TLR9 Agonist SD-101, Anti-OX40 Antibody BMS 986178, and Radiation Therapy in Treating Patients With Low-Grade B-Cell Non-Hodgkin Lymphomas

PRIMARY OBJECTIVES:

I. To determine the safety and tolerability of TLR9 agonist SD-101 (SD-101) in combination
with anti-OX40 antibody BMS 986178 (BMS-986178) and local low-dose radiation in patients with
low-grade B-cell lymphoma. Adverse events and grades to be assessed by Common Terminology
Criteria for Adverse Events (CTCAE) II. To determine the recommended phase 2 dose (RP2D) of
BMS-986178 in combination with intratumoral SD-101 and radiation in patients with low-grade
B-cell lymphoma.

SECONDARY OBJECTIVES:

I. To evaluate preliminary efficacy by assessing overall response rate and progression-free
survival after treatment with intratumoral SD-101 in combination with BMS-986178 and
radiation in patients with low-grade B-cell lymphoma.

OUTLINE: This is a phase I study of the combination of TLR9 agonist SD-101, anti-OX40
antibody BMS 986178, and local low-dose radiation therapy.

Patients receive radiation therapy on days 1-2, TLR9 agonist SD-101 intratumorally on days 2,
9, 16, 23, and 30, and anti-OX40 antibody BMS-986178 intravenously (IV) on days 3, 30, 58,
86, 114, and 142 in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3-6 months for 72 weeks.

Inclusion Criteria:

- Biopsy confirmed low-grade B-cell lymphoma, excluding gastric MALT lymphoma, high-risk
mantle cell lymphoma, and currently transformed lymphoma

- Patients must have at least one site of disease (cervical, axillary, inguinal, or
subcutaneous) that is accessible for intratumoral injection of SD-101 (diameter ≥10mm)
percutaneously and presents a low risk for complications from direct injections.

- Patients must have at least one site of measurable disease, other than the injection
site, which is not included in the radiation field

- Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1

- Absolute neutrophil count (ANC) >= 1000/mm^3 independent of growth factor support

- Platelets: >= 100,000/mm^3 or >= 50,000/mm^3 if known or suspected bone marrow
involvement, independent of transfusion support in either situation

- Hemoglobin: >= 8 g/dL (may be transfused)

- Creatinine: Creatinine clearance > 25 ml/min

- Aspartate aminotransferase (AST)/alanine aminotransferase (ALT): =< 3 x upper limit of
normal (ULN)

- Bilirubin: =< 1.5 x ULN (except for subjects with Gilbert's Syndrome or of non-hepatic
cause)

- Must be at least 4 weeks since treatment with standard or investigational
chemotherapy, biochemotherapy, surgery, radiation, cytokine therapy, any monoclonal
antibodies or immunotherapy, and recovered from any clinically significant toxicity
experienced during treatment

- Women of childbearing potential and men who are sexually active must be practicing a
highly effective method of birth control during and after the study consistent with
local regulations regarding the use of birth control methods for subjects
participating in clinical trials; men must agree to not donate sperm during and after
the study; for sexually active women of childbearing potential, these restrictions
apply for 5 months after the last dose of study drug; for sexually active men, these
restrictions apply for 7 months after the last dose of study drug

- Women of childbearing potential must have a negative serum (beta-human chorionic
gonadotropin [beta-hCG]) or urine pregnancy test at screening, within 24 hours of the
first dose of anti-OX40 antibody, and every four weeks while on study treatment; women
who are pregnant or breastfeeding are ineligible for this study

- Life expectancy greater than 3 months

- Ability to comply with the treatment schedule

- Ability to understand and willingness to sign a written informed consent document

Exclusion Criteria:

- Currently transformed lymphoma, high-risk mantle cell lymphoma, or gastric MALT
lymphoma.

- Need for immediate treatment or cytoreduction.

- No easily accessible site for direct percutaneous injection with low-risk for
potential complications.

- Autoimmune disease requiring treatment within the last 5 years including systemic
lupus erythematosus, rheumatoid arthritis, multiple sclerosis, Sjogren's syndrome,
autoimmune thrombocytopenia, uveitis, or other if clinically significant

- Major surgery within 4 weeks of enrollment, or a wound that has not fully healed

- Vaccinated with live, attenuated vaccines within 4 weeks of enrollment

- Known history of human immunodeficiency virus (HIV) or active hepatitis C virus or
active hepatitis B virus infection or any uncontrolled active systemic infection

- Known central nervous system (CNS) lymphoma

- Patients with a history of prior malignancy with the exception of non-melanoma skin
cancer, carcinoma in situ of the cervix, in situ carcinoma of the bladder, or other
malignancy that has undergone potentially curative therapy with no evidence of disease
for the last > 2 years and that is deemed by the investigator to be a low risk for
recurrence

- History of significant allergic reactions attributed to compounds of similar
composition to SD-101 or BMS-986178

- Treatment with an immunosuppressive regimen of corticosteroids or other
immunosuppressive medication (e.g., methotrexate, rapamycin) within 30 days of study
treatment; Note: patients may take up to 5 mg of prednisone or equivalent daily;
topical and inhaled corticosteroids in standard doses are allowed

- Significant cardiovascular disease (i.e. New York Heart Association [NYHA] class 3
congestive heart failure; myocardial infarction within the past 6 months; unstable
angina; coronary angioplasty with the past 6 months; uncontrolled atrial or
ventricular cardiac arrhythmias)

- Pregnant or breast feeding

- Any other medical history, including laboratory results, deemed by the investigator
likely to interfere with their participation in the study, or to interfere with the
interpretation of the results