *address:*
De Marzo Laboratory Koch Cancer Research Building II 1550 Orleans Street, Room 138 Baltimore, Maryland 21231 Please email a copy of the Tissue Sample Information Form (Appendix G) and the shipment tracking number to the Lead Site coordinator on the day of shipment. Be sure to include a copy inside of the shipping *container.* Tumor Tissue *Specimens:*
5 unstained slides and 1 H&E slide representative of tumor collected during the Screening period only, will be prepared and sent to Foundation Medicine for FoundationOne testing. Tumor will be placed in the FoundationOne specimen kit and shipped to the following address by the De Marzo Laboratory: Foundation Medicine, Inc. 7010 Kit Creek Road Morrisville, NC 27560 Phone: 888.988.3639 20 unstained slides representative of tumor will be prepared from all collected biopsies and sent to the De Marzo Laboratory for PD-1, PD-L1, CD4, CD8, Ki-67, gamma-H2AX, 53BP1, and RAD51 analysis.  
5 unstained slides representative of tumor will be prepared from all collected biopsies and banked in the De Marzo Laboratory for optional tissue banking to be utilized for future research.  
JHU Only: Page Tracy Jones (3-3186) for pick-up, processing, and transport of all tumor tissue to the De Marzo Laboratory.  
MANAs/TAAs assay blood collection for JHU patients *ONLY:*
1. Blood will be drawn into ten 10mL purple top (EDTA) tubes for a total volume of 100mL for the MANAs/TAAs assay at C1D1, C4D1, and at progression (EOT).  
2. Tubes will be sent to the Johns Hopkins Immune Processing Core Lab for PBMC
processing & plasma isolation for immune studies.  
3. Call the Immune Processing Core Lab (410-283-0693) for pick-up, processing, and transport.  
4. Once processing is complete, the Immune Processing Core Lab will contact Eugene Shenderov, MD and/or Mark Markowski, MD within 24-48 hours for transfer to long-term storage.  
Processing Instructions of MANAs/TAAs assay blood *collection:*
1. Uncap purple tops and pour blood into 50mL conicals. 2. Spin conicals at 2500rpm for 15min, 4°C, decel on 1. 3. Collect plasma layer and immediately freeze in 2mL cryovials at -80°C; 1.5mL per vial.  
4. Dilute remaining blood 1 in 2 with PBS, gently mix up and down with a 10mL
pipette.  
5. Allow blood to sit at room temperature on a rocker for ~30min to bring up temperature.  
6. Split diluted blood so there is ~35mL in each 50mL conical. 7. Continue processing according to Leucosep protocol. 8. Spin at 2200rpm for 20 minutes with accel and decel on "1" or off, depending on the centrifuge.  
9. Collect the buffy coat layer into 50mL conicals, ensuring no more than 20mL of buffy coat layer goes into each conical.  
10. Fill up remaining volume in the tubes with PBS. 11. Spin at 1400rpm for 10min. 12. Decant supernatant, break up pellet, and add 10mL PBS to each tube. 13. Spin at 1000rpm for 10min. 14. Assess the pellet. If there are a lot of RBCs, remove a few microliters and add 4mL
ACK lysis buffer.  
15. Fill 50mL conical with PBS and spin for 5min at 1400rpm. 16. Continue to decant off supernatant, break up pellet, and resuspend in 10mL PBS
(30mL PBS for large blood draws or relevant volume depending on volume of blood received).  
17. Count cells, spin at 1400rpm for 5min, continue to decant off supernatant. 18. Resuspend PBMC in pre-chilled AIM V media at a concentration of 10x106 cells/mL. 19. Transfer 0.5mL aliquots (5x106 cells) to pre-labeled cryovials. Labels should contain patient lab ID, study number, time point, total number of cells, and date.  
20. Quickly add 0.5mL 10% AIM V to each vial and cap. Gently rotate upside down twice.  
21. Place in a slow freeze container at -80°C. Leave undisturbed overnight or for a minimum of 12 hours and a maximum of 24 hours.  
22. Transfer into liquid nitrogen for long-term storage.  
Chemokines Assay blood collection for JHU patients *ONLY:*
1. Blood will be drawn into one 10mL EDTA purple top tube at C1D1 predose, 3 hours post BAT injection on C1D1, 3 days after the first BAT injection (C1D4), C2D1 predose, and C7D1 predose.  
2. Tubes should be sent to the Denmeade Laboratory for PBMC processing & plasma isolation for chemokine studies.  
3. Call Marc Rosen (410-502-3825/443-275-8982/410-502-8810) or Mark Markowski, MD for pickup when collection is complete.  
4. The Denmeade Laboratory will process the specimens and transport them to the Immune Processing Core Lab for analysis.  
Processing instructions of Chemokines *assay:*
1. Uncap purple top tubes and transfer blood into 15mL conicals. 2. Spin conicals at 2500rpm for 15min, 4°C, decel on "1". 3. Collect plasma layer and immediately freeze in 2mL cryovials at -80°C; 1mL per vial.  
Rectal swab collection for JHU patients *ONLY:*
1. Rectal swabs will be collected via culture swab predose at C1D1, C4D1, and at C7D1. 2. Culture swabs will be sent to the Sfanos Laboratory for processing. 3. Call Sarah Ernst (443-386-8057) for pickup when collection is complete.  
Collection instructions of Rectal swab *cultures:*
1. Write the subject ID, cycle visit, and the date and time of collection on the culture tubes for identification purposes.  
2. Gently insert each swab about 1.2 inches (3cm) into anus and swirl the swab in a circular motion for 15-30 seconds.  
3. Slowly remove each swab from anus without touching the skin and insert back into the tube.  
| 17-AAG    | 17-allylamino-17-demethoxygeldanamycin                                                                     |
|-----------|------------------------------------------------------------------------------------------------------------|
| 17-DMAG   | 17-dimethylaminoethylamino-17-demethoxygeldanamycin                                                        |
| 2-MPPA    | 2-(3-mercaptopropyl) Pentanedioic acid                                                                     |
| AdEERS    | Adverse Event Expedited Reporting System                                                                   |
| ADR       | Adverse drug reaction                                                                                      |
| ADT       | Androgen-deprivation therapy                                                                               |
| AE        | Adverse event                                                                                              |
| AGA       | Androgenetic alopecia                                                                                      |
| AI        | Accumulation index                                                                                         |
| ALT       | Alanine aminotransferase                                                                                   |
| AML       | Acute myeloid leukemia                                                                                     |
| ANC       | Absolute neutrophil count                                                                                  |
| ANOVA     | Analysis of variance                                                                                       |
| APTT      | Activated partial thromboplastin time                                                                      |
| AR        | Androgen receptor                                                                                          |
| ASAEL     | Agent Specific Adverse Event List                                                                          |
| AST       | Aspartate aminotransferase                                                                                 |
| AUC       | Area under the plasma concentration-time curve                                                             |
| AUC(INF)  | Area under the concentration-time curve from time zero extrapolated to infinite  time                      |
| AUC(0-T)  | Area under the concentration-time curve from time zero to the time of the last  quantifiable concentration |
| AUC(TAU)  | Area under the concentration-time curve in one dosing interval                                             |
| AUMC(INF) | Area under the moment concentration time curve extrapolated to infinity                                    |
| A-V       | Atrioventricular                                                                                           |
| -HCG     | Beta-human chorionic gonadotrophin                                                                         |
| %BE       | Percent biliary excretion                                                                                  |
| bid       | bis in die (twice a day)                                                                                   |
| BLQ       | Below limit of quantification                                                                              |
| BMI       | Body mass index                                                                                            |
| BP        | Blood pressure                                                                                             |
| BSA       | Body Surface Area                                                                                          |
| BUN       | Blood urea nitrogen                                                                                        |
| C         | Celsius                                                                                                    |
| Ca++      | Calcium                                                                                                    |
| caBIG     | Cancer Biomedical Informatics Grid                                                                         |
| CAEPR     | Comprehensive Adverse Event and Potential Risks                                                            |
| CALGB     | Cancer and Leukemia Group B                                                                                |
neurological adverse event management algorithm
appendix d glossary of abbreviations

| CBC     | Complete blood count                                   |
|---------|--------------------------------------------------------|
| CCC     | Clinical Consortium Committee                          |
| CCD     | Central Consortium Database                            |
| CDE     | Common data element                                    |
| CDUS    | Clinical Data Update System                            |
| CFR     | Code of Federal Regulations                            |
| CI      | Confidence interval                                    |
| Cl-     | Chloride                                               |
| Clcr    | Creatinine clearance                                   |
| CLNR    | Nonrenal clearance                                     |
| CLR     | Renal clearance                                        |
| CLT     | Total body clearance                                   |
| CLT/F   | Apparent total body clearance                          |
| Cm      | Centimeter                                             |
| Cmax    | Maximum plasma concentration                           |
| Cmin    | Trough observed concentration                          |
| COSTART | Coding Symbols for Thesaurus of Adverse Reaction Terms |
| CNS     | Central nervous system                                 |
| CR      | Complete response                                      |
| CRC     | Clinical Research Center                               |
| CRDB    | Clinical Research Database                             |
| CRF     | Case report form                                       |
| CRMIS   | Clinical Research Management Information System        |
| CRPC    | Castration resistant prostate cancer                   |
| CT      | Computerized tomography                                |
| CTC     | Circulating tumor cell                                 |
| CTCAE   | Common Terminology Criteria for Adverse Events         |
| CTEP    | Cancer Therapy Evaluation Program                      |
| CTMS    | Clinical Trials Monitoring Service                     |
| CTO     | Clinical Trials Office                                 |
| CV      | Coefficient of variation                               |
| CYP     | Cytochrome p-450                                       |
| DCTD    | Division of Cancer Treatment and Diagnosis             |
| DEV     | Deviation from the nominal value                       |
| %DEV    | Percent deviation                                      |
| dL      | Deciliter                                              |
| DHEA    | Dehydroepiandrosterone                                 |
| DHEA-S  | Dehydroepiandrosterone sulfate                         |
| DHT     | Dihydrotestosterone                                    |
| DLT     | Dose-limiting toxicity                                 |  
| DSM     | Data and safety monitoring                                 |
|---------|------------------------------------------------------------|
| EA      | Extent of absorption                                       |
| ECG     | Electrocardiogram                                          |
| ECOG    | Eastern Cooperative Oncology Group                         |
| EDC     | Electronic data capture                                    |
| EEG     | Electroencephalogram                                       |
| EKG     | Electrocardiogram                                          |
| EORTC   | European Organization for Research and Treatment of Cancer |
| ESF     | Eligibility screening form                                 |
| ESR     | Expedited safety report                                    |
| F       | Bioavailability                                            |
| FDA     | Food and Drug Administration                               |
| FDG-PET | 2-[18F]fluoro-2-deoxyglucose positron emitting tomography  |
| FDHT    | 18-fluoro-dehydrotestosterone                              |
| %FE     | percent fecal excretion                                    |
| FISH    | Fluorescence in situ hybridization                         |
| FSH     | Follicle stimulating hormone                               |
| GAPDH   | Glyseraldehayde-3-phophate dehydrogenase                   |
| GC      | Gas chromatography                                         |
| GCP     | Good clinical practice                                     |
| GCPII   | Glutamate carboxypeptidase II enzyme                       |
| GFR     | Glomerular filtration rate                                 |
| GGT     | Gamma-glutamyl transferase                                 |
| GnRH    | Gonadotropin-releasing hormone                             |
| HAT     | Histone acetyltransferases                                 |
| HCO3-   | Bicarbonate                                                |
| HDAC    | Histone deacetylase                                        |
| HIPAA   | Health Insurance Portability and Accountability Act        |
| HIV     | Human immunodeficiency virus                               |
| HL7     | American National Standards Institute's Health Level Seven |
| HPF     | High power field                                           |
| HPLC    | High-performance liquid chromatography                     |
| HR      | Heart rate                                                 |
| HRPC    | Hormone-refractory prostate cancer                         |
| HRT     | Hormone replacement therapy                                |
| HSP90   | Heat-shock protein 90                                      |
| ICD     | International Classification of Diseases                   |
| ICH     | International Conference on Harmonization                  |
| IEC     | Independent Ethics Committee                               |
| IHC     | Immunochemical                                             |  
| IM       | Intramuscular                                                   |
|----------|-----------------------------------------------------------------|
| IMSL     | International Mathematical Statistical Library                  |
| IND      | Investigational new drug                                        |
| INR      | International normalized ratio                                  |
| IP       | Intraperitoneal                                                 |
| IRB      | Institutional Review Board                                      |
| ITT      | Intent-to-treat population                                      |
| IV       | Intravenous                                                     |
| K        | Slope of the terminal phase of the log concentration-time curve |
| K+       | Potassium                                                       |
| K3EDTA   | Potassium ethylenediaminetetraacetic acid                       |
| KLK1     | Kallikrein 1                                                    |
| LBD      | Ligand-binding domain                                           |
| LC       | Liquid chromatography                                           |
| LCM      | Laser capture microdissection                                   |
| LC-MS    | Liquid chromatography/mass spectrometry                         |
| LD       | Longest diameter                                                |
| LDH      | Lactate dehydrogenase                                           |
| LLQ      | Lower limit of quantitation                                     |
| ln       | Natural logarithm                                               |
| LOCF     | Last observation carried forward                                |
| LOI      | Letter of intent                                                |
| LPF      | Low power field                                                 |
| MAD      | Maximum administered dose                                       |
| MDS      | Myelodysplasia                                                  |
| MedDRA   | Medical Dictionary for Regulatory Activities                    |
| MIC      | Minimum inhibitory concentration                                |
| MMP      | Matrix metalloproteinase                                        |
| MRI      | Magnetic resonance imaging                                      |
| MRT      | Mean residence time                                             |
| MRT(INF) | Mean residence time adjusted for infusion time                  |
| MRT(PO)  | Mean residence time following oral administration               |
| MRT(SS)  | Mean residence time at steady-state                             |
| MSKCC    | Memorial Sloan-Kettering Cancer Center                          |
| MS       | Mass spectrometry                                               |
| MTD      | Maximum tolerated dose                                          |
| N        | Number of subjects or observations                              |
| NA       | Not applicable                                                  |
| N/A      | Not available                                                   |
| NBN      | National Biospecimen Network                                    |  
| NCI     | National Cancer Institute                                    |
|---------|--------------------------------------------------------------|
| NIH     | National Institutes of Health                                |
| NOAEL   | No observed adverse effect level                             |
| NOS     | Not otherwise specified                                      |
| NSAID   | Nonsteroidal anti-inflammatory drug                          |
| NTX     | N-telopeptide cross-link                                     |
| NVB     | Neurovascular bundle                                         |
| OCR     | Office of Clinical Research at MSKCC                         |
| PCCTC   | Prostate Cancer Clinical Trials Consortium                   |
| PCRP    | Department of Defense Prostate Cancer Research Program       |
| PD      | Progressive disease                                          |
| PET     | Positron emission tomography                                 |
| PFS     | Progression-free survival                                    |
| PI      | Principal investigator                                       |
| PIN     | Prostatic intraepithelial neoplasia                          |
| PK      | Pharmacokinetics                                             |
| PMB     | Pharmaceutical Management Branch                             |
| PO      | per os (by mouth)                                            |
| PR      | Partial response                                             |
| PSA     | Prostate-specific antigen                                    |
| PSA-DT  | Prostate-specific antigen doubling time                      |
| PSMA    | Prostate specific membrane antigen                           |
| PT      | Prothrombin time                                             |
| PTT     | Partial thromboplastin time                                  |
| QC      | Quality control                                              |
| qd      | quaque die (every day)                                       |
| qRT-PCR | Quantitative reverse transcription-polymerase chain reaction |
| QOL     | Quality of life                                              |
| RBC     | Red blood cell                                               |
| RC      | Research Council                                             |
| RDBMS   | Relational Database Management System                        |
| RDRC    | Radioactive Drug Research Committee                          |
| RECIST  | Response Evaluation Criteria in Solid Tumors                 |
| RP      | Radical prostatectomy                                        |
| RPC     | eResearch Program Coordinator                                |
| RSA     | Research Study Assistant                                     |
| RSD     | Relative standard deviation                                  |
| %RSD    | Percent relative standard deviation                          |
| SAE     | Serious adverse event                                        |
| SAHA    | Suberoylanilide hydroxamic acid                              |  
| SC        | Subcutaneous                                                                                                           |
|-----------|------------------------------------------------------------------------------------------------------------------------|
| SD        | Standard deviation                                                                                                     |
| SD        | Stable disease                                                                                                         |
| Seq       | Sequence                                                                                                               |
| SHBG      | Sex hormone binding globulin                                                                                           |
| SKI       | Sloan-Kettering Institute for Cancer Research                                                                          |
| SMD       | Stable metabolic disease                                                                                               |
| SOP       | Standard Operating Procedures                                                                                          |
| SPORE     | Specialized Programs of Research Excellence                                                                            |
| STAR      | Symptom Tracking and Reporting                                                                                         |
| SUV       | Standardized uptake value                                                                                              |
| t         | Temperature                                                                                                            |
| t1/2      | Terminal half-life                                                                                                     |
| T         | Time                                                                                                                   |
| TAUC(TAU) | Trapezoidal area under the concentration-time curve in one dosing interval                                             |
| TAUC(0-T) | Trapezoidal area under the concentration-time curve from time zero to the time of  the last quantifiable concentration |
| TDP       | Time to disease progression                                                                                            |
| TGP       | Prostate-specific transglutaminase                                                                                     |
| tid       | ter in die (3 times a day)                                                                                             |
| TMA       | Tissue microarray                                                                                                      |
| Tmax      | Time of maximum observed concentration                                                                                 |
| TMPRSS2   | Transmembrane protease, serine 2                                                                                       |
| TNM       | Tissue, lymph node, metastases                                                                                         |
| TX        | Treatment                                                                                                              |
| ULN       | Upper limit of normal                                                                                                  |
| ULQ       | Upper limit of quantitation                                                                                            |
| UR        | Urinary recovery                                                                                                       |
| VEGF      | Vascular endothelial growth factor                                                                                     |
| Vss       | Volume of distribution at steady-state                                                                                 |
| WBC       | White blood cell                                                                                                       |
| WHO       | World Health Organization                                                                                              |
neurological adverse event management algorithm
appendix e acceptable birth control

Subjects with partners of childbearing potential, who are sexually active, must agree to the use of TWO highly effective forms of contraception (defined as a method that can achieve a failure rate of < 1% per year when used consistently and correctly) in combination [as listed below], throughout the period of taking study treatment and for at least 7 months after last dose of study drug(s), or they must totally/truly abstain from any form of sexual intercourse [see below]. Highly Effective Non-hormonal birth control methods include:
Total sexual abstinence. Abstinence must continue for the total duration of study treatment and for at least 1 month after the last dose. Periodic abstinence (e.g. calendar ovulation, symptothermal post ovulation methods) and withdrawal are not acceptable methods of contraception.  
Vasectomised sexual partner PLUS male condom. With participant assurance that partner received post-vasectomy confirmation of azospermia.  
Tubal occlusion PLUS male condom. IUD PLUS male condom. Provided coils are copper-banded.  
Highly Effective hormonal methods:
Normal and low dose combined oral pills PLUS male condom. Cerazette (desogestrel) PLUS male condom. Cerazette is currently the only highly efficacious progesterone based pill.  
Hormonal shot or injection (e.g. Depo-Provera) PLUS male condom. Etonogestrel implants (e.g. Implanon, Norplant) PLUS male condom. Norelgestromin / EE transdermal system PLUS male condom. Intrauterine system [IUS] device (e.g. levonorgestrel releasing IUS - Mirena®) PLUS male condom.  
Intravaginal device (e.g. EE and etonogestrel) PLUS male condom.
appendix f actions required in
1. introduction

During the course of the study the Investigator will remain vigilant for increases in liver biochemistry. The investigator is responsible for determining whether a patient meets potential Hy's Law (PHL) criteria at any point during the study. The Investigator participates, together with BMS clinical project representatives, in review and assessment of cases meeting PHL criteria to agree whether Hy's Law (HL) criteria are met. HL criteria are met if there is no alternative explanation for the elevations in liver biochemistry other than Drug Induced Liver Injury (DILI) caused by the Investigational Medicinal Product (IMP). The Investigator is responsible for recording data pertaining to PHL/HL cases and for reporting Adverse Events (AE) and Serious Adverse Events (SAE) according to the outcome of the review and assessment in line with standard safety reporting processes.
appendix f actions required in
2. definitions potential hy's law

Aspartate Aminotransferase (AST) or Alanine Aminotransferase (ALT) ≥ 3x Upper Limit of Normal (ULN) and Total Bilirubin (TBL) ≥ 2xULN at any point during the study irrespective of an increase in Alkaline Phosphatase (ALP).
appendix f actions required in
hy's law (hl)

AST or ALT ≥ 3xULN and TBL ≥ 2xULN, where no other reason, other than the IMP, can be found to explain the combination of increases, e.g. elevated ALP indicating cholestasis, viral hepatitis, another drug.  
3. IDENTIFICATION OF POTENTIAL HY'S LAW *CASES* In order to identify cases of PHL it is important to perform a comprehensive review of laboratory data for any patient who meets any of the following identification criteria in isolation or in combination:
- ALT ≥ 3xULN - AST ≥ 3xULN - TBL ≥ 2xULN
The Investigator will without delay review each new laboratory report and if the identification criteria are met will:
- Determine whether the patient meets PHL criteria (see Section 2 of this Appendix for definition) by reviewing laboratory reports from all previous visits.  
- Promptly enter the laboratory data into the laboratory CRF.
appendix f actions required in
4. follow-up

Potential Hy's Law Criteria not met If the patient does not meet PHL criteria the Investigator will:
- Perform follow-up on subsequent laboratory results according to the guidance provided in the Clinical Study Protocol.  
Potential Hy's Law Criteria met If the patient does meet PHL criteria the Investigator will:
- Notify the BMS representative who will then inform the central Study Team. - The Study Physician contacts the Investigator, to provide guidance, discuss and agree an approach for the study patients' follow-up and the continuous review of data. Subsequent to this contact the Investigator will:
Monitor the patient until liver biochemistry parameters and appropriate clinical symptoms and signs return to normal or baseline levels, or as long as medically indicated.  
Investigate the etiology of the event and perform diagnostic investigations as discussed with the Study Physician.  
Complete the three Liver CRF Modules as information becomes available. If at any time (in consultation with the Study Physician) the PHL case meets serious criteria, report it as an SAE using standard reporting procedures.
appendix f actions required in
5. review and assessment of

The instructions in this Section should be followed for all cases where PHL criteria are met. No later than 3 weeks after the biochemistry abnormality was initially detected, the Study Physician contacts the Investigator in order to review available data and agree on whether there is an alternative explanation for meeting PHL criteria other than DILI caused by the IMP. BMS and the Principal Investigator will also be involved in this review together with other subject matter experts as appropriate. According to the outcome of the review and assessment, the Investigator will follow the instructions below: If there is an agreed alternative explanation for the ALT or AST and TBL elevations, a determination of whether the alternative explanation is an AE will be made and subsequently whether the AE meets the criteria for a SAE:
- If the alternative explanation is not an AE, record the alternative explanation on the appropriate CRF.  
- If the alternative explanation is an AE/SAE, record the AE/SAE in the CRF accordingly and follow BMS standard processes.  
If it is agreed that there is no explanation that would explain the ALT or AST and total bilirubin level elevations other than the IMP:
- Report an SAE (report term 'Hy's Law') according to BMS standard processes.  
The 'Medically Important' serious criterion should be used if no other serious criteria apply.  
As there is no alternative explanation for the HL case, a causality assessment of
"related" should be assigned.  
If, there is an unavoidable delay of over 3 weeks in obtaining the information necessary to assess whether or not the case meets the criteria for HL, then it is assumed that there is no alternative explanation until such time as an informed decision can be made:
- Report an SAE (report term "Potential Hy's Law") applying serious criteria and causality assessment as per above.  
- Continue follow-up and review according to agreed plan. Once the necessary supplementary information is obtained, repeat the review and assessment to determine whether HL criteria are met. Update the SAE report according to the outcome of the review.
appendix f actions required in
6. actions required for repeat

This section is applicable when a patient meets PHL criteria on study treatment and has already met PHL criteria at a previous on study treatment visit. The requirement to conduct follow-up, review and assessment of a repeat occurrence(s) of PHL is based on the nature of the alternative cause identified for the previous occurrence. The investigator should determine the cause for the previous occurrence of PHL criteria being met and answer the following question:
- Was the alternative cause for the previous occurrence of PHL criteria being met chronic or progressing malignant disease?  
If No: follow the process described in Section 4 of this Appendix. If Yes: Determine if there has been a significant change in the patient's condition\#
compared with when PHL criteria were previously met.  
If there is no significant change no action is required. If there is a significant change follow the process described in Section 4 of this Appendix.  
A "significant" change in the patient's condition refers to a clinically relevant change in any of the individual liver biochemistry parameters (ALT, AST or total bilirubin) in isolation or in combination, or a clinically relevant change in associated symptoms. The determination of whether there has been a significant change will be at the discretion of the Investigator, this may be in consultation with the Study Physician if there is any uncertainty.
appendix f actions required in
7. references

FDA Guidance for Industry (issued July 2009) 'Drug-induced liver injury: Premarketing clinical evaluation': http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/U CM174090.pdf J1812 - COMbination of Bipolar Androgen Therapy and Nivolumab in Men with Metastatic Castration-Resistant Prostate Cancer [COMBAT-CRPC]
Johns Hopkins University Multi-center Phase II Clinical Trial PI: Mark Markowski, MD, Ph.D
Appendix G: Tumor Sample Information Form Subject No.: ___________________________ Site No.: ______________________
Study Visit: Screening Period Cycle 4 Day 1 Progression/EOT
Date of Collection: ____________________
FFPE Tissue: No. of cores: _____________________
Consent obtained to allow storage of biospecimens for Future Research? Yes No Flash Frozen Tissue:
No. of cores: ______________________ Not applicable for site Label all cores and/or containers with the Fixative used (i.e. FFPE, Flash Frozen),
Subject ID \#, Cycle visit, & Date of collection.  
Shipping Address:
De Marzo Laboratory Koch Cancer Research Building II
1550 Orleans Street, Room 138 Baltimore, MD 21231 Please email a copy of this form and the shipment tracking number to the Lead Site coordinator on the day of shipment. Include a copy inside the shipping container.  
All tumor specimens should be shipped on dry ice.