Randomized Phase 2 Trial of ACP-196 and Pembrolizumab Immunotherapy Dual CHECKpoint Inhibition In Platinum Resistant Metastatic Urothelial Carcinoma (RAPID CHECK Study)
Phase: PHASE2
Conditions: Metastatic Urothelial Carcinoma
Sponsor: Acerta Pharma BV

Product: Acalabrutinib (ACP-196) 
Date: 23 May 2016 
Protocol: ACE-ST-005 
 
 
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PROTOCOL 
TITLE: 
Randomized Phase 2 Trial of ACP-196 and 
Pembrolizumab Immunotherapy Dual CHECKpoint 
Inhibition In Platinum Resistant Metastatic Urothelial 
Carcinoma (RAPID CHECK study) 
PROTOCOL NUMBER: 
ACE-ST-005 
STUDY DRUG: 
Acalabrutinib (ACP-196) and KEYTRUDA® 
(pembrolizumab) 
IND NUMBER: 
124755 
MEDICAL MONITOR: 
 
 
 
 
DCRI COORDINATING 
CENTER CONTACT: 
 
 
 
 
 
SPONSOR: 
Acerta Pharma BV 
Kloosterstraat 9 
5349 AB Oss 
The Netherlands 
PROTOCOL DATE: 
Version 0.1 – 03 January 2015 
AMENDMENT 1: 
Version 1.0 – 27 April 2015 
AMENDMENT 2: 
Version 2.0 – 22 July 2015 
AMENDMENT 3: 
Version 3.0 – 13 January 2016 
AMENDMENT 4: 
Version 4.0 – 23 May 2016 
 
Confidentiality Statement 
This document contains proprietary and confidential information of Acerta Pharma BV 
that must not be disclosed to anyone other than the recipient study staff and members 
of the institutional review board (IRB)/independent ethics committee (IEC). This 
information cannot be used for any purpose other than the evaluation or conduct of 
the clinical investigation without the prior written consent of Acerta Pharma BV.  

Product: Acalabrutinib (ACP-196) 
Date: 23 May 2016 
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PROTOCOL APPROVAL PAGE 
 
I have carefully read Protocol ACE-ST-005 entitled “Randomized Phase 2 Trial of 
ACP-196 and Pembrolizumab Immunotherapy Dual Checkpoint Inhibition in Platinum 
Resistant Metastatic Urothelial Carcinoma”.  I agree to conduct this study as outlined 
herein and in compliance with Good Clinical Practices (GCP) and all applicable 
regulatory requirements.  Furthermore, I understand that the sponsor, Acerta Pharma, 
and the IRB/ IEC must approve any changes to the protocol in writing before 
implementation. 
I agree not to divulge to anyone, either during or after the termination of the study, 
any confidential information acquired regarding the investigational product and 
processes or methods of Acerta Pharma.  All data pertaining to this study will be 
provided to Acerta Pharma.  The policy of Acerta Pharma requires that any 
presentation or publication of study data by clinical investigators be reviewed by 
Acerta Pharma, before release, as specified in the protocol. 
 
Principal Investigator’s Signature 
Date 
 
 
Print Name 
 
 
 

Product: Acalabrutinib (ACP-196) 
Date: 23 May 2016 
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TABLE OF CONTENTS 
SUMMARY OF AMENDMENT 4 ...................................................................... 8 
1.0 
BACKGROUND INFORMATION ........................................................ 29 
1.1 
Urothelial Carcinoma ........................................................................... 29 
1.2 
The Role of Stroma in Urothelial Carcinoma........................................ 29 
1.3 
Programmed Death Ligand/Receptor Interactions in Urothelial 
Carcinoma ........................................................................................... 30 
1.4 
Bruton Tyrosine Kinase Inhibition in Cancer ........................................ 31 
1.5 
A Case for Combination BTK and Checkpoint Blockade ..................... 36 
1.6 
Acalabrutinib ........................................................................................ 37 
1.6.1 
Mechanism of Action .............................................................. 38 
1.6.2 
Safety Pharmacology ............................................................. 38 
1.6.3 
Drug-drug Interaction Potential .............................................. 38 
1.7 
In Vivo General Toxicology – Acalabrutinib ......................................... 39 
1.8 
Clinical Experience – Acalabrutinib ...................................................... 39 
1.8.1 
Pharmacokinetics and Pharmacodynamics of Acalabrutinib .. 40 
1.8.2 
Acalabrutinib in CLL ............................................................... 41 
1.9 
KEYTRUDA (Pembrolizumab) ............................................................. 42 
1.10 
Benefit/Risk .......................................................................................... 42 
2.0 
STUDY OBJECTIVES ......................................................................... 43 
2.1 
Primary Objectives: .............................................................................. 43 
2.2 
Secondary Objectives: ......................................................................... 43 
2.3 
Exploratory Objectives ......................................................................... 43 
3.0 
STUDY DESIGN .................................................................................. 43 
3.1 
Study Parameters ................................................................................ 46 
3.1.1 
Safety Parameters .................................................................. 46 
3.1.2 
Pharmacodynamic and Biomarker Parameters ...................... 47 
3.1.3 
Efficacy Parameters ............................................................... 47 
3.2 
Rationale for Study Design and Dosing Regimen ................................ 48 
3.3 
Selection of Study Population .............................................................. 50 
3.3.1 
Inclusion Criteria..................................................................... 50 
3.3.2 
Exclusion Criteria ................................................................... 51 
3.3.3 
Replacement of Subjects ....................................................... 53 
3.3.4 
Enrollment and Randomization Procedures ........................... 53 
3.4 
Study Drugs ......................................................................................... 53 
3.4.1 
Premedications....................................................................... 53 
3.4.2 
Formulation, Packaging, and Storage .................................... 54 
3.4.3 
Administration of Study Drug .................................................. 54 

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3.4.4 
Assuring Subject Compliance ................................................ 55 
3.5 
Study Treatment Schedule .................................................................. 56 
3.5.1 
Arm 1 – Pembrolizumab Monotherapy ................................... 56 
3.5.2 
Arm 2 – Combination Treatment ............................................ 56 
3.6 
Duration of Therapy ............................................................................. 56 
3.7 
Assessment of Dose-Limiting Toxicity (DLT) ....................................... 56 
3.8 
Dosing Delays and Modifications ......................................................... 57 
3.8.1 
Dose Modifications for Pembrolizumab .................................. 58 
3.8.2 
Supportive Care Guidelines for Pembrolizumab .................... 59 
3.9 
Concomitant Therapy .......................................................................... 62 
3.9.1 
Permitted Concomitant Therapy ............................................. 62 
3.9.2 
Prohibited or Restricted Concomitant Therapy ....................... 63 
3.10 
Precautions .......................................................................................... 63 
3.10.1 Transaminase Elevations for Acalabrutinib in Combination with 
Pembrolizumab ...................................................................... 63 
3.10.2 Hepatitis B Reactivation ......................................................... 64 
3.10.3 Dietary Restrictions ................................................................ 64 
3.10.4 Drug-drug Interactions ............................................................ 64 
3.10.5 Surgery ................................................................................... 65 
3.10.6 Reproductive Toxicity ............................................................. 65 
3.10.7 Overdose Instructions ............................................................ 67 
3.11 
Treatment After Initial Radiologic Progression ..................................... 68 
3.12 
Withdrawal of Subjects From Study Treatment .................................... 70 
3.13 
Reasons for Study Exit ........................................................................ 71 
3.14 
Data and Safety Monitoring ................................................................. 72 
4.0 
STUDY ACTIVITIES AND ASSESSMENTS ....................................... 72 
4.1 
Description of Procedures.................................................................... 72 
4.1.1 
Informed Consent ................................................................... 72 
4.1.2 
Medical History ....................................................................... 72 
4.1.3 
Adverse Events ...................................................................... 73 
4.1.4 
Concomitant Medications and Therapy .................................. 73 
4.1.5 
Confirmation of Eligibility ........................................................ 73 
4.1.6 
ECOG Performance Status .................................................... 73 
4.1.7 
Physical Examination, Vital Signs, Height & Weight ............... 73 
4.1.8 
Electrocardiogram .................................................................. 73 
4.1.9 
Urine or Serum Pregnancy Test ............................................. 74 
4.1.10 Hematology ............................................................................ 74 
4.1.11 Coagulation ............................................................................ 74 
4.1.12 Serum Chemistry .................................................................... 74 

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4.1.13 Amylase and Lipase ............................................................... 75 
4.1.14 Thyroid Panel ......................................................................... 75 
4.1.15 Hepatitis B and C Testing ....................................................... 75 
4.1.16 Urinalysis ................................................................................ 75 
4.1.17 T/B/NK Cell Count .................................................................. 76 
4.1.18 Serum Immunoglobulin .......................................................... 76 
4.1.19 Pharmacodynamics/Pharmacokinetics and Biomarker 
Studies ................................................................................... 76 
4.1.20 Tumor Assessments ............................................................... 77 
4.1.21 Early Termination Visit ........................................................... 77 
4.1.22 Study Drug Accountability ...................................................... 77 
4.2 
Investigator’s Assessment of Response to Treatment ......................... 78 
4.2.1 
Determination of Response at Each Timepoint (RECIST) ...... 79 
4.2.2 
Confirmation of Tumor Status and Determination of Best 
Overall Response (RECIST) .................................................. 79 
4.2.3 
Immune-related Response Criteria (irRECIST) ...................... 80 
4.3 
Safety Follow-up Visit .......................................................................... 81 
4.4 
Survival ................................................................................................ 81 
4.5 
Missed Evaluations .............................................................................. 81 
5.0 
STATISTICAL METHODS OF ANALYSIS .......................................... 81 
5.1 
General Considerations ....................................................................... 81 
5.2 
Definition of Analysis Populations ........................................................ 82 
5.3 
Missing Data Handling ......................................................................... 82 
5.4 
Endpoint Data Analysis ........................................................................ 82 
5.4.1 
Safety Endpoint ...................................................................... 82 
5.4.2 
Demographics and Baseline Characteristics .......................... 83 
5.4.3 
Study Treatment Administration and Compliance .................. 83 
5.4.4 
Analysis of Efficacy Parameters ............................................. 83 
5.4.5 
PD or Biomarker Analyses ..................................................... 84 
5.5 
Futility and Toxicity Monitoring ............................................................. 84 
6.0 
ASSESSMENT OF SAFETY ............................................................... 86 
6.1 
Definitions ............................................................................................ 86 
6.1.1 
Adverse Events ...................................................................... 86 
6.1.2 
Serious Adverse Event ........................................................... 86 
6.1.3 
Severity .................................................................................. 87 
6.2 
Documenting and Reporting of Adverse and Serious Adverse Events 88 
6.2.1 
Adverse Event Reporting Period ............................................ 88 
6.2.2 
Assessment of Adverse Events .............................................. 88 
6.2.3 
Pregnancy .............................................................................. 89 

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6.2.4 
Expedited Reporting Requirements for Serious Adverse 
Events .................................................................................... 90 
6.2.5 
Reporting Events of Clinical Interest ...................................... 91 
6.2.6 
Type and Duration of Follow-up of Subjects after Adverse 
Events .................................................................................... 92 
6.2.7 
Other Safety Issues Requiring Expedited Reporting .............. 92 
7.0 
STUDY ADMINISTRATION AND INVESTIGATOR OBLIGATIONS .. 92 
7.1 
Institutional Review Board and Independent Ethics Committee........... 92 
7.2 
Informed Consent and Protected Subject Health Information 
Authorization ........................................................................................ 93 
7.3 
Subject Screening Log ......................................................................... 94 
7.4 
Case Report Forms ............................................................................. 94 
7.5 
Study Monitoring Requirements ........................................................... 94 
7.6 
Investigational Study Drug Accountability ............................................ 95 
7.7 
Record Retention ................................................................................. 96 
7.8 
Protocol Amendments ......................................................................... 96 
7.9 
Publication of Study Results ................................................................ 97 
7.10 
Clinical Trial Insurance ........................................................................ 97 
7.11 
General Investigator Responsibilities ................................................... 97 
8.0 
REFERENCES .................................................................................... 98 
9.0 
APPENDICES ................................................................................... 102 
 
 
 

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IN–TEXT TABLES 
 
Table 3-1 Pembrolizumab Product Descriptions ........................................................54 
Table 3-2.  Dose Reduction for Acalabrutinib ............................................................56 
Table 3-3.  Dose Modification Guidelines for Drug-Related Adverse Events .............58 
Table 3-4.  Infusion Reaction Treatment Guidelines ..................................................62 
Table 3-5.  Imaging and Treatment After 1st Radiologic Evidence of Disease 
Progression .......................................................................................................70 
Table 4-1.  Evaluation of Target Lesions (RECIST) ...................................................78 
Table 4-2.  Evaluation of Nontarget Lesions (RECIST) .............................................78 
Table 4-3.  Timepoint Response (RECIST) ...............................................................79 
Table 4-4.  Best Overall Response Assessment and Requirements for Confirmation 
(RECIST) ...........................................................................................................80 
Table 5-1.  Stopping Boundaries for Toxicity Monitoring............................................85 
Table 5-2.  Operating Characteristics of the Design ..................................................86 
 
IN–TEXT FIGURES 
 
Figure 1-1.  Efficacy of Acalabrutinib Monotherapy in a Genetic Model of Pancreatic 
Cancer ..............................................................................................................33 
Figure 1-2.  Effects of Acalabrutinib on Tumor-Associated  Immunosuppressive Cells 
in a Genetic Model of Pancreatic Cancer ...........................................................33 
Figure 1-3.  Effects of Acalabrutinib on Cytolytic T Cells in a Genetic Model of 
Pancreatic Cancer .............................................................................................34 
Figure 1-4.  Acalabrutinib Impairs ID8 Ovarian Cancer Growth and Decreased 
Immunosuppressive Cellular Subsets in Syngeneic Murine Model ....................34 
Figure 1-5.  Efficacy of Acalabrutinib Monotherapy and Combination Therapy  with 
Gemcitabine in an Orthotopic Model of Pancreatic Cancer ................................35 
Figure 1-6.  Acalabrutinib Enhances the Antitumor Effects of α-PD-L1 in the 
Orthotopic CT26 Colon Cancer Model ...............................................................36 
Figure 1-7.  BTK Inhibition Leads to Modulation of Infiltrating Immature Myeloid Cells 
Which Can Limit the Activity of Anti-PD-L1 Antibodies .......................................37 
Figure 3-1.  Study Schema ........................................................................................46 
 
 
 

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SUMMARY OF AMENDMENT 4 
This protocol is being amended to include findings from aggregate analyses from the 
acalabrutinib (ACP-196) clinical program of observed increases in frequency and 
severity of serum transaminase elevations in subjects exposed to the combination of 
acalabrutinib and pembrolizumab, as compared with subjects exposed to 
pembrolizumab monotherapy and subjects exposed to acalabrutinib monotherapy. 
Additional changes in this protocol amendment include updated background 
information on acalabrutinib and changes made to align this protocol with other Acerta 
Pharma protocols. 
Clarifying edits and typographical changes have been made throughout the protocol.  
In addition, the following substantive changes were made as part of this amendment: 
Change 
Rationale 
Title Page 
Changed medical monitor to Tianling Chen, MD, MSc. 
 
Revised text as shown (bold indicates new text): 
DCRI COORDINATING CENTER CONTACT PRINCIPAL 
INVESTIGATOR 
 
 
Acerta Pharma medical 
monitor change. 
 
Updated contact 
information. 
Protocol Approval Page:  Removed Acerta approver. 
Acerta Pharma process 
change. 
Synopsis  
Updated to reflect 
changes made 
throughout the protocol.   
Section 1.6.3 Drug-drug Interaction Potential 
Replaced text with reference to the Acalabrutinib Investigator 
Brochure. 
The Investigator 
Brochure is the primary 
source for detailed 
information on 
acalabrutinib drug-drug 
interaction potential. 
Section 1.8.2 Acalabrutinib in CLL 
Updated summary of data from the ACE-CL-001 study. 
 
Deleted Tables 1-1, 1-2, and 1-3. 
The summary of data 
from the ACE-CL-001 
study was updated 
based on the most recent 
data cut (October 2015) 
per the Acalabrutinib 
Investigator Brochure. 
Section 1.9 KEYTRUDA (Pembrolizumab) 
Revised text as shown (bold indicates new text): 
Pembrolizumab (Keytruda [United States]), is a potent and 
highly selective humanized monoclonal antibody against the 
programmed death receptor-1 (PD-1) protein, has been 
developed by Merck & Co for the treatment of patients 
Updated text to reflect 
currently approved 
indications in the 
KEYTRUDA US 
prescribing information. 

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with cancer of the IgG4/kappa isotype designed to directly 
block the interaction between PD-1 and its ligands, PD-L1 and 
PD-L2.  Pembrolizumab is approved for treatment of patients 
with melanoma in several countries; in the United States 
and European Union it is approved for the treatment of  
adult patients with advanced (unresectable or metastatic) 
melanoma.  Pembrolizumab has also been granted approval 
approved for treatment of patients with non-small cell 
lung cancer (NSCLC) in several countries; in the United 
States it is indicated for the treatment of patients with 
metastatic non-small cell lung cancer (NSCLC) whose tumors 
express PD-L1 as determined by an FDA-approved test and 
who have disease progression on or after platinum-containing 
chemotherapy.  Patients with NSCLC and EGFR or ALK 
genomic tumor aberrations should also have disease 
progression on FDA-approved therapy for these 
aberrations prior to receiving pembrolizumab.   
Section 1.10 Benefit/Risk 
Revised text as shown (bold indicates new text): 
 
In the Phase 1/2 study of acalabrutinib in subjects with CLL, 
an ORR of 95% has been observed with a median 
follow-up of 14.3 months.  no DLTs have been identified and 
no SAEs related to study drug have occurred at dosages of 
≤ 400 mg QD or 100 to 200 mg BID.  The ORR in the 
evaluable subjects for this study is currently 94% with some 
subjects obtaining PRs after only 2 cycles of therapy. 
Revised text to match 
updates made in Section 
1.8.2. 
Section 3.0 Study Design 
Revised text as shown (bold indicates new text): 
 
Subjects who progress on the combination of pembrolizumab 
and acalabrutinib will discontinue study treatment while those 
with progression of disease in the pembrolizumab 
monotherapy arm will continue on pembrolizumab with the 
addition of acalabrutinib until a second disease progression.  
For subjects who cross over to receive combination 
treatment, acalabrutinib treatment will begin at the next 
visit at which subjects are scheduled to receive 
pembrolizumab.   
 
Refer to Appendix 4 and Appendix 5 for a comprehensive 
lists of study assessments and their timing.   
 
Section 3.8 Dosing Delays and Modifications 
Revised text as shown (bold indicates new text): 
For treatment-emergent hepatotoxicity in the combination arm 
only or for subjects who cross over to receive 
combination therapy:  Important guidelines for 
treatment-emergent hepatotoxicity are provided in Section 
3.8.2 for pembrolizumab.  In the combination arm or for 
Given the new findings of 
observed increases in 
frequency and severity of 
serum transaminase 
elevations in subjects 
exposed to acalabrutinib 
and pembrolizumab in 
combination as 
compared with subjects 
exposed to 
pembrolizumab 
monotherapy and 
subjects exposed to 
acalabrutinib 
monotherapy, additional 
assessments have been 
added for subjects who 
cross over to receive 
acalabrutinib and 
pembrolizumab to allow 
for more frequent 
monitoring.   

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subjects who cross over to receive combination therapy, 
treatment with acalabrutinib should be withheld for Grade 3 or 
4 hepatitis.   
 
Added Appendix 5 Schedule of Assessments - Crossover 
Section 3.3.2 Exclusion Criteria 
Revised text as shown (bold indicates new text): 
6. 
Prior therapy with an anti-PD-1, anti-PD-L1, 
anti-PD-L2, anti-CD137, or anti-CTLA-4 antibody (including 
ipilimumab, tremelimumab, nivolumab, pembrolizumab, 
MPDL3280A or any other antibody or drug specifically 
targeting T-cell co-stimulation or checkpoint pathways). 
Added tremilumumab as 
an example therapy. 
Section 3.4.2 Formulation, Packaging, and Storage 
Revised text as shown: 
If a drug shipment arrives damaged, or if there are any other 
drug complaints, a SAE/Product Complaint Form should be 
completed and emailed or faxed to the sponsor or the 
sponsor’s representative.   
Section 6.2 Documenting and Reporting of Adverse and 
Serious Adverse Events 
Revised text as shown: 
All SAEs must be reported on the SAE/Product Complaint 
form or clinical database. 
Section 6.2.4 Expedited Reporting Requirements for Serious 
Adverse Events 
Revised text as shown (bold is new text): 
If electronic SAE reporting is not available, paper SAE/Product 
Complaint forms must be emailed or faxed to Acerta Pharma 
Drug Safety, or designee.   
Revised for consistency 
with other acalabrutinib 
protocols. 
Section 3.4.4 Assuring Subject Compliance 
Added the following text: 
Missed doses of pembrolizumab should not be made up, 
with the next dose occurring in agreement with the 
original schedule for this agent (every 3 weeks). 
Section 3.8 Dosing Delays and Modifications 
In cases where pembrolizumab is held, pembrolizumab 
should be restarted in agreement with its original dosing 
schedule (every 3 weeks).   
Text added to clarify that 
missed doses of 
pembrolizumab should 
not be made up. 
Added Section 3.10.1 Transaminase Elevations for 
Acalabrutinib in Combination with Pembrolizumab 
Section has been added 
based on findings from 
aggregate data analyses 
from the acalabrutinib 

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Serum transaminase elevations (including elevations of 
AST and/or ALT) may be increased in severity and 
frequency in subjects exposed to the combination of 
acalabrutinib and pembrolizumab, as compared with 
subjects exposed to pembrolizumab monotherapy and 
subjects exposed to acalabrutinib monotherapy. Routine 
monitoring for serum transaminase elevations must 
follow the Schedule of Assessments (serum chemistry 
lab assessments in Appendix 4 and Appendix 5). Dosing 
delays and modifications for subjects with serum 
transaminase elevations must follow guidance provided 
in Section 3.8. 
clinical program of 
observed increases in 
frequency and severity of 
serum transaminase 
elevations in subjects 
exposed to the 
combination of 
acalabrutinib and 
pembrolizumab, as 
compared with subjects 
exposed to 
pembrolizumab 
monotherapy and 
subjects exposed to 
acalabrutinib 
monotherapy. 
Section 3.14 Data and Safety Monitoring 
Revised text as shown (bold is new text): 
This trial will be monitored in accordance with the sponsor’s 
Pharmacovigilance Committee pharmacovigilance 
procedures.   
Revised for consistency 
with other acalabrutinib 
protocols. 
 
 
 
  
Section 4.1.1 Informed Consent  
Revised text as shown (bold is new text): 
The subject must read, understand and sign the ICF approved 
by the institutional review board or independent ethics 
committee (IRB/IEC), confirming his or her willingness to 
participate in this study before initiating any screening activity 
that is not considered standard of care by institutional 
standards.  Subjects must also grant permission to use 
protected health information if required by local regulations. 
Revised text to align with 
language in other 
acalabrutinib protocols. 
Section 4.1.15 Hepatitis B and C Testing 
Revised text as shown (bold is new text): 
Hepatitis serology testing must include hepatitis B surface 
antigen (HBsAg), hepatitis B surface antibody (anti-HBsAb), 
hepatitis B core antibody (anti-HBc), and hepatitis C (HCV) 
antibody.  In addition, any subjects testing positive for any 
hepatitis serology, must have PCR testing during screening 
and on study (see Appendix 4 and exclusion criterion #16).  
Testing will be done by local or central laboratory.   
Subjects who are anti-HBc positive should have 
quantitative PCR testing for HBV DNA performed during 
screening and monthly thereafter.  Monitoring should 
continue every 4 weeks (± 7 days) until 12 months after 
last dose of study drug(s).  Any subject with a rising viral 
load (above lower limit of detection) should discontinue 
study drug and have antiviral therapy instituted and a 
Clarified on-study testing 
criteria for subjects who 
test positive for any 
hepatitis serology during 
screening.  Added HCV 
PCR testing at Weeks 13 
and 25 to ensure that 
subjects maintain a 
sustained virologic 
response, based on 2015 
guidelines from the 
American Association for 
the Study of Liver 
Diseases. 

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consultation with a physician with expertise in managing 
hepatitis B.   
Subjects with a known history of hepatitis C or who are 
hepatitis C antibody positive should have quantitative 
PCR testing for HCV DNA performed during screening 
and at Weeks 13 and 25.  No further testing beyond Week 
25 is necessary if PCR results are negative.   
Refer to Section 3.10.2 and Appendix 4 regarding monitoring 
of subjects who are anti-HBc positive or hepatitis C antibody 
positive or who have a known history of HBV or HCV 
infection. 
Appendix 4 Schedule of Assessments – Treatment Arms 1 
and 2 
Added HBV PCR testing at screening; revised text to clarify 
that in Week ≥ 10, HBV PCR is conducted at Week 12, then 
every 4 weeks.   
Added row for HCV PCR, with HCV PCR testing at screening, 
Week 13, and Week 25. 
Revised footnotes as shown (bold is new text): 
u. Subjects who are hepatitis B core antibody positive (or have 
a known history of HBV infection) should be monitored 
monthly with have a quantitative PCR test for HBV DNA 
during screening and monthly thereafter.  Monthly 
Mmonitoring should continue Q4W (± 7 days) until 12 months 
after last dose of study drug(s).  Any subject with a rising viral 
load (above lower limit of detection) should discontinue study 
drug(s) and have antiviral therapy instituted and a consultation 
with a physician with expertise in managing hepatitis B. 
v. Subjects with a known history of hepatitis C or who are 
hepatitis C antibody positive should have quantitative 
PCR testing for HCV DNA performed during screening 
and at Weeks 13 and 25.  No further testing beyond 
Week 25 is necessary if, PCR results are negative.    
Section 4.3 Safety Follow-up Visit 
Revised text as shown (bold is new text): 
Each subject should be followed for 30 (+ 7) days after his or 
her last dose of study drug (ie, the “safety follow-up visit”) to 
monitor for resolution or progression of AEs (see 
Section 6.2.6) and to document the occurrence of any new 
events; unless, the subject receives a new anticancer therapy 
within this timeframe, regardless of whether the subject 
receives a new anticancer therapy or demonstrates 
disease progression within this timeframe.   
Revised for consistency 
with other acalabrutinib 
protocols. 
Section 5.2 Definition of Analysis Populations Sets 
Revised text as shown (bold is new text): 
Revised for consistency 
with other acalabrutinib 
protocols. 

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The following definitions will be used for the efficacy and 
safety analysis populations sets. 
All-treated population Safety analysis set: All enrolled 
subjects who receive ≥ 1 dose of any study drug (either 
acalabrutinib or pembrolizumab).  The safety and primary 
efficacy analyses will be performed on the All-treated 
population.  
Efficacy-evaluable population Per-protocol (PP) analysis 
set: All enrolled subjects in the All-treated population who 
have ≥ 1 evaluable response assessment after the first 
dose of study drug (either acalabrutinib or 
pembrolizumab) who receive ≥ 1 dose of study drug, have 
sufficient baseline measurements, and undergo 
≥ 1 assessment for the endpoint of interest (eg, response and 
PD parameters) after treatment.  Sensitivity analyses for 
efficacy will be carried out on the Efficacy-evaluable 
population. 
The safety analysis set will be used for evaluating the safety 
and efficacy parameters in this study (with the exception of 
assessment of duration of response).  The PP analysis sets 
will be analyzed for efficacy and PD parameters in this study.. 
Section 5.5 Futility and Toxicity Monitoring 
Revised text as shown (bold is new text): 
Enrollment in the combination arm will be stopped early if 
there is > 95% probability that the irDCR is < 20% or there is 
> 90% probability that the toxicity rate is higher than 30% in 
that arm.  Where θE denotes the marginal response rate, 
assuming that θE follows a prior distribution of beta (a, b), 
where a and b represent nonresponse and nonresponse rates 
(0.2, 0.8), and TE denotes the marginal toxicity rate, assuming 
that TE has a prior distribution of beta (a, b), where a and b 
represent toxicity and no toxicity (0.3, 0.7).     
Correction to text. 
Section 6.1.1 Adverse Events 
Revised text as shown (bold is new text): 
An AE is any unfavorable and unintended sign, symptom, or 
disease temporally associated with the use of an 
investigational (medicinal) product or other protocol-imposed 
intervention, regardless of attribution. 
This includes the following: 
• 
AEs not previously observed in the subject that 
emerge during the protocol-specified AE reporting 
period, including signs or symptoms associated 
with bladder cancer that were not present before 
the AE reporting period (see Section 6.2.1). 
• 
Complications that occur as a result of protocol-
Revised text to be 
consistent with ICH and 
FDA guidelines. 

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mandated interventions (eg, invasive procedures 
such as biopsies). 
• 
Preexisting medical conditions (other than the 
condition being studied) judged by the investigator 
to have worsened in severity or frequency or 
changed in character during the protocol-specified 
AE reporting period. 
Abnormal laboratory values should not be reported as AEs; 
however, any considered clinically significant laboratory 
values (eg, causing withdrawal from study or any type of 
intervetions)by the investigator should be reported as AEs. 
Section 6.2.1 Adverse Event Reporting Period 
Revised text as shown (bold is new text): 
After the signing of the ICF, all SAEs must be reported.  
After the first dose of study drug, all AEs, irrespective of 
seriousness, must be reported.  
For acalabrutinib, AE reporting, irrespective of 
seriousness, ends 30 days after the last dose of study 
drug(s).  For pembrolizumab, all AEs must be reported 
through 30 days after the last dose of pembrolizumab; 
any SAEs, or follow-up to a SAE, including death due to 
any cause other than progression of the cancer under 
study, must be reported through 90 days after the last 
dose or 30 days after the last dose of pembrolizumab if 
the subject initiates a new anticancer therapy within the 
90-day posttreatment timeframe.   
SAEs considered related to study drug(s) occurring after 
the end of the AE reporting period (as defined above) 
must be reported.   
If an SAE is present at the last study visit, the SAE should 
be followed to resolution or until the investigator 
assesses the subject as stable, or the subject is lost to 
follow-up or withdraws consent.  Resolution/stable means 
the subject has returned to baseline state of health or the 
investigator does not expect any further improvement or 
worsening of the event. 
 The AE reporting period for this study begins when the 
subject receives the first dose of study drug and ends with the 
safety follow-up visit unless a subject received a new 
anticancer therapy before the safety follow-up visit.  An 
exception to this reporting period is any AE occurring due to a 
protocol-defined screening procedure.  If a fatal AE occurs 
beyond 30 days after the last dose of acalabrutinib and/or 
pembrolizumab AND it is assessed by the investigator as 
related to acalabrutinib and/or pembrolizumab it must be 
reported as an SAE. 
Revised to match recent 
language from Merck 
Sharp & Dohme Corp 
and for consistency with 
other acalabrutinib 
protocols. 

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Section 6.2.2 Assessment of Adverse Events 
Revised text as shown (bold is new text): 
All AEs and SAEs whether volunteered by the subject, 
discovered by study personnel during questioning, or detected 
through physical examination, or other means, that occur to 
any subject from the time of first dose through 30 days 
following the cessation of study drug(s), and all SAEs 
that occur to any subject receiving pembrolizumab from 
the time of first dose through 90 days following cessation 
of pembrolizumab, or 30 days following cessation of 
pembrolizumab if the subject initiates new anticancer 
therapy (whichever is earlier) will be recorded in the 
subject’s medical record and on the AE CRF. 
Revised guidance for 
documenting AEs and 
SAEs to match recent 
language from Merck 
Sharp & Dohme Corp 
and for consistency with 
other acalabrutinib 
protocols. 
 
 
 
 
 
Section 6.2.3 Pregnancy 
Revised text as shown (bold is new text): 
All pregnancies and partner pregnancies that are identified 
during or after this study, wherein the estimated date of 
conception is determined to have occurred from the time of 
consent to 90 days after the last dose of acalabrutinib, 
120 days after the last dose of pembrolizumab, or 30 days 
after the last dose of either treatment if the subject initiates a 
new anticancer threapy (whichever is earlier) will be reported, 
followed to conclusion, and the outcome reported, as long as 
the subject or partner is willing to participate in follow-up. 
Added the following text: 
Upon completion of the pregnancy, additional information 
on the mother, pregnancy, and baby will be collected and 
sent to DrugSafety@acerta-pharma.com. 
Revised for consistency 
with other acalabrutinib 
protocols. 
Section 6.2.4 Expedited Reporting Requirements for Serious 
Adverse Events 
Revised text as shown (bold indicates new text): 
Whenever possible, AEs/SAEs should be reported by 
diagnosis term, not as a constellation of symptoms.   
Death due to disease progression should be recorded on 
the appropriate form in the electronic data capture 
system.  If the primary cause of death is disease 
progression, the death due to disease progression should 
not be reported as an SAE.  If the primary cause of death 
is something other than disease progression, then the 
death All deaths should be reported as an SAE with the 
primary cause of death as the event AE term, as death is 
typically the outcome of the event, not the event itself.  The 
primary cause of death on the autopsy report should be the 
term reported.  Autopsy and postmortem reports must be 
forwarded to Acerta Pharma Drug Safety, or designee, as 
Greater detail has been 
added to aid sites with 
reporting of deaths due 
to disease progression 
and to encourage sites to 
report causality of SAEs 
on the initial report. 

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outlined above. If study drug is discontinued because of an 
SAE, this information must be included in the SAE report. 
An SAE may qualify for mandatory expedited reporting to 
regulatory authorities if the SAE is attributable to the 
investigational product (or if a causality assessment is not 
provided for the SAE, in which case the default of 
‘related’ must be used for expedited reporting purposes) 
and the SAE is not listed in the current Investigator’s 
Brochure (ie, an unexpected event).   
Added Section 6.2.7 Other Safety Issues Requiring  
Expedited Reporting 
For studies being conducted in Europe expedited 
reporting is required for safety issues that might 
materially alter the current benefit-risk assessment of an 
investigational medicinal product or that would be 
sufficient to consider changes in the investigational 
medicinal products administration or in the overall 
conduct of the trial.  For a detailed description of safety 
issues that may qualify for expedited reporting please 
refer to the European Commission guidance titled, 
“Detailed guidance on the collection, verification and 
presentation of adverse reaction reports arising from 
clinical trials on medicinal products for human use – April 
2006” available at 
http://ec.europa.eu/health/files/eudralex/vol-
10/21_susar_rev2_2006_04_11_en.pdf. 
Added new section and 
text that is standard 
across all Acerta Pharma 
protocols  
Section 7.6 Investigational Study Drug Accountability 
Revised text as shown (bold is new text): 
Acalabrutinib and pembrolizumab capsules must be kept in a 
locked limited access cabinet or space, under appropriate 
storage conditions. 
Revised to correct 
omission of 
pembrolizumab. 
Section 8.0 References 
Revised as needed to 
reflect changes in the 
protocol. 
Appendix 4. Schedule of Assessments – Treatment Arms 1 
and 2 
Thyroid panel, ≥ 10 Weeks: Revised text to clarify than thyroid 
panel is conducted at Week 13, then every 6 weeks. 
Removed study window from Week 1 visit. 
 
 
 
Clarifying edits. 
 
Correction, as the study 
window does not apply to 
the Week 1 visit. 
 

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ABBREVIATIONS 
λz 
terminal elimination rate constant 
ACP-196 
acalabrutinib 
AE 
adverse event 
AKT 
protein kinase b 
ALT 
alanine aminotransferase 
ANC 
absolute neutrophil count 
anti-HBc 
hepatitis B core antibody 
anti-HBs 
hepatitis B surface antibody 
aPTT 
activated partial thromboplastin time 
AST 
aspartate aminotransferase 
AUC 
area under the concentration-time curve 
AV 
atrioventricular 
BCG 
Bacillus Calmette Guerin 
BCRP 
breast cancer resistance protein  
BID 
twice per day (dosing) 
BOR 
best overall response 
BTK 
Bruton tyrosine kinase 
BUN 
blood urea nitrogen 
CBC 
complete blood count 
CD 
cluster of differentiation (cell surface marker) 
CFR 
Code of Federal Regulations 
cGMP 
current Good Manufacturing Practice 
CI 
confidence interval 
CL/F 
oral clearance 
CLL 
chronic lymphocytic leukemia 
Cmax 
maximum concentration 
CR 
complete response (remission) 
CRF 
case report form 
CSSF 
Clinical Supplies Shipping Receipt Form 
CT 
computed tomography 
CTCAE 
Common Terminology Criteria For Adverse Events 
CTLA-4 
cytotoxic t-lymphocyte-associated protein 4 
CYP 
cytochrome p450 
DCR 
disease control rate 
DLT 
dose-limiting toxicity 
DOR 
duration of response 
ECG 
electrocardiogram 
ECI 
Events of Clinical Interest 
ECOG 
Eastern Cooperative Oncology Group 

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EGFR 
epidermal growth factor receptor 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
HBsAg 
hepatitis B surface antigen 
HBV 
hepatitis B virus 
HCV 
hepatitis C virus 
hERG 
human ether-à-go-go-related gene 
HIV 
human immunodeficiency virus 
HNSTD 
highest non-severely toxic dose 
IC50 
half-maximal inhibitory concentration 
ICF 
informed consent form 
IEC 
independent ethics committee 
Ig 
immunoglobulin 
IRB 
institutional review board 
ir 
immune-related 
irAE 
immune-related adverse event 
irRECIST 
immune-related response criteria 
IUD 
intrauterine device 
IV 
intravenous or intravenously  
JAK 
Janus kinase 
LDH 
lactate dehydrogenase 
MDSC 
myeloid suppressive monocyte 
MedDRA 
Medical Dictionary for Regulatory Activities 
MRP 
multidrug-resistance-associated protein 
MTD 
maximum tolerated dose 
mTOR 
mammalian target of rapamycin 
NE 
nonevaluable 
NK 
natural killer (cells) 
NOAEL 
no observed adverse effect level 
NSCLC 
non-small cell lung cancer 
NTCP 
sodium taurochlorate co-transporting polypeptide 
ORR 
overall response rate 
OS 
overall survival 
PCR 
polymerase chain reaction 
PBMC 
peripheral blood mononuclear cells 
PFS 
progression-free survival 
PD 
pharmacodynamic, pharmacodynamics, or progressive disease 
PD-1 
programmed death-1 (receptor) 

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PD-L1 
programmed death ligand-1 
PD-L2 
programmed death ligand-2 
P-gp 
p-glycoprotein 1 (transporter) 
PI3K 
phosphatidylinositol-3 kinase 
PK 
pharmacokinetic or pharmacokinetics 
PR 
partial response (remission) 
PSA 
prostate-specific antigen 
PT 
prothrombin time 
Q3M 
every 3 months 
Q3W 
every 3 weeks 
Q12W 
every 12 weeks 
QD 
once per day (dosing) 
QM 
every month 
QTc 
corrected QT interval 
RECIST 
Response Evaluation Criteria in Solid Tumors 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SD 
stable disease 
SUSAR 
suspected unexpected serious adverse reaction 
SYK 
spleen tyrosine kinase 
t½ 
terminal elimination half-life 
T3 
triiodothyronine 
T4 
thyroxine 
TAM 
tumor-associated macrophage 
TGF-β 
transforming growth factor-β 
Tmax 
time to maximum concentration 
TSH 
thyroid-stimulating hormone (thyrotropin) 
Treg 
regulatory T cells 
TURBT 
transurethral resection of bladder tumor 
ULN 
upper limit of normal 
Vz 
volume of distribution 
Vz/F 
oral volume of distribution 
WHODRUG 
World Health Organization Drug Dictionary 
 

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STUDY SYNOPSIS  
Protocol Number: 
ACE-ST-005 
Study Drugs: 
Acalabrutinib (also known as ACP-196) 
KEYTRUDA® (pembrolizumab) 
Protocol Title: 
Randomized Phase 2 Trial of ACP-196 and Pembrolizumab 
Immunotherapy Dual Checkpoint Inhibition in Platinum Resistant 
Metastatic Urothelial Carcinoma 
Phase: 
Phase 2 
Comparator: 
KEYTRUDA® (pembrolizumab) 
Study Centers: 
Up to 30 centers in the United States will participate on this 
protocol. 
Background and 
Rationale for Study 
Urothelial carcinoma is common in the US, and metastatic 
urothelial carcinoma is an aggressive disease with high mortality. 
The checkpoint ligand, programmed death-1 ligand (PD-L1) 
expression in urothelial carcinoma was found to correlate with 
increased stage, grade, and tissue-infiltrating mononuclear cells in 
urothelial carcinoma (Inman 2007).  The checkpoint interaction of 
PD-L1 on urothelial carcinoma cells and PD-1 receptor on 
infiltrating T cells may have an important role in dampening 
cytotoxic T-cell response to urothelial carcinoma.  Targeting 
immune infiltrates and disrupting PD-1 ligand-receptor interactions 
may impair stromal support and enhance immune cell destruction 
of tumors that could offer therapeutic benefits to patients with 
urothelial carcinoma.  Indeed, a monoclonal antibody directed at 
PD-L1 was shown recently to have a 26% response rate in 
unselected patients with metastatic urothelial carcinoma after 
disease progression with cisplatin-based chemotherapy 
(Powles 2014). A Phase 2 study of pembrolizumab (Keytruda®), a 
monoclonal antibody against PD-1, in 33 patients with PD-L1 
positive urothelial carcinoma showed an overall response rate of 
24.1% and complete response rate of 10.3% (Plimack 2014). 
Myeloid derived suppressor cells (MDSCs) are important in 
promoting tumor growth and metastases by inducing 
epithelial-mesenchymal transition, allowing tumor invasion, and 
promoting angiogenesis (Condamine 2014).  Therefore, MDSCs 
can be a mechanism of resistance to anti-PD-1 therapy.  When 
used in combination with checkpoint inhibitors, agents that inhibit 
MDSCs can improve outcomes in murine models of metastatic 
disease (Kim 2014).  
Bruton tyrosine kinase (BTK) is a non-receptor enzyme of the Tec 
kinase family that is expressed in B cells, myeloid cells, and mast 
cells, where it regulates cellular proliferation, differentiation, 
apoptosis, and cell migration. BTK inhibition leads to preferential 

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differentiation of macrophages into M1 instead of 
immunosuppressive M2 macrophages; BTK inhibition thus 
decreases the tumor-associated macrophages that promote tumor 
invasion and metastasis.  
Acerta Pharma BV is developing acalabrutinib, an orally 
administered, small-molecule inhibitor of BTK.  A Phase 1 study of 
acalabrutinib in 
 with relapsed/refractory chronic 
lymphocytic leukemia showed an overall response rate of 95%.  
Acalabrutinib monotherapy has shown robust antitumor activity in 
murine solid tumor models.  The antitumor effect observed with 
acalabrutinib correlates with biomarkers of response similar to 
those reported for other immunomodulating agents such as 
inhibitors of CTLA-4, PD-1 and PD-L1.  
To determine whether there is potential synergy between BTK 
inhibition and PD-1 blockade, Acerta has conducted a nonclinical 
study of acalabrutinib in combination with an anti-PD ligand 1 
(anti-PD-L1) antibody in an orthotopic colon cancer murine model.  
Treatment with anti-PD-L1 as a single agent reduced tumor 
growth, but tumor regression was not observed. However, 
combined anti-PD-L1 and acalabrutinib treatment showed a further 
reduction in tumor growth.  Specifically, 6 of 9 animals displayed 
tumor regression compared with no animals treated with 
anti-PD-L1 alone (Figure 1-6).  These results suggest the 
combination therapy of BTK inhibition and PD-1 blockade leads to 
greater benefit compared with PD-1 blockade alone. 
This proof-of-concept study will assess the clinical potential of a 
targeted dual inhibition approach by evaluating the safety, 
pharmacodynamics (PD), and efficacy of acalabrutinib and 
pembrolizumab in subjects with metastatic urothelial carcinoma 
who have progressed after treatment with cisplatin-based 
chemotherapy. 
Study Design: 
This clinical trial is a Phase 2, multicenter, open-label, randomized 
study evaluating pembrolizumab monotherapy and the 
combination of acalabrutinib and pembrolizumab in subjects who 
have metastatic bladder cancer with disease progression on or 
after platinum-based chemotherapy.  
Subjects meeting the eligibility criteria for the study will be 
randomized 1:1 to one of the following arms: 
Arm 1:  Pembrolizumab 200 mg administered as an intravenous 
(IV) infusion every 3 weeks (Q3W) 
Arm 2:  Acalabrutinib 100 mg administered orally (PO) twice per 
day (BID) plus pembrolizumab 200 mg IV Q3W 
Although acalabrutinib has not demonstrated any dose-limiting 
toxicities (DLTs) to date, the safety of acalabrutinib in combination 
with pembrolizumab in this patient population needs to be 
assessed. Thus, standard DLT criteria will be applied to Arm 2 of 
the study.  Therefore an interim safety analysis will occur once 
 have been successfully randomized to the combination 
arm (Arm 2) and have been treated a minimum of 4 weeks. 

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Enrollment will be paused while the interim safety analysis occurs. 
If a  DLT rate of < 33% is observed in Arm 2 (ie, DLT review is 
cleared), then randomization will continue to evaluate the objective 
response rates of pembrolizumb monotherapy and the combination 
of pembrolizumab and acalabrutinib (ie, up to 
 per 
arm).  If a DLT rate of ≥ 33% is observed in Arm 2, then enrollment 
(1:1) will continue until an additional 
 are randomized to 
Arm 2, and consideration will be given to reducing the dose of 
acalabrutinib (Level -1), taking into account the nature of the DLTs 
and the DLT rate in the single-agent arm.  In addition, analyses for 
continuous futility and toxicity monitoring will also be done as 
outlined in Section 5.5. 
Acalabrutinib treatment can continue for subjects who are 
tolerating therapy and not progressing.  Pembrolizumab treatment 
is for 24 months from the date of first dose for subjects who are 
tolerating therapy and not progressing.  Subjects who have 
confirmed progressive disease on the combination of 
pembrolizumab and acalabrutinib will discontinue study treatment 
while those with confirmed progressive disease in the 
pembrolizumab monotherapy arm will continue on pembrolizumab 
with the addition of acalabrutinib until a second disease 
progression.  For subjects who cross over to receive combination 
treatment, acalabrutinib treatment will begin at the next visit at 
which subjects are scheduled to receive pembrolizumab.  The 
immune-related response criteria (irRECIST; Appendix 8 and 
Section 3.11) will be used to determine progression on this study. 
Pembrolizumab treatment can end for subjects with confirmed 
complete response (CR) if treatment has been administered for at 
least 24 weeks and 2 doses of pembrolizumab have been 
administered after confirmation of CR.  The end of study is defined 
as 12 months after the last subject is randomized.   
Refer to Appendix 4 and Appendix 5 for comprehensive lists of 
study assessments and their timing.  A study schema is provided 
in Figure 3-1. 
Definition of Dose-
limiting Toxicity: 
A DLT will be defined as the occurrence of any of the following 
study drug-related adverse events (note: Adverse events [AEs] 
clearly related to disease progression or the subject’s current 
medical history and associated comorbidities will not be 
considered DLTs): 
1. Grade 4 vomiting or diarrhea 
2. Grade 3 nausea, vomiting, or diarrhea lasting for > 72 hours 
3. Other Grade ≥ 3 toxicites (Note: Transient Grade 3-4 laboratory 
abnormalities that are not clinically significant will not be 
considered DLTs) 
4. Dosing delay due to toxicity for > 21 consecutive days 
Study Objectives: 
Primary Objectives: 

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• 
To characterize the safety profile of acalabrutinib and 
pembrolizumab in subjects with metastatic, platinum-refractory 
bladder cancer 
• 
To determine the best overall response rate (BOR) and overall 
response rate (ORR) of pembrolizumab monotherapy and the 
combination of acalabrutinib and pembrolizumab in subjects 
with metastatic, platinum-refractory bladder cancer 
Secondary Objectives: 
• 
To determine progression-free survival (PFS) in subjects 
treated with pembrolizumab monotherapy and the combination 
of acalabrutinib and pembrolizumab 
• 
To evaluate the overall survival (OS) in subjects treated with 
pembrolizumab monotherapy and the combination of 
acalabrutinib and pembrolizumab 
Exploratory Objectives: 
• 
Determine the effects of acalabrutinib plus pembrolizumab on 
peripheral blood T cells and myeloid-derived suppressor cells 
(MDSCs) 
• 
Determine the PK of acalabrutinib alone and in combination 
with pembrolizumab 
• 
Determine if any characteristics of peripheral blood T cells 
and/or MDSCs correlate with immune-mediated toxicities 
• 
Determine if any characteristics of peripheral blood T cells 
and/or MDSCs correlate with response to acalabrutinib and 
pembrolizumab  
• 
Determine if any baseline tumor characteristics correlate with 
response to acalabrutinib and pembrolizumab 
• 
To evaluate the efficacy of adding acalabrutinib to 
pembrolizumab in subjects who progress on pembrolizumab 
monotherapy 
Safety Endpoints: 
Type, frequency, severity, timing of onset, duration, and 
relationship to study drug of any treatment-emergent AEs or 
abnormalities of laboratory tests; serious adverse events (SAEs); 
DLTs or AEs leading to discontinuation of study treatment. 
Pharmacodynamic, 
Pharmacokinetic and 
Biomarker 
Parameters: 
The occupancy of BTK by acalabrutinib will be measured in 
peripheral blood mononuclear cells (PBMCs) with the aid of a 
biotin-tagged acalabrutinib analogue probe.  The effect of 
acalabrutinib and pembrolizumab on B cells, T cells, and MDSCs 
will also be evaluated.  Tumor tissue, when available, will be 
evaluated for PD-L1 expression.  Acalabrutinib will be measured in 
blood plasma. 

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Efficacy Endpoints: 
• 
BOR 
• 
ORR, defined as partial response (PR) and complete response 
(CR), based on modified RECIST 1.1 criteria (Appendix 7) 
• 
Disease control rate (DCR), defined as CR, PR, and stable 
disease (SD) based on modified RECIST 1.1 criteria 
• 
Duration of response (DOR) 
• 
Progression-free survival (PFS) 
• 
Overall survival (OS) 
Exploratory endpoints for efficacy based on immune-related 
response criteria (irRECIST) (Appendix 8): 
• 
Immune-related BOR (irBOR) 
• 
irORR, defined as immune-related partial response (irPR) and 
immune-related complete response (irCR) 
• 
irDCR 
• 
irDOR 
• 
irPFS 
Sample Size: 
An interim safety analysis will occur once 
 have been 
successfully randomized to the combination arm (Arm 2) and have 
been treated a minimum of 4 weeks.  Provided the DLT period is 
cleared in the combination arm, the study will proceed to full 
enrollment of 
 per arm for a total enrollment of 
. 
Inclusion Criteria: 
1. Men and women ≥ 18 years of age. 
2. Histologically or cytologically confirmed urothelial (transitional 
cell) carcinoma of the bladder or mixed histology bladder 
cancer (with transitional cell components). 
3. Presence of metastic bladder cancer that has either 
progressed during or after platinum-based chemotherapy 
administered for metastatic disease or has recurred during or 
within 1 year after the completion of platinum-based 
neoadjuvant or adjuvant therapy. 
4. Any primary site of urothelial carcinoma including upper tract, 
renal pelvis, bladder, and ureters. 
5. Prior therapy with ≥ 1 systemic chemotherapy regimens for 
urothelial carcinoma 
6. Presence of radiographically measurable disease as defined 
by RECIST 1.1. 
7. Eastern Cooperative Oncology Group (ECOG) performance 
status of 0 or 1. 
8. Completion of all therapy (including surgery, radiotherapy, 
chemotherapy, immunotherapy, or investigational therapy) for 

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the treatment of cancer ≥ 2 weeks before the start of study 
therapy and recovered (ie, Grade ≤ 1 or baseline) from AEs 
associated with prior cancer therapy.  Note:  Subjects with 
Grade ≤ 2 neuropathy or Grade ≤ 2 alopecia are an exception 
to the latter criterion and may qualify for the study. 
9. Women who are sexually active and can bear children must 
agree to use acceptable forms of contraception during the 
study and for 90 days after the last dose of acalabrutinib or 
120 days after the last dose of pembrolizumab, whichever is 
longer.  Note:  Acceptable forms of contraception are defined in 
Section 3.10.6. 
10. Men who are sexually active and can beget children must 
agree to use acceptable forms of contraception during the 
study and for 90 days after the last dose of acalabrutinib or 
120 days after the last dose of pembrolizumab, whichever is 
longer. 
11. Men must agree to refrain from sperm donation during the 
study and for 90 days after the last dose of acalabrutinib or 
120 days after the last dose of pembrolizumab, whichever is 
longer. 
12. Able to provide tissue for biomarker analysis from either an 
archived tissue sample or newly obtained core or excisional 
biopsy of a tumor lesion not previously irradiated. 
13. Willing and able to participate in all required evaluations and 
procedures in this study protocol including swallowing capsules 
without difficulty. 
14. Ability to understand the purpose and risks of the study and 
provide signed and dated informed consent and authorization 
to use protected health information (in accordance with 
national and local patient privacy regulations). 
Exclusion Criteria: 
1. Prior malignancy (other than bladder cancer), except for 
treatment-naive prostate cancer (defined as Stage T1/T2a, 
Gleason score ≤ 6, and prostate-specific antigen [PSA] 
< 10 ng/mL) undergoing active surveillance; or localized, very 
low to intermediate risk prostate cancer treated with curative 
intent and absence of PSA relapse; or adequately treated basal 
cell or squamous cell skin cancer, in situ cancer, or other 
cancer from which the subject has been disease free for 
≥ 2 years. 
2. Known central nervous system metastases and/or 
carcinomatous meningitis.  Note: Imaging studies of the central 
nervous system are not required as a condition of study 
enrollment 
3. Significant cardiovascular disease such as uncontrolled or 
symptomatic arrhythmias, congestive heart failure, or 
myocardial infarction within 6 months of screening, or any 
Class 3 or 4 cardiac disease as defined by the New York Heart 
Association Functional Classification and corrected QT interval 
(QTc) > 480 msec. 

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4. Malabsorption syndrome, disease significantly affecting 
gastrointestinal function, or resection of the stomach or small 
bowel, symptomatic inflammatory bowel disease, partial or 
complete bowel obstruction, or gastric restrictions and bariatric 
surgery, such as gastric bypass. 
5. Prior therapy with any inhibitor of BTK, protein kinase B (AKT), 
Janus kinase (JAK), mammalian target of rapamycin (mTOR), 
phosphatidylinositol-3 kinase (PI3K), or spleen tyrosine kinase 
(SYK). 
6. Prior therapy with an anti-PD-1, anti-PD-L1, anti-PD ligand 2 
(anti-PD-L2), anti-CD137, or anti-cytotoxic T-lymphocyte-
associated antigen-4 (CTLA-4) antibody (including ipilimumab, 
tremelimumab, nivolumab, pembrolizumab, MPDL3280A or any 
other antibody or drug specifically targeting T-cell co-stimulation 
or checkpoint pathways) 
7. Receiving ongoing immunosuppressive therapy, including 
systemic or enteric corticosteroids except for minimally 
systemically absorbed treatments (such as inhaled or topical 
steroid therapy for asthma, chronic obstructive pulmonary 
disease, or allergic rhinitis) within 7 days before the first dose of 
pembrolizumab.  
8. Active autoimmune disease that has required systemic 
treatment in past 2 years (ie, with use of disease modifying 
agents, corticosteroids or immunosuppressive drugs).  Note: 
Replacement therapy (eg, thyroxine, insulin, or physiologic 
corticosteroid replacement therapy for adrenal or pituitary 
insufficiency) is not considered a form of systemic treatment. 
9. Has history of interstitial lung disease or evidence of active 
non-infectious pneumonitis. 
10. History of severe allergic, anaphylactic, or other hypersensitivity 
reactions to chimeric or humanized antibodies or fusion 
proteins. 
11. History of bleeding diathesis (eg, hemophilia or von Willebrand 
disease). 
12. Requires treatment with a strong cytochrome P450 3A (CYP3A) 
inhibitor/inducer. 
13. Requires or receiving anticoagulation with warfarin or 
equivalent vitamin K antagonists (eg, phenprocoumon) within 
7 days of first dose of study drug. 
14. Requires treatment with proton-pump inhibitors (eg, 
omeprazole, esomeprazole, lansoprazole, dexlansoprazole, 
rabeprazole, or pantoprazole). 
15. Has received a live vaccine within 30 days of planned start of 
study therapy. 
16. Known history of human immunodeficiency virus (HIV) or 
serologic status indicating active hepatitis C virus (HCV) or 
hepatitis B virus (HBV) infection or any uncontrolled active 
systemic infection.  Subjects with hepatitis B core antibody 
positive who are surface antigen negative or who are hepatitis 

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C antibody positive will need to have a negative polymerase 
chain reaction (PCR) result before enrollment.  Those who are 
hepatitis B surface antigen positive or hepatitis B PCR positive 
and those who are hepatitis C PCR positive will be excluded. 
17. History of stroke or intracranial hemorrhage within 6 months 
before the first dose of study drug. 
18. Major surgical procedure within 28 days of first dose of study 
drug.  Note:  If a subject had major surgery, they must have 
recovered adequately from any toxicity and/or complications 
from the intervention before the first dose of study drug. 
19. Absolute neutrophil count (ANC) < 1.5 x 109/L or platelet count 
< 100 x 109/L or hemoglobin < 8.0 g/dL. 
20. Total bilirubin > 1.5 x ULN; or aspartate aminotransferase 
(AST) or alanine aminotransferase (ALT) > 3.0 x ULN. 
21. Estimated creatinine clearance of < 30 mL/min, calculated 
using the formula of Cockroft and Gault [(140-Age) • Mass 
(kg)/(72 • creatinine mg/dL); multiply by 0.85 if female]. 
22. Breastfeeding or pregnant or expecting to conceive or father 
children within the projected duration of the trial, starting with 
the screening visit through 120 days after the last dose of trial 
treatment. 
23. Is currently participating in a clinical trial and receiving study 
therapy or has participated in a study of an investigational 
agent and received study therapy or used an investigational 
device within 4 weeks of the first dose of treatment. 
24. Immediate family members of the sponsor personnel or site 
staff directly involved with the conduct of this protocol are 
excluded from participating on this study. 
25. Presence of a gastrointestinal ulcer diagnosed by endoscopy 
within 3 months prior to screening. 
Dose Regimen/Route 
of Administration: 
Acalabrutinib is provided as hard gelatin capsules for oral 
administration. 
KEYTRUDA® (pembrolizumab) for injection is provided as a 
100 mg/4 mL (25 mg/mL) solution in a single-use vial or as a 
lyophilized powder for reconstitution (50 mg/vial).  It is 
administered as an IV infusion over 30 minutes. 
Arm 1: 
Pembrolizumab 200 mg every 3 weeks (Q3W) 
Arm 2:  
Dose Level 
Acalabrutinib 
Pembrolizumab 
Starting Dose 
100 mg BID PO 
200 mg Q3W IV 
Level -1 
100 mg QD PO 
200 mg Q3W IV 

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Level -2 
50 mg BID PO 
200 mg Q3W IV 
Abbreviations: BID = twice per day; IV = intravenous, PO = oral; Q3W = every 3 weeks 
 
Concomitant 
Medications: 
The concomitant use of strong inhibitors/inducers of CYP3A or 
P-gp with acalabrutinib should be avoided when possible.  The 
effect of agents that reduce gastric acidity (eg, proton-pump 
inhibitors, H2-receptor antagonists or antacids) on acalabrutinib 
absorption was evaluated in a healthy volunteer study 
(ACE-HV-004).  Results from this study indicate that subjects 
should avoid the use of calcium carbonate-containing drugs or 
supplements and short-acting H2-receptor antagonists for a period 
of at least 2 hours before and after taking acalabrutinib.  Use of 
omeprazole or esomeprazole or any other proton-pump inhibitors 
while taking acalabrutinib is not recommended due to a potential 
decrease in study drug exposure.   
Statistical Methods: 
Descriptive statistics (including means, standard deviations, and 
medians for continuous variables and proportions and confidence 
intervals [CIs] for discrete variables) will be used to summarize 
data as appropriate. 
Statistical Basis for the Sample Size 
For the interim safety analysis (DLT review), enrollment of 
6 subjects in the combination arm for DLT review is consistent with 
sample sizes used in oncology studies for determination of 
maximum tolerated dose (MTD).  The trial employs the standard 
National Cancer Institute definition of MTD (dose associated with 
DLT in ≤ 17% of subjects).  Provided the DLT period is cleared in 
the combination arm, and this arm is not stopped early due to 
futility or toxicity, then up to 31 subjects will be added per arm. 
The sample size for this 2-arm trial was determined by a Z-test for 
normal approximation of binomial distribution, based on one-sided 
α = 0.10, 80% power, with projected response rates of 40% in 
pembrolizumab/acalabrutinib arm and 18% in pembrolizumab arm. 
The final sample size is 37 in each arm.  
 

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1.0 
BACKGROUND INFORMATION 
1.1 
UROTHELIAL CARCINOMA 
In 2014, approximately 141,610 people in the United States will be diagnosed with 
urothelial carcinoma of the bladder, renal pelvis, or ureter (Siegel 2014).  Although 
many newly diagnosed patients have localized disease, urothelial carcinoma is often 
fatal for those diagnosed with metastatic disease.  Approximately 30,350 people are 
anticipated to die from this disease in 2014.  In most patients with localized disease, 
treatment includes localized excision with transurethral resection of bladder tumor 
(TURBT) and intravesicular Bacillus Calmette Guerin (BCG) infusions 
(Martyn-Hemphill 2013). In the ~30% of patients who develop metastatic disease, 
chemotherapy with a platinum-based regimen is the primary treatment (Gartrell 2013). 
Current standard of care first-line therapy includes combination chemotherapy with 
cisplatin or carboplatin with gemcitabine, or the combination of methotrexate, 
vinblastine, adriamycin, and cisplatin (MVAC).  However, because of the inherent 
chemoresistance of bladder cancer, median progression-free survival (PFS) with 
these chemotherapy regimens is approximately 7.4 months (von der Maase 2000). 
The addition of paclitaxel to gemcitabine/cisplatin has improved PFS to 8.3 months 
(Bellmunt 2012).  Currently, second-line therapies are limited, and no therapies have 
been approved by the United States Food and Drug Administration (FDA) for patients 
who survive to undergo second-line treatment.  Survival at 2 years is therefore < 20% 
(Bellmunt 2012).  Thus, while antitumor benefit has been observed with such 
regimens, toxicity is substantial and therapeutic options are limited. Novel, less toxic 
approaches are needed for metastatic, platinum-refractory urothelial carcinoma. 
1.2 
THE ROLE OF STROMA IN UROTHELIAL CARCINOMA 
The importance of the stroma in urothelial carcinoma has been increasingly 
recognized (van der Horst 2012), particularly in its role in tumor progression and 
formation of metastases. Several stromal-changing growth factors, such as FGF2, 
VEGF, PDGF, EGFR ligands, and TGF-β are important in mediating tumor 
progression, supporting tumor associated fibroblasts in urinary bladder tumor 
specimens (Enkelmann 2011).  Tumor-associated fibroblasts have also shown 
increased populations in invasive bladder tumors and not in superficial bladder 
tumors, thus associating with muscle invasion and formation of metastases 
(Alexa 2009).  Furthermore, tumor-associated macrophages have been shown to 
mediate hypoxia-driven angiogenesis, contributing to tumor progression in bladder 

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cancer (Onita 2002).  The TGF-β mediator is also known to shift macrophages from 
an M1 antitumor phenotype to an M2 protumor phenotype, leading to remodeling of 
the microenvironment, angiogenesis, and epithelial plasticity (Fuxe 2012).  In 
summary, urothelial carcinoma exists in a complex desmoplastic microenvironment 
providing stromal support for tumor growth, resembling wound healing, thus 
increasing motility, invasion, and angiogenesis. 
1.3 
PROGRAMMED DEATH LIGAND/RECEPTOR INTERACTIONS IN 
UROTHELIAL CARCINOMA 
Several negative regulatory checkpoint molecules function to check overstimulation of 
immune responses and contribute to the maintenance of immune tolerance to 
self-antigens (McDermott 2013).  These molecules include cytotoxic T-lymphocyte 
antigen-4 (CTLA-4) as well as the programmed death (PD)-1 receptor and its ligands 
(PD-L1 and PD-L2). CTLA-4 acts as a signal dampener that acts largely within the 
lymph nodes to regulate the magnitude of early activation of naive and memory 
T cells.  By contrast, PD-1 is induced on T cells after activation in response to 
inflammatory signals and limits T-cell function at sites of infection or tumor in 
peripheral tissues.  As the T-cell response increases, these negative regulatory 
molecules are induced, limiting the magnitude and duration of the response to prevent 
healthy tissue damage.  Tumors are capable of exploiting the homeostatic 
mechanisms regulated by these checkpoint molecules, thus limiting immune 
destruction.  
Such checkpoint pathways appear to be operative in urothelial carcinoma. 
Immunohistochemistry analyses have shown PD-L1 positivity is associated with 
increased staging, high-grade tumors, and tissue-infiltrating mononuclear cells in 
urothelial carcinoma (Inman 2007).  In a series of 318 patients with urothelial 
carcinoma, PD-L1 and PD-1 expression were associated with advanced disease, and 
PD-L1 expression independently predicted for mortality (Boorjian 2008).  PD-L1 
expression may protect cancer cells from immune-mediated destruction.  In a clinical 
study of subjects with urothelial carcinoma evaluating the efficacy of an anti-PD-L1 
antibody, high expression of PD-L1 in tumor-infiltrating immune cells correlated with a 
higher overall response rate (ORR, 40% to 50%) compared with an ORR of 13% and 
8% for low PD-L1 or no PD-L1 expression (Powles 2014).  In a clinical study of the 
anti-PD-1 monoclonal antibody, pembrolizumab, in subjects with recurrent or 
metastatic urothelial carcinoma, a 24% ORR, including 10% CR rate, was observed 

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across the 33 subjects treated.  Analysis of the relationship between PD-L1 
expression and pembrolizumab efficacy was pending at the time of publication 
(Plimack 2014).  
1.4 
BRUTON TYROSINE KINASE INHIBITION IN CANCER 
Bruton tyrosine kinase (BTK) is a non-receptor enzyme in the Tec kinase family that is 
expressed among cells of hematopoietic origin, including B cells, myeloid cells, mast 
cells and platelets, where it regulates multiple cellular processes including 
proliferation, differentiation, apoptosis, and cell migration (Khan 2001, 
Mohamed 2009, Bradshaw 2010).  In addition, BTK-dependent activation of mast 
cells, myeloid cells, and other immunocytes in peritumoral inflammatory stroma has 
been shown to sustain the complex microenvironment needed for lymphoid and solid 
tumor maintenance (Soucek 2011, Ponader 2012, de Rooij 2012).  Taken together, 
these findings suggest inhibition of BTK may offer an attractive strategy for treating 
B-cell neoplasms, other hematologic malignancies, and solid tumors.   
In model systems, ex vivo analyses demonstrated BTK inhibition results in 
macrophages that polarize into M1 macrophages, instead of showing enhanced 
induction of immunosuppressive M2 macrophages (Ni Gabhann 2014, 
Lannutti personal communication).  These data suggest inhibition of BTK may impair 
the capacity of tumor-associated macrophages critical for promotion of tumor invasion 
and metastasis (Mouchemore 2013).  Several lines of evidence demonstrate BTK 
inhibition interferes with cross-talk between malignant cells and their 
microenvironment, suggesting disruption of intrinsic and extrinsic survival signals may 
be a critical mechanism for the clinical activity of BTK inhibitors (Ponader 2012, 
Herman 2013).  Furthermore, epithelial derived tumors contain large numbers of 
tumor-associated macrophages (TAMs), which are the dominant innate immune cell 
in mammary cancers of humans (Pollard 2009).  Therefore, the clinical usefulness of 
BTK inhibitors may extend to the treatment of invasive solid tumors. 
BTK is also a signaling hub in immature myeloid cells known as myeloid derived 
suppressor cells (MDSCs) (Schmidt 2004).  Recent evidence suggests MDSC play an 
important part in suppression of host immune responses through several mechanisms 
such as production of arginase 1, release of reactive oxygen species, nitric oxide and 
secretion of immune-suppressive cytokines.  This leads to an immunosuppressive 

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environment necessary for the growth of malignant cells (Condamine 2014, 
Wesolowski 2013).   
Immune evasion is one of the multiple characteristics of cancer.  Monoclonal 
antibodies that block negative regulators of T cells, such as PD-1, amplify immune 
responses.  Antibodies against PD-1 are showing impressive results in advanced 
hematologic and solid malignancies (Hamid 2013, Westin 2014, Berger 2008, 
Topalian 2014).  nterestingly, studies examining circulating MDSCs in anti-CTL4 and 
anti-PD-1/PD-L1-treated patients have shown alterations in the myeloid cell 
compartment correlate with clinical outcome.  Specifically, solid tumor progressors 
had proportionally higher circulating MDSC levels and a high myeloid gene signature 
(Powles 2014, Heery 2014, Weide 2014, Meyer 2014).  Recent preclinical results 
show elevated MDSC levels are responsible for this lack of response and elimination 
of MDSCs may lead to increased efficacy with immune checkpoint blockade 
(Highfill 2014, Kim 2014).  
Given the potential for BTK inhibition to affect TAMs and MDSCs, single-agent 
acalabrutinib was evaluated in mice with advanced pancreatic cancer arising as the 
result of genetic modifications of oncogenes KRAS and p53, and the pancreatic 
differentiation promoter PDX-1 (KPC mice).  The KPC mouse model recapitulates 
many of the molecular, histopathologic, and clinical features of human disease 
(Westphalen 2012).  Mice were enrolled after identification of spontaneously 
appearing tumors in the pancreas that were ≥100 mm3 (as assessed by 
high-resolution ultrasonography).  Mice were treated with vehicle (N=6) or 
acalabrutinib administered orally at a dosage of 15 mg/kg/dose twice per day (BID) 
(N=6).  As shown in Figure 1-1, treatment with single-agent acalabrutinib substantially 
slowed pancreatic cancer growth and increased animal survival.  

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Figure 1-1.  Efficacy of Acalabrutinib Monotherapy in a Genetic Model of 
Pancreatic Cancer 
 
Abbreviation:  ACP-196 = acalabrutinib. 
Analysis of tumor tissues showed that immunosuppressive TAMs 
(CD11b+Ly6ClowF4/80+Csf1r+), MDSCs (Gr1+Ly6CHi), and Treg (CD4+CD25+FoxP3+) 
were significantly reduced with acalabrutinib treatment by 47%, 30%, and 20%, 
respectively (Figure 1-2).  As expected the decrease in these immunosuppressive cell 
subsets correlated with a significant increase in CD8+ cells (Figure 1-3).  
Figure 1-2.  Effects of Acalabrutinib on Tumor-Associated  
Immunosuppressive Cells in a Genetic Model of Pancreatic Cancer 
 
Abbreviations: ACP-196 = acalabrutinib; MDSC = myeloid-derived suppressor cell; TAM = tumor-
associated macrophage; Treg = regulatory T cell. 

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Figure 1-3.  Effects of Acalabrutinib on Cytolytic T Cells in a Genetic Model of 
Pancreatic Cancer 
 
Abbreviation:  ACP-196 = acalabrutinib. 
Similar single-agent activity was also observed with acalabrutinib (15 mg/kg BID) in 
the ID8 syngeneic orthotopic ovarian model.  Figure 1-4 shows a substantial decrease 
of tumor growth in this model with acalabrutinib monotherapy compared with vehicle.  
This antitumor effect correlated with a significant decrease in immunosuppressor cells 
and an increase in cytolytic T cells similar to the KPC pancreatic model. 
Figure 1-4.  Acalabrutinib Impairs ID8 Ovarian Cancer Growth and Decreased 
Immunosuppressive Cellular Subsets in Syngeneic Murine Model 
 
Abbreviations: ACP-196 = acalabrutinib; MDSC=myeloid-derived suppressor cell. 

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Lastly, the activity of acalabrutinib was confirmed in an orthotopic mouse model 
evaluating both single-agent and combination efficacy.  In this study, 10,000 KPC 
mouse pancreatic cancer cells were injected into the pancreases of 24 female mice. 
After one week of expansion, drug treatment was started in mice developing 
pancreatic tumors. Animals were treated with vehicle (N=6); acalabrutinib, 
15 mg/kg/BID given orally (N=6); gemcitabine 50 mg/kg intravenous (IV) administered 
every 4 days for 3 injections (N=6); or acalabrutinib, 15 mg/kg/BID given orally 
together with gemcitabine, 50 mg/kg IV administered every 4 days for 3 injections 
(N=6).  At 2 weeks after initiation of treatment, mice in the vehicle group showed 
signs of deteriorating health and all groups were euthanized.  Tumors were collected 
and measured (Figure 1-5); relative to the vehicle treatment, acalabrutinib 
monotherapy resulted in a 2-fold reduction in tumor growth, results which compared 
favorably with gemcitabine alone.  The combination of acalabrutinib and gemcitabine 
resulted in a further reduction in tumor growth when compared to each single agent. 
Figure 1-5.  Efficacy of Acalabrutinib Monotherapy and Combination Therapy  
with Gemcitabine in an Orthotopic Model of Pancreatic Cancer 
 
Abbreviations: ACP-196 = acalabrutinib; Gem = gemcitabine. 
In summary, acalabrutinib alone and in combination with gemcitabine produces robust 
antitumor effects in established solid tumor models.  The antitumor effect observed 
with acalabrutinib correlates with biomarkers of response similar to those reported for 
other immunomodulating agents such as inhibitors of CTLA-4, PD-1 and PD-L1.   

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1.5 
A CASE FOR COMBINATION BTK AND CHECKPOINT BLOCKADE 
To determine whether there is potential synergy between BTK inhibition and PD-1 
blockade, Acerta has conducted a nonclinical study of acalabrutinib in combination 
with an anti-PD-L1 antibody in an orthotopic colon cancer murine model.  Mice were 
inoculated with syngeneic CT26 colorectal cancer cells on Day 0; Anti-PD-L1 (150 μg 
on Day 6, 9, 12, 15) and acalabrutinib (15 mg/kg BID) treatment was begun on Day 6, 
when the tumor was well established.  Treatment with anti-PD-L1 as a single agent 
reduced tumor growth, but tumor regression was not observed (Figure 1-6). However, 
combined anti-PD-L1 and acalabrutinib treatment showed a further reduction in tumor 
growth (anti-PD-L1, 820 mm3 vs anti-PD-L1/acalabrutinib, 411 mm3).  Most strikingly, 
6 of 9 animals displayed tumor regression (Figure 1-6).  These results suggest the 
combination therapy of BTK inhibition and PD-1 blockade leads to greater benefit 
compared with PD-1 blockade alone. 
Figure 1-6.  Acalabrutinib Enhances the Antitumor Effects of α-PD-L1 in the 
Orthotopic CT26 Colon Cancer Model 
 
Abbreviation:  ACP-196 = acalabrutinib. 
In the tumor microenvironment, we observed a significant reduction in the number of 
MDSCs within the tumor in mice treated with the anti-PD-L1/acalabrutinib combination 
when compared with anti-PD-L1 treatment alone (Figure 1-7).  The decrease of 
MDSCs is directly related to BTK inhibition.  This effect has been observed in 
monotherapy studies of acalabrutinib in murine pancreatic and ovarian cancer models 
(as described in Section 1.4).  Together, these data implicate tumor-associated 
MDSCs in preventing the full benefit of immune checkpoint blockade and offer a 
translatable, therapeutic option by targeting the MDSCs population with acalabrutinib 
to improve the efficacy of checkpoint blockade. 

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Figure 1-7.  BTK Inhibition Leads to Modulation of Infiltrating Immature Myeloid 
Cells Which Can Limit the Activity of Anti-PD-L1 Antibodies 
 
Abbreviation:  ACP-196 = acalabrutinib. 
This proof-of-concept study will assess the clinical potential of combined BTK 
inhibition and checkpoint blockade by evaluating the safety, PD, and efficacy of 
acalabrutinib and pembrolizumab in subjects with previously treated metastatic 
urothelial carcinoma. 
Summaries of preclinical and clinical studies for acalabrutinib are provided below.  For 
more detailed information please refer to the investigator brochure for acalabrutinib.  
For detailed information on pembrolizumab refer to the KEYTRUDA package insert 
provided in Appendix 6 or to the investigator brochure for pembrolizumab. 
1.6 
ACALABRUTINIB 
Acalabrutinib is an imidazopyrazine analogue with a molecular weight of 465.5 g/mol. 
The compound has 1 stereogenic center and acalabrutinib is the S-enantiomer. 
Acalabrutinib is orally administered in animals and is suitable for formulating in 
capsules.  For clinical testing, acalabrutinib has been manufactured and formulated 
according to current Good Manufacturing Practices (cGMP). 
Acalabrutinib is an investigational product and has not been approved for marketing in 
any country.   

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1.6.1 
Mechanism of Action 
Acalabrutinib was specifically designed to be a more potent and selective inhibitor of 
BTK to avoid off-target side effects as seen with ibrutinib.  When profiled against 
395 human kinases, acalabrutinib is more selective than ibrutinib (Covey 2015).  For 
additional details, refer to the Acalabrutinib Investigator Brochure.   
1.6.2 
Safety Pharmacology 
In vitro and in vivo safety pharmacology studies with acalabrutinib have demonstrated 
a favorable nonclinical safety profile.  
When screened at 10 μM in binding assays evaluating interactions with 80 known 
pharmacologic targets such as G-protein-coupled receptors, nuclear receptors, 
proteases, and ion channels, acalabrutinib shows significant activity only against the 
A3 adenosine receptor; follow-up dose-response experiments indicated an IC50 of 
2.7 µM, suggesting a low clinical risk of off-target effects.  
The in vitro effect of acalabrutinib on human ether-à-go-go-related gene (hERG) 
channel activity was investigated in vitro in human embryonic kidney cells stably 
transfected with hERG.  Acalabrutinib inhibited hERG channel activity by 25% at 
10 μM, suggesting a low clinical risk that acalabrutinib would induce clinical QT 
prolongation as predicted by this assay. 
Acalabrutinib was well tolerated in standard in vivo Good Laboratory Practices (GLP) 
studies of pharmacologic safety.  A functional observation battery in rats at doses 
through 300 mg/kg (the highest dose level) revealed no adverse effects on 
neurobehavioral effects or body temperature.  A study of respiratory function in rats 
also indicated no treatment-related adverse effects at doses through 300 mg/kg (the 
highest dose level).  In a cardiovascular function study in awake telemeterized male 
Beagle dogs, single doses of acalabrutinib at dose levels through 30 mg/kg (the 
highest dose level) induced no meaningful changes in body temperature, 
cardiovascular, or electrocardiographic (including QT interval) parameters.  The 
results suggest that acalabrutinib is unlikely to cause serious off-target effects or 
adverse effects on critical organ systems. 
1.6.3 
Drug-drug Interaction Potential 
For more detailed information on drug-drug interaction potential for acalabrutinib, refer 
to the Investigator Brochure. 

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Please refer to Section 3.10.4 for guidance on drugs that may cause drug-drug 
interactions. 
1.7 
IN VIVO GENERAL TOXICOLOGY – ACALABRUTINIB 
The systemic toxicity of acalabrutinib has been investigated in six repeat-dose 
general toxicology studies, three with recovery periods, in the rat and the dog.  The 
pivotal GLP studies were two 28-day repeat dose studies in Sprague Dawley rats with 
32- and 28-day recovery periods, and a 28-day study in Beagle dogs with a 28-day 
recovery period. 
The no observed adverse effect level (NOAEL) in the dog was 30 mg/kg/day, which 
was the highest dose evaluated. In rats, 30 mg/kg/day resulted in minimal 
inflammation of the pancreas in some animals, with reversal, indicating the rat to be 
the more sensitive preclinical species.  The pancreatic effects were minimally 
increased at 100 mg/kg/day in the rat though there was no clinical evidence of 
toxicity.  Hence, 100 mg/kg/day was selected to conservatively represent the highest 
non-severely toxic dose (HNSTD).  The pancreatic findings were investigated in 
subsequent rat toxicology studies and found to be treatment related, non-adverse at 
lower doses, and not associated with systemic toxicity or changes in biomarkers of 
pancreatic function.  The islet cell changes resemble a spontaneous pancreatic lesion 
that is described as an age-related finding in male rats of this strain.  In dogs at 
30 mg/kg/day, there were no microscopic findings in the pancreas, and all clinical 
biomarkers of pancreatic function were normal.  
In rats and dogs, no adverse ECG or histopathologic cardiovascular effects were 
noted at the planned conclusion of the 28-day toxicology studies.  However, in 5 of 
6 rats from the 300-mg/kg dose group that died early in the study, slight to moderate 
necrosis of the myocardium and/or white blood cell infiltration/inflammation of the 
myocardium were noted on microscopic examination of the hearts.  These findings 
were most likely incidental postmortem changes. 
1.8 
CLINICAL EXPERIENCE – ACALABRUTINIB 
For more detailed information on the clinical experience for acalabrutinib please refer 
to the Investigator Brochure.   

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1.8.1 
Pharmacokinetics and Pharmacodynamics of Acalabrutinib 
ACE-HV-001 was a PK/pharmacodynamic (PD), dose-ranging, food-effect, and 
drug-drug interaction study evaluating BID and QD dosing for 1 or 2 days in healthy 
volunteers.  This study evaluated the PK/PD of acalabrutinib at various dose levels 
and regimens.  The starting dose for acalabrutinib was 2.5 mg BID.  This study has 
been completed and no adverse laboratory, vital signs, or ECG findings were 
observed (2.5 to 50 mg BID; 50 to 100 mg QD).  Three adverse events (AEs) related 
to study drug were reported.  Each AE was Grade 1 and resolved without treatment.  
The AEs were constipation (2.5 mg BID), feeling cold (75 mg QD), and somnolence 
(75 mg QD). 
In Part 1, PK properties of acalabrutinib were evaluated after oral administration of 2 
daily divided doses of 2.5 to 50 mg and a single dose of 100 mg.  Of the 30 subjects 
evaluated, all had observed systemic concentrations of acalabrutinib.  Acalabrutinib 
plasma time to maximum concentration (Tmax) values were between 0.5 and 1.0 hour 
for all dose cohorts and were independent of dose level.  The increase in mean Cmax 
values was greater than dose proportional based on the increases of Cmax from the 
first dose administered.  When evaluating AUC0-12, AUC0-24 or AUC0-inf, the mean 
values increased in a dose-proportional manner based on the increases of the total 
dose administered.  Mean half-life (t1/2) values ranged from 0.97 to 2.1 hours, and 
appeared to decrease as the dose increased.  The mean calculated oral clearance 
(CL/F: 165 to 219 L/h) and volume of distribution values (Vz/F: 233 to 612 L) 
appeared to be independent of the dose administered. 
Acalabrutinib was not detected in the urine of subjects receiving the 2.5- or 5.0-mg 
BID doses of acalabrutinib.  Acalabrutinib was detected in urine of other subjects 
(0.4% to 0.6% of dose) and amounts increased in a dose-dependent manner. 
In Part 2, the effect of food on the PK of acalabrutinib (75 mg) after a single oral 
administration was evaluated in 6 men and 6 women.  Median time to maximum 
plasma acalabrutinib (Tmax) values were increased in the fed state (2.5 hours) relative 
to the fasted state (0.5 hour).  The mean plasma acalabrutinib Cmax fed values 
decreased to 27.3% of the Cmax values observed in the fasted state.  In contrast, the 
relative AUC exposure of acalabrutinib remained mostly unchanged in both states.  

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In Part 3, the effect of itraconazole on the PK of acalabrutinib (50 mg) after a single 
oral administration was evaluated in 17 subjects.  No difference in acalabrutinib Tmax 
values was observed in the presence or absence of itraconazole. 
Mean acalabrutinib exposures (as assessed by Cmax, AUC0-last, AUC0-24, and AUC0-inf) 
increased in the presence of itraconazole.  The mean plasma acalabrutinib Cmax 
values increased 3.7-fold in the presence of itraconazole.  The mean plasma 
AUC0-last, AUC0-24, and AUC0-inf values also increased between 4.9- to 5.1-fold in the 
presence of itraconazole. Mean CL/F and Vz/F values decreased in the presence of 
itraconazole (CL/F: 217 vs 44 L/h; Vz/F: 1190 vs 184 L).  No differences in half-life 
values were observed (3.3 vs 2.5 hours). 
The PD of acalabrutinib was evaluated using a BTK occupancy assay and correlated 
with a functional assay that determines the level of BTK inhibition by measuring 
expression of CD69 and CD86 on B cells.  A dose-dependent increase in BTK 
occupancy and corresponding decrease in CD69/86 expression was observed in this 
study.  Full BTK occupancy (≥ 90%) and complete CD86 and CD69 inhibition (≥ 90%) 
occurred at the 75- and 100-mg single dosed cohorts 1 to 3 hours after 
administration.  However, only the 100-mg cohort maintained high BTK occupancy 
(91.5%) and high BCR functional inhibition (CD86: 86 ± 3% and CD69: 78 ± 8%) at 
24 hours.  For subjects receiving a second dose of acalabrutinib 12 hours after the 
first administration, full BTK target occupancy was observed 3 hours after the second 
dose for the 50-mg dosed cohort (BTK occupancy 97 ± 4%). 
1.8.2 
Acalabrutinib in CLL 
As of 01 October 2015, acalabrutinib has been administered to > 800 participants in 
clinical studies, including subjects with hematologic malignancies, solid tumors, or 
rheumatoid arthritis, and participants who are healthy volunteers or with mild to 
moderate hepatic impairment.  No SAEs have been reported in the hepatic 
impairment study or in the healthy volunteer studies.  For more detailed information 
on the clinical experience for acalabrutinib, please refer to the Investigator Brochure.   
This section briefly summarizes data from ACE-CL-001 (NCT02029443), an ongoing 
non-randomized, sequential group, dose-escalation Phase 1/2 study in subjects with 
relapsed/refractory or previously untreated CLL, Richter’s syndrome, or 
prolymphocytic leukemia. 

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As of 01 October 2015, 60 subjects with relapsed CLL have been evaluated for tumor 
response based on International Working Group response criteria (Hallek 2008) as 
recently updated (Cheson 2012) to include PR with treatment-induced lymphocytosis 
(PRL).  With a median follow up of 14.3 months, an ORR of 95% has been observed 
(Byrd 2016).  Few subjects have had disease progression and no Richter’s 
transformation has been observed in these subjects. 
1.9 
KEYTRUDA (PEMBROLIZUMAB) 
Pembrolizumab (Keytruda [United States]), a humanized monoclonal antibody against 
the programmed death receptor-1 (PD-1) protein, has been developed by Merck & Co 
for the treatment of patients with cancer.  Pembrolizumab is approved for treatment of 
patients with melanoma in several countries; in the United States and European 
Union it is approved for the treatment of adult patients with advanced (unresectable or 
metastatic) melanoma. Pembrolizumab has also been approved for treatment of 
patients with non-small cell lung cancer (NSCLC) in several countries; in the United 
States it is indicated for the treatment of patients with metastatic NSCLC whose 
tumors express PD-L1 as determined by an FDA-approved test and who have 
disease progression on or after platinum-containing chemotherapy.  Patients with 
NSCLC and EGFR or ALK genomic tumor aberrations should also have disease 
progression on FDA-approved therapy for these aberrations prior to receiving 
pembrolizumab.  For complete information on pembrolizumab refer to the 
KEYTRUDA package insert (Appendix 6) or the Pembrolizumab Investigator 
Brochure.   
Serious adverse reactions associated with pembrolizumab are described in the 
package insert (Appendix 6) and also Section 3.8.1 of this protocol. 
1.10 BENEFIT/RISK 
Acalabrutinib is a potent, orally administered small-molecule inhibitor of BTK.  A 
PK/PD study has been completed with acalabrutinib in healthy volunteers 
(ACE-HV-001; Section 1.8.1).  The safety results showed no safety risk was identified 
in healthy subjects receiving 1 or 2 days of acalabrutinib ≤ 100 mg.  In the Phase 1/2 
study of acalabrutinib in subjects with CLL, an ORR of 95% has been observed with a 
median follow-up of 14.3 months.  In summary, the preliminary data suggest that 
acalabrutinib is well tolerated and has robust activity as a single agent in the 
treatment of subjects with CLL including those with 17p del.   

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The nonclinical and toxicology results of acalabrutinib suggest it may have an 
improved therapeutic window relative to ibrutinib; it may be more readily combined 
with other agents for the treatment of cancer.  Based on the currently known toxicity 
profiles of acalabrutinib and pembrolizumab overlapping toxicities are not anticipated.  
Preliminary results in preclinical cancer models suggests a synergistic antitumor 
effect of BTK inhibition in combination with PD-1 blockade, which support evaluating 
the combination in clinical trials. 
2.0 
STUDY OBJECTIVES 
2.1 
PRIMARY OBJECTIVES: 
• 
To characterize the safety profile of acalabrutinib and pembrolizumab in 
subjects with metastatic, platinum-refractory bladder cancer 
• 
To determine the BOR and ORR of pembrolizumab monotherapy and the 
combination of acalabrutinib and pembrolizumab in subjects with metastatic, 
platinum-refractory bladder cancer 
2.2 
SECONDARY OBJECTIVES: 
• 
To determine PFS in subjects treated with pembrolizumab monotherapy and 
the combination of acalabrutinib and pembrolizumab 
• 
To evaluate the OS in subjects treated with pembrolizumab monotherapy and 
the combination of acalabrutinib and pembrolizumab 
2.3 
EXPLORATORY OBJECTIVES 
• 
Determine the effects of acalabrutinib plus pembrolizumab on peripheral blood 
T cells and MDSCs 
• 
Determine the PK of acalabrutinib alone and in combination with 
pembrolizumab 
• 
Determine if any characteristics of peripheral blood T cells and/or MDSCs 
correlate with immune-mediated toxicities 
• 
Determine if any characteristics of peripheral blood T cells and/or MDSCs 
correlate with response to acalabrutinib and pembrolizumab  
• 
Determine if any baseline tumor characteristics correlate with response to 
acalabrutinib and pembrolizumab 
• 
Evaluate the efficacy of adding acalabrutinib to pembrolizumab in subjects 
who progress on pembrolizumab monotherapy 
3.0 
STUDY DESIGN 
This clinical trial is a Phase 2, multicenter, open-label, randomized study evaluating 
pembrolizumab monotherapy and the combination of acalabrutinib and 

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pembrolizumab in subjects who have metastatic bladder cancer with disease 
progression on or after platinum-based chemotherapy.  
Subjects meeting the eligibility criteria for the study will be randomized 1:1 to one of 
the following arms: 
Arm 1:  Pembrolizumab 200 mg administered as an IV infusion every 3 weeks (Q3W) 
Arm 2:  Acalabrutinib 100 mg administered PO BID plus pembrolizumab 200 mg IV 
Q3W 
Although acalabrutinib has not demonstrated any DLTs to date the safety of 
acalabrutinib in combination with pembrolizumab in this patient population needs to 
be assessed and standard DLT criteria will be applied to Arm 2 of the study.  
Therefore an interim safety analysis will occur once 6 subjects have been 
successfully randomized to the combination arm (Arm 2) and have been treated a 
minimum of 4 weeks.  Enrollment will be paused while the interim safety analysis 
occurs.  If a DLT rate of < 33%  is observed in Arm 2 (ie, DLT review is cleared), then 
randomization will continue to evaluate the objective response rates of 
pembrolizumab monotherapy and the combination of pembrolizumab and 
acalabrutinib (ie, up to 37 total subjects per arm).  If a DLT rate of ≥ 33% is observed 
in Arm 2, then enrollment (1:1) will continue until an additional 6 subjects are 
randomized to Arm 2 and consideration will be given to reducing the dose of 
acalabrutinib (Level -1), taking into account the nature of the DLTs and the DLT rate 
in the single-agent arm.  In addition, analyses for continuous futility and toxicity 
monitoring will also be done as outlined in Section 5.5. 
Acalabrutinib treatment can continue for subjects who are tolerating therapy and not 
progressing.  Pembrolizumab treatment is for 24 months from the date of first dose for 
subjects who are tolerating therapy and not progressing.  Subjects who progress on 
the combination of pembrolizumab and acalabrutinib will discontinue study treatment 
while those with progression of disease in the pembrolizumab monotherapy arm will 
continue on pembrolizumab with the addition of acalabrutinib until a second disease 
progression.  For subjects who cross over to receive combination treatment, 
acalabrutinib treatment will begin at the next visit at which subjects are scheduled to 
receive pembrolizumab.  The dose of acalabrutinib for these subjects will be 
determined based on the DLT review of Arm 2.  Disease progression will be 
determined based on irRECIST guidelines (Appendix 8 and detailed in Section 3.11).  

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Also pembrolizumab treatment can end for subjects with confirmed CR if treatment 
has been administered for at least 24 weeks and 2 doses of pembrolizumab have 
been administered after confirmation of CR.  The end of study is defined as 
12 months after the last subject is randomized.   
All subjects will have hematology, chemistry, and urinalysis safety panels performed 
at screening.  Once dosing commences (Day 1), all subjects will be evaluated for 
safety, including serum chemistry, serum amylase and lipase, and hematology. 
Pharmacodynamic and PK testing will be performed during the first few months of 
treatment.  Radiologic tumor assessments will be completed at baseline and at 
~6-week intervals during the trial.  Subjects who discontinue study drug for any 
reason other than disease progression, death, lost to follow-up, or withdrawal of 
consent will be followed for tumor assessment until disease progression or initiation of 
any other anticancer therapies, whichever comes first. 
Refer to Appendix 4 and Appendix 5 for comprehensive lists of study assessments 
and their timing.  The study schema is provided below (Figure 3-1). 

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Figure 3-1.  Study Schema 
 
Abbreviations:  ACP-196 = acalabrutinib; BID = twice per day; IV = intravenous; Q3W = every 3 weeks. 
*Acalabrutinib and pembrolizumab administration begin on the same day except for the first 6 subjects 
enrolled due to pharmacokinetic sampling.  In the first 6 subjects, acalabrutinib will be administered on 
Day 1 of Week 1.  On Day 2 of Week 1, the first pembrolizumab infusion will occur.  When both are 
administered on the same day, acalabrutinib is administered first followed by the pembrolizumab 
infusion. 
3.1 
STUDY PARAMETERS 
3.1.1 
Safety Parameters 
The safety of acalabrutinib and pembrolizumab will be characterized by the type, 
frequency, severity, timing of onset, duration, and relationship to study drug(s) of any 

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treatment-emergent AEs or abnormalities of laboratory tests; SAEs; DLTs or AEs 
leading to discontinuation of study treatment.  
3.1.2 
Pharmacodynamic and Biomarker Parameters 
The occupancy of BTK by acalabrutinib will be measured in peripheral blood 
mononuclear cells (PBMCs) with the aid of a biotin-tagged acalabrutinib analogue 
probe.  The effect of acalabrutinib and pembrolizumab on B cells, T cells and MDSCs 
will also be evaluated.  Tumor tissue, when available, will be evaluated for PD-L1 
expression.  Additional exploratory correlative studies of tumor tissue, when available, 
may include characterization of tumor subtypes by immunohistochemistry, gene 
expression or mutation analysis.   
The following PK parameters will be calculated, whenever possible, from plasma 
concentrations of acalabrutinib: 
• 
AUC0-last:  Area under the plasma concentration-time curve calculated using 
linear trapezoidal summation from time 0 to time last, where “last” is the time 
of the last measurable concentration. 
• 
AUC0-12:  Area under the plasma concentration-time curve from 0 to 12 hours, 
calculated using linear trapezoidal summation. 
• 
AUC0-inf:  Area under the plasma concentration-time curve from 0 to infinity, 
calculated using the formula: AUC0-inf = AUC0-last + Clast / λz, where λz is the 
apparent terminal elimination rate constant. 
• 
AUC0-24calc:  Area under the plasma concentration-time curve from 0 to 
24 hours, calculated by doubling the value for AUC0-12 
• 
Cmax:  Maximum observed plasma concentration 
• 
Tmax:  Time of the maximum plasma concentration (obtained without 
interpolation) 
• 
t½:  Terminal elimination half-life (whenever possible) 
• 
λz: Terminal elimination rate constant (whenever possible) 
• 
CL/F:  Oral clearance 
• 
Vz/F:  Oral volume of distribution 
3.1.3 
Efficacy Parameters 
Efficacy will be evaluated based on assessments of tumor response and progression 
using the standardized Response Evaluation Criteria in Solid Tumors (RECIST), 
Version 1.1 (Eisenhauer 2009; Appendix 7). 
Efficacy endpoints will include: 

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• 
Best overall response rate (BOR) 
• 
Overall response rate (ORR)  
• 
Disease control rate (DCR) 
• 
Duration of response (DOR) 
• 
Progression-free survival (PFS) 
• 
Overall survival (OS) 
Exploratory efficacy endpoints in this study will use the immune-related response 
criteria (irRECIST) to take into account the clinical finding that some study subjects 
receiving immunotherapies can experience transient increases in lesion size or new 
lesions (“pseudoprogression”) before immunotherapy-induced tumor regression 
(Wolchok 2009, Hamid 2013, Nishino 2013, Bohnsack 2014).  Guidelines on the 
irRECIST are provided in Appendix 8.  
Efficacy endpoints will include: 
• 
irBOR  
• 
irORR (irCR + irPR) 
• 
irDCR (irCR + irPR + irSD) 
• 
irDOR 
• 
irPFS 
3.2 
RATIONALE FOR STUDY DESIGN AND DOSING REGIMEN 
As described in Section 1.8, acalabrutinib is currently being evaluated in a Phase 1/2 
study in subjects with CLL (ACE-CL-001).  In this study, subjects have received oral 
dosages of 100 to 400 mg QD and 100 to 200 mg BID of acalabrutinib.  All tested 
dose levels have been well tolerated and, to date, no drug-related toxicities have 
been observed.  Robust clinical responses have been observed with dosages as low 
as 100 mg QD.  Preliminary PK data from ACE-CL-001 suggests a plateauing of 
exposure after 250 mg QD.  Pharmcodynamic results from this study also show 100 
and 200 mg BID have the highest BTK occupancy at 24 hours of all the regimens 
evaluated.   
The dose of pembrolizumab planned to be studied in this trial is 200 mg Q3W.  The 
dose recently approved in the United States and several other countries for treatment 

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of melanoma subjects is 2 mg/kg Q3W.  Information on the rationale for selecting 
200 mg Q3W is summarized below. 
KEYNOTE-001 was an open-label Phase 1 study conducted to evaluate the safety, 
tolerability, PK and PD, and anti-tumor activity of pembrolizumab when administered 
as monotherapy.  The dose escalation portion of this trial evaluated 3 dose levels, 
1 mg/kg, 3 mg/kg and 10 mg/kg, administered every 2 weeks (Q2W) and dose 
expansion cohorts evaluated 2 mg/kg Q3W and 10 mg/kg Q3W in subjects with 
advanced solid tumors.  All dose levels were well tolerated and no DLTs were 
observed.  This first-in-human study of pembrolizumab showed evidence of target 
engagement and objective evidence of tumor size reduction at all dose levels.  No 
MTD has been identified.  In addition, 2 randomized cohort evaluations of melanoma 
subjects receiving pembrolizumab at a dose of 2 mg/kg versus 10 mg/kg Q3W have 
been completed, and 1 randomized cohort evaluating 10 mg/kg Q3W versus 
10 mg/kg Q2W has also been completed.  The clinical efficacy and safety data 
demonstrate a lack of important differences in efficacy or safety profile across doses.  
An integrated body of evidence suggests that 200 mg Q3W is expected to provide 
similar response to 2 mg/kg Q3W, 10 mg/kg Q3W and 10 mg/kg Q2W.  Previously, a 
flat pembrolizumab exposure-response relationship for efficacy and safety has been 
found in subjects with melanoma in the range of doses between 2 mg/kg and 
10 mg/kg.  Exposures for 200 mg Q3W are expected to lie within this range and will 
be close to those obtained with 2 mg/kg Q3W dose.   
A population pharmacokinetic (PK) model, which characterized the influence of body 
weight and other patient covariates on exposure, has been developed.  The PK profile 
of pembrolizumab is consistent with that of other humanized monoclonal antibodies, 
which typically have a low clearance and a limited volume of distribution.  The 
distribution of exposures from the 200 mg fixed dose are predicted to considerably 
overlap those obtained with the 2 mg/kg dose and importantly will maintain individual 
patient exposures within the exposure range established in melanoma as associated 
with maximal clinical response.  Pharmacokinetic properties of pembrolizumab, and 
specifically the weight-dependency in clearance and volume of distribution are 
consistent with no meaningful advantage to weight-based dosing relative to fixed 
dosing. 

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In translating to other tumor indications, similarly flat exposure-response relationships 
for efficacy and safety as observed in subjects with melanoma can be expected, as 
the anti-tumor effect of pembrolizumab is driven through immune system activation 
rather than through a direct interaction with tumor cells, rendering it independent of 
the specific tumor type.  In addition, available PK results in subjects with melanoma, 
NSCLC, and other tumor types support a lack of meaningful difference in 
pharmacokinetic exposures obtained at tested doses among tumor types.  Thus the 
200 mg Q3W fixed-dose regimen is considered an appropriate fixed dose for other 
tumor indications as well.   
A fixed dose regimen will simplify the dosing regimen to be more convenient for 
physicians and to reduce potential for dosing errors.  A fixed dosing scheme will also 
reduce complexity in the logistical chain at treatment facilities and reduce wastage.  
The existing data suggest 200 mg Q3W as the appropriate dose for pembrolizumab.  
As described in Section 1.5, Acerta Pharma has conducted a nonclinical study to 
evaluate the potential synergy of BTK inhibition with PD-1 blockade and has seen 
encouraging results which warrant testing the hypothesis in a clinical trial.   
3.3 
SELECTION OF STUDY POPULATION 
3.3.1 
Inclusion Criteria 
Eligible subjects will be considered for inclusion in this study if they meet all of the 
following criteria:  
1. Men and women ≥ 18 years of age. 
2. Histologically or cytologically confirmed urothelial carcinoma of the bladder or 
mixed histology bladder cancer. 
3. Presence of metastic bladder cancer that has either progressed during or after 
platinum-based chemotherapy administered for metastatic disease or has 
recurred during or within 1 year after the completion of platinum-based 
neoadjuvant or adjuvant therapy. 
4. Any primary site of urothelial carcinoma including upper tract, renal pelvis, 
bladder, and ureters. 
5. Prior therapy with ≥ 1 chemotherapy regimens for urothelial carcinoma 
6. Presence of radiographically measurable disease as defined by RECIST 1.1. 
7. Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. 
8. Completion of all therapy (including surgery, radiotherapy, chemotherapy, 
immunotherapy, or investigational therapy) for the treatment of cancer ≥ 2 weeks 
before the start of study therapy and recovered (ie, Grade ≤ 1 or baseline) from 
AEs associated with prior cancer therapy.  Note:  Subjects with Grade ≤ 2 

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neuropathy or Grade ≤ 2 alopecia are an exception to the latter criterion and may 
qualify for the study. 
9. Women who are sexually active and can bear children must agree to use 
acceptable forms of contraception during the study and for 90 days after the last 
dose of acalabrutinib or 120 days after the last dose of pembrolizumab, whichever 
is longer.  Note:   Acceptable forms of contraception are defined in Section 3.10.6. 
10. Men who are sexually active and can beget children must agree to use acceptable 
forms of contraception during the study and for 90 days after the last dose of 
acalabrutinib or 120 days after the last dose of pembrolizumab, whichever is 
longer. 
11. Men must agree to refrain from sperm donation during the study and for 90 days 
after the last dose of acalabrutinib or 120 days after the last dose of 
pembrolizumab, whichever is longer. 
12. Able to provide tissue for biomarker analysis from either an archived tissue 
sample or newly obtained core or excisional biopsy of a tumor lesion not 
previously irradiated. 
13. Willing and able to participate in all required evaluations and procedures in this 
study protocol including swallowing capsules without difficulty. 
14. Ability to understand the purpose and risks of the study and provide signed and 
dated informed consent and authorization to use protected health information (in 
accordance with national and local patient privacy regulations).  
3.3.2 
Exclusion Criteria 
Subjects will be ineligible for this study if they meet any of the following criteria: 
1. Prior malignancy (other than bladder cancer), except for treatment-naive prostate 
cancer (defined as Stage T1/T2a, Gleason score < 6, and prostate-specific 
antigen [PSA] < 10 ng/mL) undergoing active surveillance; or localized, very low 
to intermediate risk prostate cancer treated with curative intent and absence of 
PSA relapse; or adequately treated basal cell or squamous cell skin cancer, in situ 
cancer, or other cancer from which the subject has been disease free for 
≥ 2 years. 
2. Known central nervous system metastases and/or carcinomatous meningitis. 
Note:  Imaging studies of the central nervous symptom are not required as a 
condition of study enrollment 
3. Significant cardiovascular disease such as uncontrolled or symptomatic 
arrhythmias, congestive heart failure, or myocardial infarction within 6 months of 
screening, or any Class 3 or 4 cardiac disease as defined by the New York Heart 
Association Functional Classification or corrected QT interval (QTc) > 480 msec at 
screening. 
4. Malabsorption syndrome, disease significantly affecting gastrointestinal function, 
or resection of the stomach or small bowel, symptomatic inflammatory bowel 
disease, partial or complete bowel obstruction, or gastric restrictions and bariatric 
surgery, such as gastric bypass. 
5. Prior therapy with any inhibitor of BTK, protein kinase B (AKT), Janus kinase 
(JAK), mammalian target of rapamycin (mTOR), phosphatidylinositol-3 kinase 
(PI3K), or spleen tyrosine kinase (SYK). 
6. Prior therapy with an anti-PD-1, anti-PD-L1, anti-PD ligand 2 (anti-PD-L2), 
anti-CD137, or anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) 

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antibody (including ipilimumab, tremelimumab, nivolumab, pembrolizumab, 
MPDL3280A or any other antibody or drug specifically targeting T-cell 
co-stimulation or checkpoint pathways) 
7. Receiving ongoing immunosuppressive therapy, including systemic or enteric 
corticosteroids except for minimally systemically absorbed treatments (such as 
inhaled or topical steroid therapy for asthma, chronic obstructive pulmonary 
disease or allergic rhinitis) within 7 days before the first dose of pembrolizumab. 
8. Active autoimmune disease that has required systemic treatment in past 2 years 
(ie, with use of disease modifying agents, corticosteroids or immunosuppressive 
drugs).  Note:  Replacement therapy (eg, thyroxine, insulin, or physiologic 
corticosteroid replacement therapy for adrenal or pituitary insufficiency) is not 
considered a form of systemic treatment. 
9. Has history of interstitial lung disease or evidence of active non-infectious 
pneumonitis. 
10. History of severe allergic, anaphylactic, or other hypersensitivity reactions to 
chimeric or humanized antibodies or fusion proteins. 
11. History of bleeding diathesis (eg, hemophilia or von Willebrand disease). 
12. Requires treatment with a strong CYP3A inhibitor/inducer. 
13. Requires or receiving anticoagulation with warfarin or equivalent vitamin K 
antagonists (eg, phenprocoumon) within 7 days of first dose of study drug. 
14. Requires treatment with proton-pump inhibitors (eg, omeprazole, esomeprazole, 
lansoprazole, dexlansoprazole, rabeprazole, or pantoprazole). 
15. Has received a live vaccine within 30 days of planned start of study therapy. 
16. Known history of human immunodeficiency virus (HIV) or serologic status 
indicating active hepatitis C virus (HCV) or hepatitis B virus (HBV) infection or any 
uncontrolled active systemic infection.  Subjects with hepatitis B core antibody 
positive who are surface antigen negative or who are hepatitis C antibody positive 
will need to have a negative PCR result before enrollment.  Those who are 
hepatitis B surface antigen positive or hepatitis B PCR positive and those who are 
hepatitis C PCR positive will be excluded. 
17. History of stroke or intracranial hemorrhage within 6 months before the first dose 
of study drug. 
18. Major surgical procedure within 28 days of first dose of study drug.  Note:  If a 
subject had major surgery, they must have recovered adequately from any toxicity 
and/or complications from the intervention before the first dose of study drug. 
19. ANC < 1.5 x 109/L or platelet count < 100 x 109/L or hemoglobin < 8.0 g/dL. 
20. Total bilirubin > 1.5 x ULN; and AST or ALT > 3.0 x ULN. 
21. Estimated creatinine clearance of < 30 mL/min, calculated using the formula of 
Cockroft and Gault [(140-Age) • Mass (kg)/(72 • creatinine mg/dL); multiply by 
0.85 if female]. 
22. Breastfeeding or pregnant or expecting to conceive or father children within the 
projected duration of the trial, starting with the screening visit through 120 days 
after the last dose of trial treatment. 
23. Is currently participating in a clinical trial and receiving study therapy or has 
participated in a study of an investigational agent and received study therapy or 
used an investigational device within 4 weeks of the first dose of treatment. 

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24. Immediate family members of the sponsor personnel or site staff directly involved 
with the conduct of this protocol are excluded from participating on this study. 
25. Presence of a gastrointestinal ulcer diagnosed by endoscopy within 3 months 
prior to screening. 
3.3.3 
Replacement of Subjects 
Subjects will not be replaced on this study except if needed to complete the DLT 
assessment (N=6).  However, subjects who discontinue from the study due to a DLT 
during the DLT assessment period will not be replaced.   
3.3.4 
Enrollment and Randomization Procedures 
Enrollment of a subject into the study will be performed according to the following 
procedure:  
The study center will notify the sponsor when a clinically eligible subject is identified 
and is ready to screen, to ensure enrollment availability on the study. 
After the subject has signed and dated the Informed Consent Form (ICF), all 
screening procedures have been completed, and eligibility has been confirmed, the 
subject can be officially enrolled into the study.  
To enroll a subject, the study center will fax/email a completed Enrollment 
Confirmation Form to the sponsor.  The enrollment date will be the date that the 
sponsor confirms enrollment.  The sponsor will aim to fax/email a completed 
Enrollment Confirmation Form to the study center within 24 hours. 
The Enrollment Confirmation Form will contain treatment allocation.  The treatment 
assignment is based on the randomization list generated by the sponsor before study 
enrollment begins. 
Treatment must begin within the screening window (Section 4.1.5) and after the site 
has received the treatment allocation from the sponsor.   
3.4 
STUDY DRUGS 
3.4.1 
Premedications 
No specific premedications or supporting medications are required in conjunction with 
acalabrutinib or pembrolizumab administration.  

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3.4.2 
Formulation, Packaging, and Storage 
Acalabrutinib 
Acalabrutinib is manufactured according to cGMP regulations and will be provided to 
the investigational site by Acerta Pharma or designee.  Acalabrutinib should be stored 
according to the instructions on the label that is affixed to the package of the drug 
product.  Acalabrutinib will be provided in white, high-density polyethylene bottles.   
If a drug shipment arrives damaged, or if there are any other drug complaints, a 
Product Complaint Form should be completed and emailed or faxed to the sponsor or 
the sponsor’s representative.  Refer to the Acalabrutinib Investigator Brochure for 
additional information regarding the drug product to be used in this trial. 
Pembrolizumab 
Commercially available pembrolizumab (KEYTRUDA) will be provided by the sponsor 
for use on this study (Table 3-1).  Pembrolizumab (100 mg/4 mL) is provided as 
25-mg/mL solution in single-use vials or as a lyophilized powder for reconstitution 
(50 mg/vial). 
Table 3-1 Pembrolizumab Product Descriptions 
Product Name & Potency 
Dosage Form 
MK-3475 50 mg 
Lyophilized Powder for Injection 
MK-3475 100 mg/ 4mL 
Solution for Injection 
Information on the formulation, packaging and storage of pembrolizumab is provided 
in the package insert (Appendix 6). 
3.4.3 
Administration of Study Drug  
Investigators are prohibited from supplying acalabrutinib to any subjects not properly 
enrolled in this study.  The investigator must ensure that subjects receive 
acalabrutinib or pembrolizumab only from personnel who fully understand the 
procedures for administering the drugs. 
Acalabrutinib 100 mg is intended to be administered orally twice daily with 8 ounces 
(approximately 240 mL) of water (avoid grapefruit juice or Seville orange juice due to 
potential inhibition of CYP3A).  Doses should be administered 12 hours apart (a 
window of ± 1 hour is allowed).  The capsules should be swallowed intact and 
subjects should not attempt to open capsules or dissolve them in water.   
If a dose is missed, it can be taken up to 3 hours after the scheduled time with a 
return to the normal schedule the same or following day.  If it has been > 3 hours, the 

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dose should not be taken and the subject should take the next dose at the scheduled 
time the next day.  The missed dose will not be made up and must be returned to the 
site at the next scheduled visit. 
Refer to Section 3.10.4 for guidance on concomitant dosing of acalabrutinib with 
agents that affect gastric pH. 
Pembrolizumab will be administered as a dose of 200 mg using a 30-minute IV 
infusion.  Sites should make every effort to target infusion timing to be as close to 
30 minutes as possible.  However, given the variability of infusion pumps from site to 
site, a window between -5 minutes and +10 minutes is permitted (ie, infusion time is 
30 minutes -5 min/+10 min).  Detailed information on preparation of pembrolizumab 
for infusion is provided in Appendix 6.  
When acalabrutinib and pembrolizumab are administered on the same day, 
acalabrutinib should be administered first, followed by pembrolizumab.  When PK 
sampling is done, the pembrolizumab infusion should begin within 10 minutes of 
ingesting acalabrutinib. 
3.4.4 
Assuring Subject Compliance 
For treatments that are taken in the clinic, subjects should take the dose from the 
drug dispensed for them for that particular time period.  All other acalabrutinib 
treatments will be taken at home.  Subjects will receive a drug diary to record the 
specific time each dose was taken and to record reasons for any missed doses.   
Pembrolizumab infusions will be administered only at the clinics per the study 
schedule.  Missed doses of pembrolizumab should not be made up, with the next 
dose occurring in agreement with the original schedule for this agent (every 3 weeks). 
Subject compliance with acalabrutinib dosing will be assessed at every visit.  The 
subject will be instructed to bring the diary and any remaining capsules to the clinic at 
their next visit.  The study staff will review the diary and ask the subject if all of the 
capsules were administered.  Any remaining or returned capsules will be counted and 
recorded as described in Section 7.6.  Returned capsules must not be redispensed to 
another subject.  

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3.5 
STUDY TREATMENT SCHEDULE 
3.5.1 
Arm 1 – Pembrolizumab Monotherapy 
Pembrolizumab 200 mg will be administered every 3 weeks by IV infusion.  
3.5.2 
Arm 2 – Combination Treatment 
The dose of acalabrutinib is 100 mg BID PO.  The doses may be modified for DLTs 
as summarized in Table 3-2.  
Pembrolizumab 200 mg will be administered every 3 weeks by IV infusion.   
Acalabrutinib and pembrolizumab dosing will begin on the same day on Week 1 
except for the first 6 subjects enrolled due to PK sampling.  The first 6 subjects 
enrolled will receive acalabrutinib on Day 1 of Week 1.  Then on Day 2 of Week 1 the 
first pembrolizumab infusion will be administered. 
Table 3-2.  Dose Reduction for Acalabrutinib 
Dose Level 
Acalabrutinib 
Pembrolizumab 
Starting Dose 
100 mg BID PO 
200 mg Q3W IV 
Level -1 
100 mg QD PO 
200 mg Q3W IV 
Level -2 
50 mg BID PO 
200 mg Q3W IV 
Abbreviations: BID = twice per day; IV = intravenous, PO = oral; Q3W = every 3 weeks; QD = once per 
day 
3.6 
DURATION OF THERAPY 
Acalabrutinib treatment can continue for subjects who are tolerating therapy and not 
progressing.  Pembrolizumab treatment is for 24 months from the date of first dose for 
subjects who are tolerating therapy and not progressing.  Pembrolizumab treatment 
can end for subjects with confirmed CR if treatment has been administered for at least 
24 weeks and 2 doses of pembrolizumab have been administered after confirmation 
of CR. 
3.7 
ASSESSMENT OF DOSE-LIMITING TOXICITY (DLT) 
As outlined in Section 3.0, DLT review will be applied to Arm 2 as the combination of 
acalabrutinib plus pembrolizumab has not been evaluated before, therefore an interim 
safety analysis will occur once 6 subjects have been successfully randomized to the 
combination arm (Arm 2) and have been treated a minimum of 4 weeks.  Enrollment 
will be paused while the interim safety analysis occurs.   

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A DLT will be defined as the occurrence of any of the following study-drug-related 
AEs (note: AEs clearly related to disease progression or the subject’s current medical 
history and associated comorbidities will not be considered DLTs): 
1. Grade 4 vomiting or diarrhea 
2. Grade 3 nausea, vomiting, or diarrhea lasting for > 72 hours 
3. Other Grade ≥ 3 toxicities (Note: transient Grade 3-4 laboratory abnormalities that 
are not clinically significant will not be considered DLTs) 
4. Dosing delay due to toxicity for > 21 consecutive days. 
3.8 
DOSING DELAYS AND MODIFICATIONS 
Subjects should be followed closely for AEs or laboratory abnormalities that might 
indicate acalabrutinib- or pembrolizumab-related toxicity.  If a subject experiences a 
treatment-related DLT or other intolerable AE during the course of therapy, then 
acalabrutinib, pembrolizumab, or both drugs should be held, as necessary, until the 
AE resolves or stabilizes to an acceptable degree.  In cases where pembrolizumab is 
held, pembrolizumab should be restarted in agreement with its original dosing 
schedule (every 3 weeks).  As appropriate, certain laboratory abnormalities may 
warrant more frequent monitoring (eg, once per week) until abnormalities have 
recovered to Grade ≤ 1.  Dose reductions for acalabrutinib are provided in Table 3-2.  
If acalabrutinib is reduced for apparent treatment-related toxicity, the dose need not 
be re-escalated, even if there is minimal or no toxicity with the reduced dose.  
However, if the subject tolerates a reduced dose of acalabrutinib for ≥ 4 weeks then 
the dose may be increased to the next higher dose level, at the discretion of the 
investigator.  Such re-escalation may be particularly warranted if further evaluation 
reveals that the AE that led to the dose reduction was not treatment-related.  
However, the maximum dose of acalabrutinib is 100 mg BID for this protocol. 
For treatment-emergent hepatotoxicity in the combination arm or for subjects 
who cross over to receive combination therapy:  Important guidelines for 
treatment-emergent hepatotoxicity are provided in Section 3.8.2 for pembrolizumab.  
In the combination arm or for subjects who cross over to receive combination therapy, 
treatment with acalabrutinib should be withheld for Grade 3 or 4 hepatitis.  For 
Grade 4 events, acalabrutinib may be restarted only after discussion with the medical 
monitor.  For Grade 3 events, treatment with acalabrutinib can be considered after the 
LFT laboratory values have returned to Grade ≤ 1 or to baseline. 

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Note:  Temporary withholding of study drug for as little as 7 days can cause a 
transient worsening of disease and/or of constitutional symptoms.  Refer to 
Section 3.11 for more information on assessing disease progression under these 
circumstances. 
3.8.1 
Dose Modifications for Pembrolizumab 
Adverse events (nonserious and serious) associated with pembrolizumab exposure 
may represent an immunologic etiology.  These adverse events may occur shortly 
after the first dose or several months after the last dose of treatment.  Pembrolizumab 
must be withheld for drug-related toxicities and severe or life-threatening AEs as per 
Table 3-3 below.  See Section 3.8.2 for supportive care guidelines, including use of 
corticosteroids. 
Table 3-3.  Dose Modification Guidelines for Drug-Related Adverse Events 
Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting 
Treatment 
Treatment Discontinuation 
Diarrhea/Colitis 
2-3 
 
Toxicity resolves to Grade 
0-1. 
Toxicity does not resolve within 12 weeks 
of last dose or inability to reduce 
corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 
12 weeks. 
4 
Permanently discontinue 
Permanently discontinue 
AST, ALT, or 
Increased Bilirubin 
2 
Toxicity resolves to Grade 
0-1 
Toxicity does not resolve within 12 weeks 
of last dose. 
3-4 
Permanently discontinue 
(see exception below)a 
Permanently discontinue 
Type 1 diabetes 
mellitus (if new 
onset) or 
Hyperglycemia 
T1DM or  
3-4 
Hold pembrolizumab for 
new onset Type 1 diabetes 
mellitus or Grade 3-4 
hyperglycemia associated 
with evidence of beta cell 
failure. 
Resume pembrolizumab when patients are 
clinically and metabolically stable. 
Hypophysitis 
2-4 
Toxicity resolves to Grade 
0-1. Therapy with 
pembrolizumab can be 
continued while endocrine 
replacement therapy is 
instituted 
Toxicity does not resolve within 12 weeks 
of last dose or inability to reduce 
corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 
12 weeks. 
Hyperthyroidism  
3 
Toxicity resolves to Grade 
0-1 
Toxicity does not resolve within 12 weeks 
of last dose or inability to reduce 
corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 
12 weeks. 
4 
Permanently discontinue 
Permanently discontinue 
Hypothyroidism 
 
Therapy with 
pembrolizumab can be 
continued while thyroid 
replacement therapy is 
instituted 
Therapy with pembrolizumab can be 
continued while thyroid replacement 
therapy is instituted. 
Infusion Reaction 
2b 
Toxicity resolves to Grade 
0-1 
Permanently discontinue if toxicity develops 
despite adequate premedication. 
3-4 
Permanently discontinue 
Permanently discontinue 

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Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting 
Treatment 
Treatment Discontinuation 
Pneumonitis 
2 
Toxicity resolves to Grade 
0-1 
Toxicity does not resolve within 12 weeks 
of last dose or inability to reduce 
corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 
12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
Renal Failure or 
Nephritis 
2 
Toxicity resolves to Grade 
0-1 
Toxicity does not resolve within 12 weeks 
of last dose or inability to reduce 
corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 
12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
All Other Drug-
Related Toxicityc 
3 or Severe 
Toxicity resolves to Grade 
0-1 
Toxicity does not resolve within 12 weeks 
of last dose or inability to reduce 
corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 
12 weeks. 
4 
Permanently discontinue 
Permanently discontinue 
Note:  Permanently discontinue for any severe or Grade 3 (Grade 2 for pneumonitis) drug-related AE that 
recurs or any life-threatening event. 
a For patients with liver metastasis who begin treatment with Grade 2 AST or ALT, if AST or ALT increases by greater 
than or equal to 50% relative to baseline and lasts for at least 1 week then patients should be discontinued 
b. If symptoms resolve within one hour of stopping drug infusion, the infusion may be restarted at 50% of the original 
infusion rate   (e.g., from 100 mL/hr to 50 mL/hr).  Otherwise dosing will be held until symptoms resolve and the subject 
should be premedicated  for the next scheduled dose; Refer to Table 3-4  for further management details. 
c. Patients with intolerable or persistent Grade 2 drug-related AE may hold study medication at physician discretion.  
Permanently discontinue study drug for persistent Grade 2 adverse reactions for which treatment with study drug has 
been held, that do not recover to Grade 0-1 within 12 weeks of the last dose. 
 
3.8.2 
Supportive Care Guidelines for Pembrolizumab 
Subjects should receive appropriate supportive care measures as deemed necessary 
by the treating investigator.  Suggested supportive care measures for the 
management of adverse events with potential immunologic etiology are outlined 
below.  Where appropriate, these guidelines include the use of oral or intravenous 
treatment with corticosteroids as well as additional anti-inflammatory agents if 
symptoms do not improve with administration of corticosteroids.   Note that several 
courses of steroid tapering may be necessary as symptoms may worsen when the 
steroid dose is decreased.  For each disorder, attempts should be made to rule out 
other causes such as metastatic disease or bacterial or viral infection, which might 
require additional supportive care.  The treatment guidelines are intended to be 
applied when the investigator determines the events to be related to pembrolizumab.  
Note:  If after the evaluation the event is determined not to be related, the investigator 
does not need to follow the treatment guidance (as outlined below).  Refer to 
Section 3.8.1 for dose modification.  

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It may be necessary to perform conditional procedures such as bronchoscopy, 
endoscopy, or skin photography as part of evaluation of the event.   
• 
Pneumonitis:  
o For Grade 2 events, treat with systemic corticosteroids. When 
symptoms improve to Grade 1 or less, steroid taper should be started 
and continued over no less than 4 weeks. 
o For Grade 3-4 events, immediately treat with intravenous steroids.  
Administer additional anti-inflammatory measures, as needed. 
o Add prophylactic antibiotics for opportunistic infections in the case of 
prolonged steroid administration. 
• 
Diarrhea/Colitis:  
Subjects should be carefully monitored for signs and symptoms of enterocolitis 
(such as diarrhea, abdominal pain, blood or mucus in stool, with or without 
fever) and of bowel perforation (such as peritoneal signs and ileus).   
o All subjects who experience diarrhea/colitis should be advised to drink 
liberal quantities of clear fluids.  If sufficient oral fluid intake is not 
feasible, fluid and electrolytes should be substituted via IV infusion.  
For Grade 2 or higher diarrhea, consider GI consultation and 
endoscopy to confirm or rule out colitis. 
o For Grade 2 diarrhea/colitis, administer oral corticosteroids.  
o For Grade 3 or 4 diarrhea/colitis, treat with intravenous steroids 
followed by high dose oral steroids.   
o When symptoms improve to Grade 1 or less, steroid taper should be 
started and continued over no less than 4 weeks. 
• 
Type 1 diabetes mellitus (if new onset, including diabetic ketoacidosis 
[DKA]) or ≥ Grade 3 Hyperglycemia, if associated with ketosis (ketonuria) 
or metabolic acidosis (DKA) 
o For T1DM or Grade 3-4 Hyperglycemia 
 
Insulin replacement therapy is recommended for Type I 
diabetes mellitus and for Grade 3-4 hyperglycemia associated 
with metabolic acidosis or ketonuria.  
 
Evaluate patients with serum glucose and a metabolic panel, 
urine ketones, glycosylated hemoglobin, and C-peptide.  
• 
Hypophysitis: 
o For Grade 2 events, treat with corticosteroids.  When symptoms 
improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks.  Replacement of appropriate 
hormones may be required as the steroid dose is tapered. 
o For Grade 3-4 events, treat with an initial dose of IV corticosteroids 
followed by oral corticosteroids.  When symptoms improve to Grade 1 
or less, steroid taper should be started and continued over no less than 
4 weeks.  Replacement of appropriate hormones may be required as 
the steroid dose is tapered. 

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• 
Hyperthyroidism or Hypothyroidism:  
Thyroid disorders can occur at any time during treatment.  Monitor patients for 
changes in thyroid function (at the start of treatment, periodically during 
treatment, and as indicated based on clinical evaluation) and for clinical signs 
and symptoms of thyroid disorders. 
o Grade 2 hyperthyroidism events (and Grade 2-4 hypothyroidism): 
 
In hyperthyroidism, non-selective beta-blockers (eg, 
propranolol) are suggested as initial therapy. 
 
In hypothyroidism, thyroid hormone replacement therapy, with 
levothyroxine or liothyroinine, is indicated per standard of care. 
o Grade 3-4 hyperthyroidism  
 
Treat with an initial dose of IV corticosteroid followed by oral 
corticosteroids.  When symptoms improve to Grade 1 or less, 
steroid taper should be started and continued over no less than 
4 weeks.  Replacement of appropriate hormones may be 
required as the steroid dose is tapered. 
• 
Hepatic: 
o For Grade 2 events, treatment with pembrolizumab should be 
withheld.  Administer corticosteroids (initial dose of 0.5 to 1 mg/kg/day 
prednisone or equivalent) (Appendix 6).  When LFT laboratory values 
resolve to baseline or return to Grade ≤ 1, then taper the 
corticosteroids over no fewer than 4 weeks while continuing to monitor 
LFTs at least weekly.  Further treatment with pembrolizumab can be 
considered after the LFT laboratory values have returned to Grade ≤ 1 
or to baseline either during the steroid taper or after stopping 
corticosteroids. 
o For Grade 3-4 events, permanently discontinue pembrolizumab.  Treat 
with corticosteroids initial dose 1 to 2 mg/kg/day prednisone or 
equivalent) (Appendix 6) until LFT laboratory values resolve to 
baseline or return to Grade ≤ 1, and then taper the corticosteroids over 
no fewer than 4 weeks while continuing to monitor LFTs at least 
weekly.  
• 
Renal Failure or Nephritis: 
o For Grade 2 events, treat with corticosteroids. 
o For Grade 3-4 events, treat with systemic corticosteroids. 
o When symptoms improve to Grade 1 or less, steroid taper should be 
started and continued over no less than 4 weeks.  
• 
Management of Infusion Reactions: 
o Signs and symptoms usually develop during or shortly after drug 
infusion and generally resolve completely within 24 hours of 
completion of infusion.  
o Table 3-4 shows treatment guidelines for subjects who experience an 
infusion reaction associated with administration of pembrolizumab. 

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Table 3-4.  Infusion Reaction Treatment Guidelines 
NCI CTCAE Grade 
Treatment 
Premedication at 
subsequent dosing 
Grade 1 
Mild reaction; infusion interruption 
not indicated; intervention not 
indicated 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of 
the investigator. 
None 
Grade 2 
Requires infusion interruption but 
responds promptly to 
symptomatic treatment (eg, 
antihistamines, NSAIDS, 
narcotics, IV fluids); prophylactic 
medications indicated for ≤ 24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy 
may include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of 
the investigator. 
If symptoms resolve within one hour of 
stopping drug infusion, the infusion may be 
restarted at 50% of the original infusion 
rate (eg, from 100 mL/hr to 50 mL/hr).  
Otherwise dosing will be held until 
symptoms resolve and the subject should 
be premedicated for the next scheduled 
dose. 
Subjects who develop Grade 2 toxicity 
despite adequate premedication should 
be permanently discontinued from 
further trial treatment administration. 
Subject may be premedicated 
1.5h (± 30 minutes) prior to 
infusion of pembrolizumab 
(MK-3475) with: 
 
Diphenhydramine 50 mg po (or 
equivalent dose of 
antihistamine). 
 
Acetaminophen 500-1000 mg 
po (or equivalent dose of 
antipyretic). 
Grades 3 or 4 
 
Grade 3: 
Prolonged (ie, not rapidly 
responsive to symptomatic 
medication and/or brief 
interruption of infusion); 
recurrence of symptoms following 
initial improvement; 
hospitalization indicated for other 
clinical sequelae (eg, renal 
impairment, pulmonary infiltrates) 
 
Grade 4: 
Life-threatening; pressor or 
ventilatory support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of 
the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued 
from further trial treatment 
administration. 
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the 
period of drug administration. 
 
 
3.9 
CONCOMITANT THERAPY 
3.9.1 
Permitted Concomitant Therapy 
Antiemetics are permitted if clinically indicated.  Standard supportive care medications 
are permitted as per institutional standards.   

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3.9.2 
Prohibited or Restricted Concomitant Therapy 
Any chemotherapy, anticancer immunotherapy, experimental therapy, or radiotherapy 
for treating urothelial carcinoma are prohibited. 
Warfarin or equivalent vitamin K antagonists (eg, phenprocoumon) are prohibited.    
At study entry, subjects may be using topical or inhaled corticosteroids as therapy for 
comorbid conditions but use of corticosteroids as therapy of the cancer is not 
permitted.  During study participation, subjects may also receive systemic or enteric 
corticosteroids at any required dosage as needed for treatment emergent 
immune-mediated adverse reactions associated with pembrolizumab therapy (see 
Section 3.8), but use of corticosteroids (at dosages equivalent to prednisone 
> 20 mg/day for longer than 2 weeks) as therapy for cancer is not permitted.  
Live vaccines within 30 days before the first dose of trial treatment and while 
participating in the trial are prohibited.  Examples of live vaccines include, but are not 
limited to, the following: measles, mumps, rubella, chicken pox, yellow fever, rabies, 
BCG, and typhoid (oral) vaccine.  Seasonal influenza vaccines for injection are 
generally killed virus vaccines and are allowed.  However, intranasal influenza 
vaccines (eg, Flu - Mist®) are live attenuated vaccines and are not allowed. 
Use of calcium carbonate containing drugs or supplements and short-acting 
H2-receptor antagonists should be avoided for at least 2 hours before or after 
acalabrutinib administration (see Section 3.10.4). 
3.10 PRECAUTIONS 
3.10.1 
Transaminase Elevations for Acalabrutinib in Combination 
with Pembrolizumab 
Serum transaminase elevations (including elevations of AST and/or ALT) may be 
increased in severity and frequency in subjects exposed to the combination of 
acalabrutinib and pembrolizumab, as compared with subjects exposed to 
pembrolizumab monotherapy and subjects exposed to acalabrutinib monotherapy. 
Routine monitoring for serum transaminase elevations must follow the Schedule of 
Assessments (serum chemistry lab assessments in Appendix 4 and Appendix 5). 
Dosing delays and modifications for subjects with serum transaminase elevations 
must follow guidance provided in Section 3.8. 

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3.10.2 
Hepatitis B Reactivation 
Serious or life-threatening reactivation of viral hepatitis may occur in subjects treated 
with acalabrutinib.  Therefore, subjects who are hepatitis B core antibody (anti-HBc) 
positive, or have a known history of HBV infection, should be monitored monthly with 
a quantitative PCR test for HBV DNA.  Monthly monitoring should continue until 
12 months after last dose of acalabrutinib.  Any subject with a rising viral load (above 
lower limit of detection) should discontinue study drug and have antiviral therapy 
instituted and a consultation with a physician with expertise in managing hepatitis B.  
Insufficient data exist regarding the safety of resuming acalabrutinib in subjects who 
develop HBV reactivation.   
3.10.3 
Dietary Restrictions 
Acalabrutinib can be taken with or without food.  Because acalabrutinib is metabolized 
by CYP3A, subjects should be strongly cautioned against excessive consumption of 
grapefruit, grapefruit juice, or Seville orange juice (which contain potent CYP3A 
inhibitors) or using herbal remedies or dietary supplements (in particular, St John’s 
wort, which is a potent CYP3A inducer). 
Otherwise subjects should maintain a normal diet unless modifications are required to 
manage an AE such as diarrhea, nausea or vomiting. 
3.10.4 
Drug-drug Interactions 
At the systemic exposure levels expected in this study, acalabrutinib inhibition of CYP 
metabolism is not anticipated.  However, concomitant administration of acalabrutinib 
with a strong CYP3A and P-gp inhibitor increased exposure by approximately 5-fold.  
Consequently, the concomitant use of strong inhibitors/inducers of CYP3A (see 
Appendix 2) should be avoided when possible.   
Based on these considerations, subjects who require therapy with drugs listed in 
Appendix 2 should not be enrolled into the study.  If medically justified, subjects may 
be enrolled if such inhibitors or inducers can be discontinued or alternative drugs that 
do not affect these enzymes can be substituted within 7 days before first dose of 
study drug.  If a subject requires a strong CYP3A inhibitor while on study, monitor the 
subject closely for potential drug-related toxicities.   
The effect of agents that reduce gastric acidity (eg, proton-pump inhibitors, 
H2-receptor antagonists or antacids) on acalabrutinib absorption was evaluated in a 

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healthy volunteer study (ACE-HV-004).  Results from this study indicate that subjects 
should avoid the use of calcium carbonate-containing drugs or supplements (eg, 
antacids and calcium supplements) and short-acting H2-receptor antagonists for a 
period of at least 2 hours before and after taking acalabrutinib.  Use of omeprazole, 
esomeprazole, lansoprazole or any other proton-pump inhibitors while taking 
acalabrutinib is not recommended due to a potential decrease in study drug exposure.   
No formal PK drug interaction studies have been conducted with pembrolizumab. 
3.10.5 
Surgery 
Susceptibility to bleeding has been observed with the first generation BTK inhibitor, 
ibrutinib [IMBRUVICA package insert].  As a precaution, it is suggested that 
acalabrutinib be held for 3 days before and after any major surgical procedure. 
3.10.6 
Reproductive Toxicity 
Acalabrutinib 
Note for subjects receiving only acalabrutinib, the information below applies. 
Pilot reproductive toxicity studies have been performed that evaluate the effects of 
acalabrutinib on embyrofetal development.  Definitive studies of acalabrutinib on 
embryofetal development are pending.  Women who are sexually active and can bear 
children (see definition below) must agree to use acceptable forms of contraception 
during the study and for 90 days after the last dose of acalabrutinib as defined below. 
Pembrolizumab 
Note for subjects receiving acalabrutinib plus pembrolizumab the information below 
applies. 
Pembrolizumab may have adverse effects on a fetus in utero.   
Women will be considered of non-reproductive potential if they are either: 
1) postmenopausal (defined as at least 12 months with no menses without an 
alternative medical cause; in women < 45 years of age a high follicle stimulating 
hormone (FSH) level in the postmenopausal range may be used to confirm a post-
menopausal state in women not using hormonal contraception or hormonal 
replacement therapy.  In the absence of 12 months of amenorrhea, a single FSH 
measurement is insufficient.);  
OR  

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(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy 
or bilateral tubal ligation/occlusion, at least 6 weeks prior to screening;  
OR  
(3) has a congenital or acquired condition that prevents childbearing. 
Men and women of reproductive potential must agree to avoid impregnating a partner 
or becoming pregnant, respectively, while receiving study drug and for 120 days after 
the last dose of study drug by complying with one of the following:   
(1) practice abstinence† from heterosexual activity;  
OR  
(2) use (or have their partner use) acceptable contraception during heterosexual 
activity.   
Acceptable methods of contraception are‡: 
  
Single method (1 of the following is acceptable): 
• 
intrauterine device (IUD) 
• 
vasectomy of a female subject’s male partner  
• 
contraceptive rod implanted into the skin 
Combination method (requires use of 2 of the following): 
• 
diaphragm with spermicide (cannot be used in conjunction with cervical 
cap/spermicide) 
• 
cervical cap with spermicide (nulliparous women only)   
• 
contraceptive sponge (nulliparous women only)  
• 
male condom or female condom (cannot be used together) 
• 
hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or 
progestin-only pill), contraceptive skin patch, vaginal contraceptive ring, or 
subcutaneous contraceptive injection 
†Abstinence (relative to heterosexual activity) can be used as the sole method of 
contraception if it is consistently employed as the subject’s preferred and usual 

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lifestyle and if considered acceptable by local regulatory agencies and ERCs/IRBs.  
Periodic abstinence (eg, calendar, ovulation, sympto-thermal, and post-ovulation 
methods) and withdrawal are not acceptable methods of contraception.  
‡If a contraceptive method listed above is restricted by local regulations/guidelines, 
then it does not qualify as an acceptable method of contraception for subjects 
participating at sites in this country/region.   
Men must refrain from sperm donation during the study and for 90 days after the last 
dose of acalabrutinib or 120 days after the last dose of pembrolizumab, whichever is 
longer. 
Subjects should be informed that taking the study medication may involve unknown 
risks to the fetus (unborn baby) if pregnancy were to occur during the study.  To 
participate in the study subjects of childbearing potential must adhere to the 
contraception requirement (described above) from the day of study medication 
initiation (or 14 days prior to the initiation of study medication for oral contraception) 
throughout the study period up to 120 days after the last dose of trial therapy.  If there 
is any question that a subject of childbearing potential will not reliably comply with the 
requirements for contraception, that subject should not be entered into the study. 
Subjects should promptly notify the investigator if they, or their partner, become 
pregnant during this period.  If a female subject becomes pregnant during the 
treatment period, she must discontinue acalabrutinib and pembrolizumab 
immediately.  Pregnancy in a female subject or a male subject’s partner must be 
reported as outlined in Section 6.2.3. 
3.10.7 
Overdose Instructions 
For any subject experiencing an acalabrutinib or pembrolizumab overdose 
(administration of a dose ≥ 1000 mg of acalabrutinib or ≥ 1000 mg of pembrolizumab 
at once), observation for any symptomatic side effects should be instituted, and vital 
signs, biochemical and hematologic parameters should be followed closely 
(consistent with the protocol or more frequently, as needed).  Appropriate supportive 
management to mitigate adverse effects should be initiated.  If the overdose ingestion 
is recent and substantial, and if there are no medical contraindications, use of gastric 
lavage or induction of emesis may be considered. 

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The medical monitor must be contacted if a study drug overdose occurs 
(Section 6.2.5).  
3.11 TREATMENT AFTER INITIAL RADIOLOGIC PROGRESSION 
RECIST 1.1 will be adapted to account for the unique tumor response characteristics 
seen with treatment of pembrolizumab.  Immunotherapeutic agents such as 
pembrolizumab may produce antitumor effects by potentiating endogenous 
cancer-specific immune responses.  The response patterns seen with such an 
approach may extend beyond the typical time course of responses seen with 
cytotoxic agents and can manifest a clinical response after an initial increase in tumor 
burden or even the appearance of new lesions.  Standard RECIST may not provide 
an accurate response assessment of immunotherapeutic agents such as 
pembrolizumab.  Therefore, RECIST 1.1 will be used with the following adaptations: 
• 
If radiologic imaging verifies initial disease progression, tumor assessment 
should be repeated ≥4 weeks later to confirm disease progression with the 
option of continuing treatment per below.   
• 
If repeat imaging shows < 20% tumor burden compared to nadir, stable or 
improved previous new lesion (if identified as cause for initial disease 
progression), and stable/improved non-target disease (if identified as cause 
for initial disease progression), treatment may be continued / resumed.   
• 
If repeat imaging confirms disease progression due to any of the scenarios 
listed below, subjects will be discontinued from study therapy (except subjects 
who cross over to receive acalabrutinib in addition to pembrolizumab; they 
would be discontinued upon a second confirmed disease progression event on 
the combination therapy).   
In determining whether or not the tumor burden has increased or decreased, site 
study team should consider all target lesions as well as non-target lesions (if needed, 
the tip sheet provided in the study binder can be used as a reference to assess 
lesions). 
Scenarios where disease progression is confirmed at repeat imaging: 
• 
Tumor burden remains ≥ 20% and at least 5 mm absolute increase compared 
to nadir 
• 
Non-target disease resulting in initial disease progression is worse (qualitative) 

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• 
New lesion resulting in initial disease progression is worse (qualitative) 
• 
Additional new lesion(s) since last evaluation 
In subjects who have initial evidence of radiological disease progression, it is at the 
discretion of the treating physician whether to continue a subject on study treatment 
until repeat imaging is obtained.  This clinical judgment decision should be based on 
the subject’s overall clinical condition, including performance status, clinical 
symptoms, and laboratory data.  Subjects may receive study treatment while waiting 
for confirmation of disease progression if they are clinically stable as defined by the 
following criteria: 
• 
Absence of signs and symptoms indicating disease progression 
• 
No decline in ECOG performance status 
• 
Absence of rapid progression of disease 
• 
Absence of progressive tumor at critical anatomical sites (eg, cord 
compression) requiring urgent alternative medical intervention 
When feasible, subjects should not be discontinued until progression is confirmed.  
This allowance to continue treatment despite initial radiologic progression takes into 
account the observation that some subjects can have a transient tumor flare in the 
first few months after the start of immunotherapy, but with subsequent disease 
response.  Subjects that are deemed clinically unstable are not required to have 
repeat imaging for confirmation of progressive disease.  The decision to continue 
study treatment after the first evidence of disease progression is at the Investigator’s 
discretion based on the clinical status of the subject as described in Table 3-5 below.   

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Table 3-5.  Imaging and Treatment After 1st Radiologic Evidence of Disease 
Progression 
Abbreviations: CR = complete response; PD = progressive disease; PR = partial response; SD = stable 
disease 
 
NOTE:  If a subject has confirmed radiographic progression (ie, 2 scans at least 
4 weeks apart demonstrating progressive disease) per irRECIST, but the subject is 
achieving a clinically meaningful benefit, an exception to continue treatment may be 
considered following consultation with the sponsor. 
irRECIST data will be collected in the clinical database. 
3.12 WITHDRAWAL OF SUBJECTS FROM STUDY TREATMENT 
Any subject has the right to withdraw from the study at any time. 
• 
Study treatment should be discontinued in the event of a toxicity lasting 
> 28 consecutive days, unless reviewed and approved by the medical monitor.   
• 
Any subject who has confirmed objective evidence of cancer progression 
while receiving acalabrutinib and pembrolizumab should discontinue study 
treatment.  Note:  Study subjects receiving immunotherapies can experience 
transient immunotherapy-related increases in lesion size 
(“pseudoprogression”) preceding tumor regression (Hodi 2010).  If there is 
uncertainty regarding whether there is true cancer progression, the subject 
may continue study treatment and remain under close observation (eg, 
evaluated at 4-week intervals) pending confirmation of progression.  In 
particular, transient worsening of disease early in therapy or during temporary 
Clinically Stable 
Clinically Unstable 
Tumor Imaging 
Treatment 
Tumor Imaging 
Treatment 
First radiologic 
evidence of PD 
Repeat imaging at 
> 4 weeks at site 
to confirm PD 
May continue study 
treatment at the 
Investigator’s discretion 
while awaiting 
confirmatory tumor 
imaging by site 
Repeat tumor imaging 
at > 4 
weeks to confirm PD 
per physician 
discretion only 
Discontinue treatment 
Repeat tumor 
imaging 
confirms 
PD 
No additional tumor 
imaging required 
 
Discontinue treatment 
No additional tumor 
imaging 
required 
N/A 
Repeat tumor 
imaging shows 
SD, PR or CR 
Continue regularly 
scheduled 
tumor imaging 
assessments 
Continue study 
treatment at the 
Investigator’s 
discretion 
Continue regularly 
scheduled tumor 
imaging 
assessments 
May restart study 
treatment if 
condition has 
improved and/or 
clinically stable per 
Investigator’s 
discretion 

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interruption of study therapy (eg, for drug-related toxicity, surgery, or 
intercurrent illness) may not indicate cancer progression (Section 3.11).  In 
such circumstances, and if medically appropriate, subjects may resume 
therapy and relevant clinical, laboratory, and/or radiographic assessment can 
be attempted to document whether tumor control can be maintained or 
whether cancer progression has occurred. 
• 
Any subject whose medical condition substantially changes after entering the 
study should be carefully evaluated by the investigator in consultation with the 
medical monitor.  Such subjects should be withdrawn from study treatment if 
continuing would place them at risk.  
• 
Any subject who becomes pregnant should be removed from study treatment. 
• 
Any subject who becomes significantly noncompliant with study drug 
administration, study procedures, or study requirements should be withdrawn 
from study treatment in circumstances that increase risk or substantially 
compromise the interpretation of study results. 
• 
The investigator, in consultation with the medical monitor, may withdraw any 
subject from study treatment, if, in the investigator’s opinion, it is not in the 
subject’s best interest to continue.  
Subjects who discontinue study therapy will continue to be followed on study for 
follow-up of safety (Section 4.3) and survival unless they withdraw consent for further 
follow-up.  Thus, all subjects receiving ≥ 1 dose of study drug will be followed during 
the immediate post-therapy and long-term follow-up assessments unless the subject 
withdraws consent for such follow-up to be conducted.  The date the subject is 
withdrawn from study treatment or from the study (including long-term follow-up) and 
the reason for discontinuation will be recorded and also should be described on the 
appropriate case report form (CRF).   
3.13 REASONS FOR STUDY EXIT 
Reasons for study exit are: 
• 
Subject’s withdrawal of consent from study 
• 
Decision by sponsor to terminate the study 
• 
Subject lost to follow-up 
• 
Death 

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3.14 DATA AND SAFETY MONITORING 
This trial will be monitored in accordance with the sponsor’s pharmacovigilance 
procedures.  Adverse events and SAEs will be reviewed internally on an ongoing 
basis to identify safety concerns.  Quarterly conference calls with the investigators 
and applicable site staff will be conducted to discuss study progress, obtain 
investigator feedback and exchange, and discuss "significant safety events" (ie, AEs 
leading to dose reductions, related SAEs, and deaths).  In addition, for the interim 
safety analysis, a mandatory safety teleconference will occur before the expansion 
phase of the protocol can open.  
4.0 
STUDY ACTIVITIES AND ASSESSMENTS 
The schedule of events is provided in Appendix 4 and Appendix 5.  Descriptions of 
the scheduled evaluations are outlined below and complete information on study drug 
and dosing is provided in Section 3.4. 
Before study entry, throughout the study, and at the follow-up evaluation, various 
clinical and diagnostic laboratory evaluations are outlined.  The purpose of obtaining 
these detailed measurements is to ensure adequate safety and tolerability 
assessments.  Clinical evaluations and laboratory studies may be repeated more 
frequently if clinically indicated.  This study will primarily use central laboratory testing 
for safety laboratory evaluations.  Samples from sites’ local laboratories will be used if 
central laboratory testing is unavailable. 
4.1 
DESCRIPTION OF PROCEDURES 
4.1.1 
Informed Consent 
The subject must read, understand and sign the ICF approved by the institutional 
review board or independent ethics committee (IRB/IEC), confirming his or her 
willingness to participate in this study before initiating any screening activity that is not 
considered standard of care by institutional standards.  Subjects must also grant 
permission to use protected health information if required by local regulations. 
4.1.2 
Medical History 
Collect and record the subject’s complete history through review of medical records 
and by interview.  Concurrent medical signs and symptoms must be documented to 
establish baseline severities.  A disease history, including the date of initial diagnosis 

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and list of all prior anticancer treatments, and responses and duration of response to 
these treatments, also will be recorded. 
4.1.3 
Adverse Events 
The accepted regulatory definition for an AE is provided in Section 6.1.  All medical 
occurrences from the time of first dose that meet this definition must be recorded. 
Important additional requirements for reporting SAEs are explained in Section 6.2. 
4.1.4 
Concomitant Medications and Therapy 
Document all concomitant medications and procedures from within 28 days before the 
start of study drug administration through 30 days after the last dose of study drug. 
4.1.5 
Confirmation of Eligibility 
Subject eligibility for enrollment will be assessed per Section 3.3.  All screening 
procedures, unless otherwise indicated, should be completed within 28 days of the 
first dose of study drug. 
4.1.6 
ECOG Performance Status 
The ECOG performance index is provided in Appendix 1. 
4.1.7 
Physical Examination, Vital Signs, Height & Weight 
The screening physical examination will include, at a minimum, the general 
appearance of the subject, height (screening only) and weight, and examination of the 
skin, eyes, ears, nose, throat, lungs, heart, abdomen, extremities, musculoskeletal 
system, nervous system, and lymphatic system. 
Symptom-directed physical exams will be done during the treatment period and at the 
safety follow-up visits. 
Vital signs (blood pressure, heart rate, respiratory rate, and body temperature) will be 
assessed after the subject has rested in the sitting position.   
4.1.8 
Electrocardiogram  
Subjects should be in supine position and resting for at least 10 minutes before any 
study related ECGs.  Before first dose of study drug on Day 1, Week 1, 3 ECGs will 
be done at least 1 minute apart.  These ECGs and the screening ECG will be 
considered the baseline ECGs.  If an unscheduled ECG is done at any time, then an 

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electrolyte panel (ie, calcium, magnesium, and potassium) must be done to coincide 
with the ECG testing. 
Single on-treatment ECGs will be done at any time during the following visits: 
• 
Week 2 
• 
Week 4 
• 
Week 7 and every 6 weeks thereafter 
• 
Early termination and/or safety follow-up visit 
4.1.9 
Urine or Serum Pregnancy Test 
Pregnancy tests will be required only for women of childbearing potential.  Women of 
childbearing potential must have a negative urine or serum pregnancy testing within 
72 hours prior to receiving the first dose of study medication.  If the urine test is 
positive or cannot be confirmed as negative, a serum pregnancy test is required.  
Testing will be done by a local or central laboratory as listed on the investigator’s 
Form FDA 1572. 
4.1.10 
Hematology 
Hematology studies must include complete blood count (CBC) with differential and 
platelet and reticulocyte counts.  Testing will be done by a local or central laboratory 
as listed on the investigator’s Form FDA 1572. 
4.1.11 
Coagulation 
Coagulation studies must include prothrombin time (PT) and activated partial 
thromboplastin time (aPTT).  Testing will be done by a local or central laboratory as 
listed on the investigator’s Form FDA 1572. 
4.1.12 
Serum Chemistry 
Chemistry will include albumin, alkaline phosphatase, ALT, AST, bicarbonate, blood 
urea nitrogen (BUN), bone-specific alkaline phosphatase, calcium, chloride, 
creatinine, glucose, lactate dehydrogenase (LDH), magnesium, phosphate, 
potassium, sodium, total bilirubin, total protein, and uric acid.  If an unscheduled ECG 
is done at any time, then an electrolyte panel (ie, calcium, magnesium, and 
potassium) must be done to coincide with the ECG testing.  Testing will be done by a 
local or central laboratory as listed on the investigator’s Form FDA 1572. 

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4.1.13 
Amylase and Lipase 
Serum amylase and serum lipase testing will be performed at the study center’s local 
laboratory or other clinical laboratory listed on the investigator’s form FDA 1572. 
4.1.14 
Thyroid Panel 
The thyroid panel will include total triiodothyronine (T3), free thyroxine (T4), and 
thyroid stimulating hormone (TSH).  Testing will be done by a local or central 
laboratory as listed on the investigator’s Form FDA 1572. 
4.1.15 
Hepatitis B and C Testing 
Hepatitis serology testing must include hepatitis B surface antigen (HBsAg), hepatitis 
B surface antibody (anti-HBs), hepatitis core antibody (anti-HBc), and hepatitis C 
(HCV) antibody.  In addition, any subjects testing positive for any hepatitis serology, 
must have PCR testing during screening and on study (see Appendix 4 and exclusion 
criterion #16).  Testing will be done by local or central laboratory.   
Subjects who are anti-HBc positive should have quantitative PCR testing for HBV 
DNA performed during screening and monthly thereafter.  Monitoring should continue 
every 4 weeks (± 7 days) until 12 months after last dose of study drug(s).  Any subject 
with a rising viral load (above lower limit of detection) should discontinue study drug 
and have antiviral therapy instituted and a consultation with a physician with expertise 
in managing hepatitis B.   
Subjects with a known history of hepatitis C or who are hepatitis C antibody positive 
should have quantitative PCR testing for HCV DNA performed during screening and 
at Weeks 13 and 25.  No further testing beyond Week 25 is necessary if PCR results 
are negative.   
Refer to Section 3.10.2 and Appendix 4 regarding monitoring of subjects who are 
anti-HBc positive or hepatitis C antibody positive or who have a known history of HBV 
or HCV infection. 
4.1.16 
Urinalysis 
Urinalysis includes pH, ketones, specific gravity, bilirubin, protein, blood, and glucose.  
Testing will be done by a local or central laboratory as listed on the investigator’s 
Form FDA 1572.  

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4.1.17 
T/B/NK Cell Count 
Flow cytometry testing will include CD3+, CD4+, CD8+, CD14+, CD19+, and CD16/56+ 
cells.  Testing will be done by a local or central laboratory as listed on the 
investigator’s Form FDA 1572. 
4.1.18 
Serum Immunoglobulin  
Testing for IgG, IgM, and IgA will be done by a local or central laboratory as listed on 
the investigator’s Form FDA 1572. 
4.1.19 
Pharmacodynamics/Pharmacokinetics and Biomarker 
Studies 
Blood samples will be used for PD testing (including, but not limited to, BTK 
occupancy, B-cell activation, MDSCs, and T-cell activation), cytokine analysis, and for 
further characterization of circulating tumor cells, lymphocyte and myeloid cell 
subsets.  
Tissue sections from archival tumor biopsies and/or any newly obtained biopsies 
performed during the study will be used for exploratory biomarker studies (including, 
but not limited to, expression of PD-L1, characterization of disease subtype, and 
evaluations of MDSCs and activated CD8+ cells).  Additional exploratory studies may 
include, but are not necessarily limited to, characterization of BTK pathway activation 
status, identification disease subtype, specific genetic markers with prognostic 
significance and evaluation of tumor microenvironment components and cell cycle 
proteins in malignant cells.  If available, de-identified pathology reports from the most 
recent diagnostic work-up, including immunohistochemistry and cytogenetic analyses 
of tumor tissue, may be requested by the sponsor. 
Refer to the laboratory manual for instructions on collection and shipment of the PD 
and biomarker samples.  All testing will be done by the sponsor or designee.  Leftover 
blood and tumor samples may also be used for genomic analyses to study 
mechanisms of action. 
Blood sampling for PK analysis of acalabrutinib will be done on all subjects in the 
combination arm only and intensive PK will be on the first 6 subjects enrolled in the 
combination arm.  For these first 6 subjects, acalabrutinib will be administered alone 
on Day 1/Week 1.  Then on Day 2/Week 1 the first pembrolizumab infusion will be 
administered.  When PK sampling is done at Week 3 and Week 7, the pembrolizumab 

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infusion should begin within 10 minutes of ingesting acalabrutinib.  The PK sampling 
timepoints for these 6 subjects is as follows: 
Visit 
PK Sample Timepoints Relative to 
Acalabrutinib Administration 
Day 1, Week 1 
predose and 0.5, 1, 2, and 4 hours  
Day 2, Week 1 
predose 
Week 3 
predose and 0.5, 1, 2, and 4 hours postdose 
Week 7 
predose and 0.5, 1, 2, and 4 hours postdose 
For all other subjects enrolled in the combination arm, PK sampling will be done pre- 
and 1 hour postdose on Week 3.   
The predose sample can be taken up to 30 minutes before dosing.  The window for all 
other timepoints is ± 5 minutes.  Testing will be done by a central lab.  Refer to the 
laboratory manual for instructions on collection and shipment of PK samples. 
4.1.20 
Tumor Assessments 
A pretreatment computerized tomography (CT) scan with contrast (unless 
contraindicated) is required of the chest, abdomen, and pelvis and any other disease 
sites (eg, neck) within 30 days before the first dose of study drug.  
On-treatment CT scans with contrast (unless contraindicated) of the chest, abdomen, 
and pelvis and any other disease sites (eg, neck) will be done for tumor assessments 
at Week 7, 13, 19 (± 7 days) then every 3 months (± 10 days) thereafter or more 
frequently at investigator discretion.  At all other visits, tumor assessments will be 
done by physical exam and laboratory results.   
RECIST 1.1 guidelines (Eisenhauer 2009) will be followed for selection of measurable 
and nonmeasurable lesions and also with regard to the number of lesions to be 
assessed (refer to Appendix 7 for more details on RECIST 1.1).  Response will also 
be assessed by irRECIST (refer to Appendix 8 for more details). 
De-identified copies of all radiology results may be requested by the sponsor.   
4.1.21 
Early Termination Visit 
An early termination visit is required for safety assessments as outlined in the 
Schedule of Assessments (Appendix 4).  The early termination visit is not required for 
subjects who discontinue from the study within 10 days of a scheduled study visit. 
4.1.22 
Study Drug Accountability 
See Section 7.6. 

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4.2 
INVESTIGATOR’S ASSESSMENT OF RESPONSE TO TREATMENT 
Responses will be categorized as CR, PR, SD, or PD.  The definitions of response in 
target lesions are provided in Table 4-1.  The definitions of response in nontarget 
lesions are provided in Table 4-2. 
Table 4-1.  Evaluation of Target Lesions (RECIST) 
Response 
Category 
Definition 
CR 
Disappearance of all target and nontarget lesions including normalization of an elevated 
tumor marker level.  Any pathological lymph nodes (whether target or nontarget) must 
have reduction in short axis to <10 mm.  
PR 
A ≥ 30% decrease in the sum of the diameters of target lesions taking as a reference the 
baseline sum of the diameters.   
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. 
PDa 
At least a 20% increase in the sum of diameters of target 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 at least 5 mm.  (Note:  The appearance of one or more new lesions is also 
considered progression).   
Abbreviations: CR=complete response, PD=progressive disease, PR=partial response, SD=stable disease. 
a. Transient apparent worsening of disease early in therapy or during temporary interruption of study 
therapy (eg, for drug-related toxicity or intercurrent illness) may not indicate true cancer progression. 
Refer to Section 3.11 for more detailed information. 
 
Evaluation of nontarget lesions:  While some nontarget lesions may actually be 
measurable, they need not be measured and instead should be assessed only 
qualitatively at the timepoints specified in the Schedule of Assessments. 
Table 4-2.  Evaluation of Nontarget Lesions (RECIST) 
Response 
Category 
Definition 
CR 
Disappearance of all non-target lesions and normalization of tumor marker level.  All 
lymph nodes must be non-pathological in size (< 10mm short axis). 
Non-
CR/Non-
PD 
Persistence of one or more non-target lesion(s) and/or maintenance of tumor marker level 
above the normal limits. 
PDa 
Unequivocal progressionb of existing non-target lesions.  (Note:  The appearance of one 
or more new lesions is also considered progression).   
Abbreviations: CR=complete response, PD=progressive disease. 
a. 
Transient apparent worsening of disease early in therapy or during temporary interruption of study 
therapy (eg, for drug-related toxicity or intercurrent illness) may not indicate true cancer progression.  
Refer to Section 3.11 for more detailed information. 
b. 
Refer to RECIST 1.1 criteria for detailed explanation of “unequivocal progression”. 

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4.2.1 
Determination of Response at Each Timepoint (RECIST) 
The tumor response at each timepoint will be determined.  Table 4-3 provides a 
summary of the overall response status calculation at each timepoint.  
Table 4-3.  Timepoint Response (RECIST) 
Target Lesions 
Nontarget Lesions 
New Lesions 
Overall 
Response 
CR 
CR 
No 
CR 
CR 
Non-CR/non-PD 
No 
PR 
CR 
Not evaluated 
No 
PR 
PR 
Non-PD or not all evaluated 
No 
PR 
SD 
Non-PD or not all evaluated 
No 
SD 
Not all evaluated 
Non-PD 
No 
NE 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
Abbreviations: CR=complete response, PD=progressive disease, PR=partial response, SD=stable disease, 
NE=nonevaluable. 
4.2.2 
Confirmation of Tumor Status and Determination of Best 
Overall Response (RECIST) 
The best overall response (BOR) recorded from the start of treatment until tumor 
progression will be determined.  Adjudication of BOR is based on evaluation of each 
successive set of 2 scans as indicated in Table 4-4.  

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Table 4-4.  Best Overall Response Assessment and Requirements for 
Confirmation (RECIST) 
Response Category 
at First Timepoint 
Response Category at 
Subsequent Timepoint 
Best Overall Response 
CR  
CR  
CR  
CR  
PR  
SD, PD, or PRa 
CR  
SD  
SD provided minimum criteria for SD duration met 
otherwise PD 
CR  
PD  
SD provided minimum criteria for SD duration met 
otherwise PD  
CR  
NE  
SD provided minimum criteria for SD duration met 
otherwise NE  
PR  
CR  
PR  
PR  
PR  
PR  
PR  
SD  
SD  
PR  
PD  
SD provided minimum criteria for SD duration met 
otherwise PD  
PR  
NE  
SD provided minimum criteria for SD duration met 
otherwise NE  
NE  
NE  
NE  
Abbreviations:  BOR=best overall response, CR=complete response, PD=progressive disease, 
PR=partial response, SD=stable disease, NE=nonevaluable 
 
a. 
If a CR is truly met at first timepoint, then any disease seen at a subsequent timepoint, even disease 
meeting PR criteria relative to baseline, makes the disease PD at that point (since disease must 
have reappeared after CR).  Best response would depend on whether minimum duration for SD was 
met.  However, sometimes ‘CR’ may be claimed when subsequent scans suggest small lesions 
were likely still present and in fact the subject had PR, not CR at the first timepoint.  Under these 
circumstances, the original CR should be changed to PR and the best response is PR. 
 
4.2.3 
Immune-related Response Criteria (irRECIST) 
RECIST 1.1 will be adapted to account for the unique tumor response characteristics 
seen with treatment of pembrolizumab.  Immunotherapeutic agents such as 
pembrolizumab may produce antitumor effects by potentiating endogenous cancer-
specific immune responses.  The response patterns seen with such an approach may 
extend beyond the typical time course of responses seen with cytotoxic agents and 
can manifest a clinical response after an initial increase in tumor burden or even the 
appearance of new lesions.  Standard RECIST may not provide an accurate response 
assessment of immunotherapeutic agents such as pembrolizumab.  Therefore, 
RECIST 1.1 will be used with the adaptations described for irRECIST (Appendix 8). 

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4.3 
SAFETY FOLLOW-UP VISIT 
Each subject should be followed for 30 (+ 7) days after his or her last dose of study 
drug (ie, the “safety follow-up visit”) to monitor for resolution or progression of AEs 
(see Section 6.2.6) and to document the occurrence of any new events, regardless of 
whether the subject receives a new anticancer therapy or demonstrates disease 
progression within this timeframe.  Subjects who withdraw consent for study treatment 
should still be encouraged to complete the safety follow-up assessments, but these 
assessments cannot be mandated if subject consent for further study participation is 
withdrawn.  The Schedule of Assessments (Appendix 4) describes the procedures 
required for safety follow-up.  
4.4 
SURVIVAL 
After discontinuing study therapy, subjects will be contacted approximately every 
12 weeks until death, withdrawal by subject, lost to follow-up, or study terminated by 
the sponsor, whichever comes first.  
4.5 
MISSED EVALUATIONS 
Missed evaluations should be rescheduled and performed as close to the original 
scheduled date as possible.  An exception is made when rescheduling becomes, in 
the investigator’s opinion, medically unnecessary or unsafe because it is too close in 
time to the next scheduled evaluation.  In that case, the missed evaluation should be 
abandoned. 
5.0 
STATISTICAL METHODS OF ANALYSIS  
5.1 
GENERAL CONSIDERATIONS 
Descriptive statistics (including means, standard deviations, and medians for 
continuous variables and proportions and confidence intervals [CIs] for discrete 
variables) will be used to summarize data as appropriate.  
For the interim safety analysis (DLT review), enrollment of 
 in the 
combination arm for DLT review is consistent with sample sizes used in oncology 
studies for determination of MTD.  The trial employs the standard National Cancer 
Institute definition of MTD (dose associated with DLT in ≤ 
).  Provided 
the DLT period is cleared in the combination treatment arm, and this arm is not 
stopped early due to futility or toxicity, 
 
   

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 in 
pembrolizumab arm.  The final sample size is 37 in each arm. 
5.2 
DEFINITION OF ANALYSIS POPULATIONS 
The following definitions will be used for the efficacy and safety analysis populations. 
All-treated population:  All enrolled subjects who receive ≥ 1 dose of any study drug 
(either acalabrutinib or pembrolizumab).  The safety and primary efficacy analyses will 
be performed on the All-treated population.  
Efficacy-evaluable population:  All subjects in the All-treated population who have 
≥ 1 evaluable response assessment after the first dose of study drug (either 
acalabrutinib or pembrolizumab).  Sensitivity analyses for efficacy will be carried out 
on the Efficacy-evaluable population. 
5.3 
MISSING DATA HANDLING 
No imputation of values for missing data will be performed except that missing or 
partial start and end dates for AEs and concomitant medication will be imputed 
according to prespecified, conservative imputation rules.  Subjects lost to follow-up (or 
drop out) will be included in statistical analyses to the point of their last evaluation. 
5.4 
ENDPOINT DATA ANALYSIS 
5.4.1 
Safety Endpoint 
Safety summaries will include summaries in the form of tables and listings.  The 
frequency (number and percentage) of treatment-emergent AEs and events of clinical 
interest will be reported in each treatment group by Medical Dictionary for Regulatory 
Activities (MedDRA) System Organ Class and Preferred Term.  Summaries will also 
be presented by the severity of the AE (per Common Terminology Criteria For 
Adverse Events [CTCAE], v4.03 or higher) and by relationship to study drug (eg, 
either acalabrutinib, pembrolizumab, or both). 
Laboratory shift tables containing counts and percentages will be prepared by 
treatment assignment, laboratory parameter, and time.  Summary tables will be 
prepared for each laboratory parameter.  Figures of changes in laboratory parameters 
over time will be generated. 

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Results of vital sign assessments and physical exams will be tabulated and 
summarized.   
5.4.2 
Demographics and Baseline Characteristics 
Additional analyses will include summaries of subject demographics, baseline 
characteristics, compliance, and concurrent treatments.  Concomitant medications will 
be coded and tabulated according to the World Health Organization Drug Dictionary 
(WHODRUG). 
5.4.3 
Study Treatment Administration and Compliance 
Descriptive information will be provided regarding the number of acalabrutinib and 
pembrolizumab doses prescribed, the total number of doses taken, the number of 
days of treatment, and the number and timing of prescribed dose reductions and 
interruptions.   
For each subject, acalabrutinib and pembrolizumab compliance will be described in 
terms of the proportion of study drug actually taken. 
5.4.4 
Analysis of Efficacy Parameters 
Disease Control and Response Rate 
The individual and composite endpoints of response and progression will be 
determined.  Tumor control will be documented at each assessment by response 
category (see Section 4.2) as defined for each response parameter, date that 
response is first documented, and date of disease progression.  DCR will be defined 
as the proportion of subjects who achieve a SD, PR or CR.  ORR will be defined as 
the proportion of subjects who achieve a CR or PR (see Section 4.2).  
DCR and ORR will be calculated and the corresponding 2-sided 95% CI will be 
derived.  
In addition to evaluation of DCR and ORR by RECIST 1.1 criteria (Eisenhauer 2009), 
ORR will also be evaluated by irRECIST criteria (Appendix 8), though the ORR by 
RECIST will be considered the primary endpoint. 
Duration of Response 
The duration of response (DOR) is defined as the interval from the first documentation 
of response to the earlier of the first documentation of definitive disease progression 
or death from any cause.  Kaplan-Meier methods will be used to estimate event-free 

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curves and corresponding quartiles (including the median).  Data from surviving, 
non-progressing subjects will be censored and detailed censoring rules will be 
specified in the statistical analysis plan (SAP).  
Progression-free Survival 
Progression-free survival (PFS) is defined as the interval from the date of first dose of 
study drug to the earlier of the first documentation of objective disease progression or 
death whichever is earlier.  Kaplan-Meier methods will be used to estimate the event-
free curves and corresponding quartiles (including the median).  Data from surviving, 
non-progressing subjects will be censored and detailed censoring rules will be 
specified in the statistical analysis plan.  
Overall Survival 
OS is defined as the time from date of first dose of study drug until date of death due 
to any cause.  Subjects who are known to be alive or whose survival status is 
unknown will be censored at the date last known to be alive.  The analysis methods 
for overall survival will be similar to those described for progression-free survival.  
5.4.5 
PD or Biomarker Analyses 
Additional pharmacodynamic, pharmacokinetic and biomarker analyses may be 
performed, as deemed appropriate. 
Correlations between subject characteristics and outcome measures and correlations 
among outcomes measures will be explored using regression models or other 
appropriate techniques. 
5.5 
FUTILITY AND TOXICITY MONITORING 
The futility and toxicity monitoring will be analyzed in the combination arm (Arm 2) 
only as data become available.  Futility will be monitored by irDCR, which is defined 
as irCR, irPR, and irSD by irRECIST (Appendix 8).  irDCR of at least 20% is clinically 
meaningful in this population.  The response outcome within the 12 weeks will be 
used in the futility analyses.  A Bayesian method (Thall 1995) will be used for futility 
and toxicity monitoring for the combination arm (Arm 2).  The stopping rules are: 
• 
Pr(θE< 0.20 |data)>0.95 
• 
Or 
• 
Pr(TE > 0.30 | data)> 0.90 

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Enrollment in the combination arm will be stopped early if there is > 95% probability 
that the irDCR is < 20% or there is > 90% probability that the toxicity rate is higher 
than 30% in that arm.  Where θE denotes the marginal response rate, assuming that 
θE follows a prior distribution of beta (a, b), where a and b represent response and 
nonresponse rates (0.2, 0.8), and TE denotes the marginal toxicity rate, assuming that 
TE has a prior distribution of beta (a, b), where a and b represent toxicity and no 
toxicity (0.3, 0.7).  The definition of toxicity will follow the same definition used for 
assessing DLTs (see Section 3.7) including the DLT assessment window. 
The above futility and toxicity monitoring rules will be implemented once the first 
10 subjects have been evaluated in the combination arm and will use safety data as 
they become available.  The corresponding stopping boundaries for the futility 
monitoring are:  Enrollment will be stopped early due to futility if (number of subjects 
with irDCR/number subjects evaluated) ≤ 0/(10-15), 1/(16-23), 2/(24-30) and 3/(31-
36).  The corresponding stopping boundaries for toxicity monitoring are listed in Table 
5-1.  
The operating characteristics of the design are presented in Table 5-2.  Multc Lean 
software V2.1 was used for the design. 
Table 5-1.  Stopping Boundaries for Toxicity Monitoring  
                  
Stop enrolling if there are this 
many DLTs total: 
No. Subjects   
(inclusive)        
# Toxicities  (inclusive)    
1-9        
Never stop with this many subjects 
10-12 
6-12 
13-14            
7-14 
15-17           
8-17 
18-20           
9-20 
21-23          
10-23 
24-25 
11-25 
26-28 
12-28 
29-31 
13-31 
32-34 
14-34 
35-36 
15-36 
37 
Always stop due to maximum 
sample size 
 

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Table 5-2.  Operating Characteristics of the Design 
irDCR 
Toxicity rate 
Probability of early stop 
Average # of subjects 
treated  
0.2 
0.1 
0.23 
32.1 
0.2 
0.3 
0.41 
28.2 
0.2 
0.5 
0.95 
14.8 
0.3 
0.1 
0.05 
35.9 
0.3 
0.3 
0.28 
31.3 
0.3 
0.5 
0.94 
15.5 
 
 
6.0 
ASSESSMENT OF SAFETY 
Safety assessments will consist of monitoring and recording DLTs, AEs and SAEs; 
measurements of protocol-specified hematology, clinical chemistry, urinalysis, and 
other laboratory variables; measurement of protocol-specified vital signs; and other 
protocol-specified tests that are deemed critical to the safety evaluation of the study 
drug(s). 
6.1 
DEFINITIONS 
6.1.1 
Adverse Events 
An AE is any unfavorable and unintended sign, symptom, or disease temporally 
associated with the use of an investigational (medicinal) product, regardless of 
attribution. 
This includes the following: 
• 
AEs not previously observed in the subject that emerge during the protocol-
specified AE reporting period, including signs or symptoms associated with 
bladder cancer that were not present before the AE reporting period (see 
Section 6.2.1). 
• 
Preexisting medical conditions (other than the condition being studied) judged 
by the investigator to have worsened in severity or frequency or changed in 
character during the protocol-specified AE reporting period. 
Abnormal laboratory values considered clinically significant laboratory values by the 
investigator should be reported as AEs. 
6.1.2 
Serious Adverse Event 
The terms “severe” and “serious” are not synonymous.  Severity (or intensity) refers to 
the grade of an AE (see below).  “Serious” is a regulatory definition and is based on 
subject or event outcome or action criteria usually associated with events that pose a 

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threat to a subject’s life or functioning.  Seriousness (not severity) serves as the guide 
for defining regulatory reporting obligations from the sponsor to applicable regulatory 
authorities. 
An AE should be classified as an SAE if it meets any 1 of the following criteria: 
• 
It results in death (ie, the AE actually causes or leads to death). 
• 
It is life-threatening (ie, the AE, in the view of the investigator, places the 
subject at immediate risk of death.  It does not include an AE that, had it 
occurred in a more severe form, might have caused death). 
• 
It requires or prolongs inpatient hospitalization. 
• 
It results in persistent or significant disability/incapacity (ie, the AE results 
in substantial disruption of the subject’s ability to conduct normal life 
functions). 
• 
It results in a congenital anomaly/birth defect in a neonate/infant born to 
a mother exposed to the investigational product. 
• 
It is considered a significant medical event by the investigator based on 
medical judgment (eg, may jeopardize the subject or may require 
medical/surgical intervention to prevent 1 of the outcomes listed above). 
6.1.3 
Severity 
Definitions found in the CTCAE version 4.03 or higher will be used for grading the 
severity (intensity) of AEs.  The CTCAE displays Grades 1 through 5 with unique 
clinical descriptions of severity for each referenced AE.  Should a subject experience 
any AE not listed in the CTCAE, the following grading system should be used to 
assess severity: 
• 
Grade 1 (Mild AE) – experiences which are usually transient, requiring no 
special treatment, and not interfering with the subject’s daily activities 
• 
Grade 2 (Moderate AE) – experiences which introduce some level of 
inconvenience or concern to the subject, and which may interfere with 
daily activities, but are usually ameliorated by simple therapeutic 
measures 
• 
Grade 3 (Severe AE) – experiences which are unacceptable or 
intolerable, significantly interrupt the subject’s usual daily activity, and 
require systemic drug therapy or other treatment 
• 
Grade 4 (Life-threatening or disabling AE) – experiences which cause the 
subject to be in imminent danger of death 
• 
Grade 5 (Death related to AE) – experiences which result in subject 
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6.2 
DOCUMENTING AND REPORTING OF ADVERSE AND SERIOUS 
ADVERSE EVENTS 
The investigator is responsible for ensuring that all AEs and SAEs that are observed 
or reported during the study, as outlined in the prior sections, are recorded on the 
CRF.  All SAEs must be reported on the SAE form or clinical database. 
6.2.1 
Adverse Event Reporting Period 
After the signing of the ICF, all SAEs must be reported.  After the first dose of study 
drug, all AEs, irrespective of seriousness, must be reported.  
For acalabrutinib, AE reporting, irrespective of seriousness, ends 30 days after the 
last dose of study drug(s).  For pembrolizumab, all AEs must be reported through 
30 days after the last dose of pembrolizumab; any SAEs, or follow-up to a SAE, 
including death due to any cause other than progression of the cancer under study, 
must be reported through 90 days after the last dose or 30 days after the last dose of 
pembrolizumab if the subject initiates a new anticancer therapy within the 90 day 
posttreatment timeframe.   
SAEs considered related to study drug(s) occurring after the end of the AE reporting 
period (as defined above) must be reported.   
If an SAE is present at the last study visit, the SAE should be followed to resolution or 
until the investigator assesses the subject as stable, or the subject is lost to follow-up 
or withdraws consent.  Resolution/stable means the subject has returned to baseline 
state of health or the investigator does not expect any further improvement or 
worsening of the event. 
6.2.2 
Assessment of Adverse Events 
Investigators will assess the occurrence of AEs and SAEs at all subject evaluation 
timepoints during the study.  All AEs and SAEs whether volunteered by the subject, 
discovered by study personnel during questioning, or detected through physical 
examination, or other means, that occur to any subject from the time of first dose 
through 30 days following the cessation of study drug(s), and all SAEs that occur to 
any subject receiving pembrolizumab from the time of first dose through 90 days 
following cessation of pembrolizumab, or 30 days following cessation of 
pembrolizumab if the subject initiates new anticancer therapy (whichever is earlier) 
will be recorded in the subject’s medical record and on the AE CRF.  

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Disease progression itself is not considered an AE; however, signs and symptoms of 
disease progression may be recorded as AEs or SAEs. 
Each recorded AE or SAE will be described by its diagnostic term, duration (eg, start 
and end dates), severity, regulatory seriousness criteria, if applicable, suspected 
relationship to the study drugs (see following guidance), and any actions taken.  The 
causality of AEs to the study drugs will be assessed by means of the question:  ‘Is 
there a reasonable possibility that the event may have been caused by the study 
drugs?’ per FDA guidance on safety reporting requirements (FDA Guidance 2012). 
See Appendix 3 for more detail on assessing causality. 
6.2.3 
Pregnancy 
The investigator should report all pregnancies and pregnancies in the partners of 
subjects within 24 hours using the Pregnancy Report Form.  This form should be 
faxed or emailed to Acerta Pharma Drug Safety.  Any pregnancy-associated SAE 
must be reported to Acerta Pharma, according to the usual timelines and directions 
for SAE reporting (Section 6.2.4). 
Any uncomplicated pregnancy that occurs with the subject or with the partner of a 
treated subject during this study will be reported.  All pregnancies and partner 
pregnancies that are identified during or after this study, wherein the estimated date 
of conception is determined to have occurred from the time of consent to 90 days 
after the last dose of acalabrutinib, 120 days after the last dose of pembrolizumab, or 
30 days after the last dose of either treatment if the subject initiates a new anticancer 
threapy (whichever is earlier) will be reported, followed to conclusion, and the 
outcome reported, as long as the subject or partner is willing to participate in 
follow-up. 
A pregnancy itself is not regarded as an AE unless there is suspicion that the 
investigational product under study may have interfered with the effectiveness of a 
contraceptive medication.  Likewise, elective abortions without complications are not 
considered AEs.  Any SAEs associated with pregnancy (eg, congenital 
abnormalities/birth defects/spontaneous miscarriage or any other serious events) 
must additionally be reported as such using the SAE report form. 
Subjects should be instructed to immediately notify the investigator of any 
pregnancies.  Any female subjects receiving study drug who become pregnant must 

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immediately discontinue study drug.  The investigator should counsel the subject, 
discussing any risks of continuing the pregnancy and any possible effects on the 
fetus. 
Upon completion of the pregnancy, additional information on the mother, pregnancy, 
and baby will be collected and sent to DrugSafety@acerta-pharma.com. 
6.2.4 
Expedited Reporting Requirements for Serious Adverse 
Events 
All SAEs must be reported within 24 hours of discovery.  All initial SAE reports and 
follow-up information will be reported using the protocol-specific electronic data 
capture system.  If electronic SAE reporting is not available, paper SAE forms must 
be emailed or faxed to Acerta Pharma Drug Safety, or designee.  Acerta Pharma may 
request follow-up and other additional information from the investigator (eg, hospital 
admission/discharge notes and laboratory results). 
Whenever possible, AEs/SAEs should be reported by diagnosis term not as a 
constellation of symptoms.   
Death due to disease progression should be recorded on the appropriate form in the 
electronic data capture system.  If the primary cause of death is disease progression, 
the death due to disease progression should not be reported as an SAE.  If the 
primary cause of death is something other than disease progression, then the death 
should be reported as an SAE with the primary cause of death as the event term, as 
death is typically the outcome of the event, not the event itself.  The primary cause of 
death on the autopsy report should be the term reported.  Autopsy and postmortem 
reports must be forwarded to Acerta Pharma Drug Safety, or designee, as outlined 
above. 
If study drug is discontinued because of an SAE, this information must be included in 
the SAE report. 
An SAE may qualify for mandatory expedited reporting to regulatory authorities if the 
SAE is attributable to the investigational product (or if a causality assessment is not 
provided for the SAE, in which case the default of ‘related’ must be used for expedited 
reporting purposes) and the SAE is not listed in the current Investigator Brochure (ie, 
an unexpected event).  In this case, Acerta Pharma Drug Safety/Designee will 
forward a formal notification describing the suspected unexpected adverse reaction 

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(SUSAR) to all investigators.  Each investigator must then notify his or her IRB/IEC of 
the SUSAR. 
Drug Safety Contact Information 
Fax: 
+1 866 467 0304 (United States) 
or +1 650 935 4996 (for outside United 
States) 
Email: 
DrugSafety@acerta-pharma.com 
 
6.2.5 
Reporting Events of Clinical Interest 
Selected non-serious and serious adverse events are also known as Events of 
Clinical Interest (ECI) and must be reported to the sponsor. 
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, any ECI, or follow up to an ECI, that occurs to any subject 
must be reported within 24 hours to the sponsor if it causes the subject to be 
excluded from the trial, or is the result of a protocol-specified intervention, including 
but not limited to washout or discontinuation of usual therapy, diet, placebo treatment 
or a procedure. 
For the time period beginning at treatment allocation/randomization through 30 days 
following cessation of treatment, any ECI, or follow up to an ECI, whether or not 
related to study drug must be reported within 24 hours to the sponsor either by 
electronic media or paper as described in Section 6.2.4. 
Events of Clinical Interest for this trial include: 
1. An overdose of study drug (overdose is defined in Section 3.10.7) that is not 
associated with clinical symptoms or abnormal laboratory results.  
2. An elevated AST or ALT lab value that is ≥ 3 times the ULN and an elevated total 
bilirubin value that is ≥ 2 times ULN and, at the same time, an alkaline phosphatase 
value that is < 2X the upper limit of normal, as determined by way of protocol-
specified laboratory testing or unscheduled laboratory testing.* 
*Note:  These criteria are based upon available regulatory guidance documents.  The 
purpose of the criteria is to specify a threshold of abnormal hepatic tests that may 
require an additional evaluation for an underlying etiology.  The guidance for 

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assessment and follow up of these criteria can be found in the study binder provided 
separately from this protocol. 
6.2.6 
Type and Duration of Follow-up of Subjects after Adverse 
Events 
All AEs and SAEs that are encountered during the protocol-specified AE reporting 
period should be followed to resolution, or until the investigator assesses the subject 
as stable, a new anticancer therapy is initiated, or the subject is lost to follow-up or 
withdraws consent. 
6.2.7 
Other Safety Issues Requiring Expedited Reporting 
For studies being conducted in Europe expedited reporting is required for safety 
issues that might materially alter the current benefit-risk assessment of an 
investigational medicinal product or that would be sufficient to consider changes in the 
investigational medicinal products administration or in the overall conduct of the trial.  
For a detailed description of safety issues that may qualify for expedited reporting 
please refer to the European Commission guidance titled, “Detailed guidance on the 
collection, verification and presentation of adverse reaction reports arising from 
clinical trials on medicinal products for human use – April 2006” available at 
http://ec.europa.eu/health/files/eudralex/vol-10/21_susar_rev2_2006_04_11_en.pdf. 
7.0 
STUDY ADMINISTRATION AND INVESTIGATOR OBLIGATIONS 
Acerta Pharma retains the right to terminate the study and remove all study materials 
from a study site at any time.  Specific circumstances that may precipitate such 
termination are: 
• 
Unsatisfactory subject enrollment with regard to quality or quantity 
• 
Significant or numerous deviations from study protocol requirements, such as 
failures to perform required evaluations on subjects and maintain adequate study 
records 
• 
Inaccurate, incomplete and/or late data recording on a recurrent basis 
• 
The incidence and/or severity of AEs in this or other studies indicating a potential 
health hazard caused by the study treatment 
7.1 
INSTITUTIONAL REVIEW BOARD AND INDEPENDENT ETHICS 
COMMITTEE 
The investigator will submit this protocol, the informed consent, Investigator’s 
Brochure, and any other relevant supporting information (eg, all advertising materials) 
to the appropriate IRB/IEC for review and approval before study initiation.  A signed 

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protocol approval page; a letter confirming IRB/IEC approval of the protocol and 
informed consent; and a statement that the IRB/IEC is organized and operates 
according to Good Clinical Practice (GCP) guidelines and the applicable laws and 
regulations; must be forwarded to Acerta Pharma before screening subjects for the 
study.  Additionally, sites must forward a signed Form FDA 1572 (Statement of 
Investigator) to Acerta Pharma before screening subjects for study enrollment.  
Amendments to the protocol must also be approved by the IRB/IEC and local 
regulatory agency, as appropriate, before the implementation of changes in this study. 
7.2 
INFORMED CONSENT AND PROTECTED SUBJECT HEALTH 
INFORMATION AUTHORIZATION 
A copy of the IRB/IEC-approved informed consent must be forwarded to Acerta 
Pharma for regulatory purposes.  The investigator, or designee (designee must be 
listed on the Study Personnel Responsibility/Signature Log, see Section 7.11), must 
explain to each subject the purpose and nature of the study, the study procedures, 
the possible adverse effects, and all other elements of consent as defined in § 21CFR 
Part 50, and other applicable national and local regulations governing informed 
consent form.  Each subject must provide a signed and dated informed consent 
before enrollment into this study.  In the case of a subject who is incapable of 
providing informed consent, the investigator (or designee) must obtain a signed and 
dated informed consent form from the subject’s legal guardian.  Signed consent forms 
must remain in each subject’s study file and be available for verification by study 
monitors at any time. 
In accordance to individual local and national patient privacy regulations, the 
investigator or designee must explain to each subject that for the evaluation of study 
results, the subject’s protected health information obtained during the study may be 
shared with Acerta Pharma and its designees, regulatory agencies, and IRBs/IECs.  
As the study sponsor, Acerta Pharma will not use the subject’s protected health 
information or disclose it to a third party without applicable subject authorization.  It is 
the investigator’s or designee’s responsibility to obtain written permission to use 
protected health information from each subject, or if appropriate, the subject’s legal 
guardian.  If a subject or subject’s legal guardian withdraws permission to use 
protected health information, it is the investigator’s responsibility to obtain the 
withdrawal request in writing from the subject or subject’s legal guardian and to 

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ensure that no further data will be collected from the subject.  Any data collected on 
the subject before withdrawal will be used in the analysis of study results. 
7.3 
SUBJECT SCREENING LOG 
The investigator must keep a record that lists all subjects considered for enrollment 
(including those who did not undergo screening) in the study.  For those subjects 
subsequently excluded from enrollment, record the reason(s) for exclusion. 
7.4 
CASE REPORT FORMS 
Authorized study site personnel (see Section 7.11) will complete CRFs designed for 
this study according to the completion guidelines that will be provided within the 
clinical database.  The investigator will ensure that the CRFs are accurate, complete, 
legible, and completed promptly.  The investigator will ensure that source documents 
that are required to verify the validity and completeness of data transcribed on the 
CRFs are never obliterated or destroyed. 
7.5 
STUDY MONITORING REQUIREMENTS 
Representatives of Acerta Pharma or its designee will monitor this study until 
completion.  Monitoring will be conducted through personal visits with the investigator 
and site staff as well as any appropriate communications by mail, fax, email, or 
telephone.  The purpose of monitoring is to ensure compliance with the protocol and 
the quality and integrity of the data.  This study is also subject to reviews or audits. 
Every effort will be made to maintain the anonymity and confidentiality of all subjects 
during this clinical study.  However, because of the experimental nature of this 
treatment, the investigator agrees to allow the IRB/IEC, representatives of Acerta 
Pharma, its designated agents, and authorized employees of the appropriate 
regulatory agencies to inspect the facilities used in this study and, for purposes of 
verification, allow direct access to the hospital or clinic records of all subjects enrolled 
into this study.  This includes providing by fax, email, or regular mail de-identified 
copies of radiology, pathology, and/or laboratory results when requested by the 
sponsor.  A statement to this effect will be included in the informed consent and 
permission form authorizing the use of protected health information. 

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7.6 
INVESTIGATIONAL STUDY DRUG ACCOUNTABILITY 
Acalabrutinib and pembrolizumab must be kept in a locked limited access cabinet or 
space, under appropriate storage conditions.  The study drug must not be used 
outside the context of the protocol. 
Study drug accountability records must be maintained and readily available for 
inspection by representatives of Acerta Pharma and are open to inspections by 
regulatory authorities at any time.  
Each shipment of study drug will contain a Clinical Supplies Shipping Receipt Form 
(CSSF) that must be appended to the site’s drug accountability records.  Additionally 
a Drug Re-order Form for requesting more study drug is provided in the pharmacy 
binder.  If it is used, then the Drug Re-order Form must also be included in the site’s 
drug accountability records.   
Contents of each shipment must be visually inspected to verify the quantity and 
document the condition of study drug capsules.  The designated recipient completes 
and signs the CSSF.  A copy of the signed CSSF must be faxed or emailed to Acerta 
Pharma at the fax number/email address listed on the form. 
An Investigational Drug Accountability Log must be used for drug accountability.  For 
accurate accountability, the following information must be noted when drug supplies 
are used during the study: 
1. 
study identification number (ACE-ST-005) 
2. 
subject identification number 
3. 
lot number(s) of acalabrutinib dispensed for that subject 
4. 
date and quantity of drug dispensed 
5. 
any unused drug returned by the subject 
At study initiation, the monitor will evaluate and approve the site’s procedure for 
investigational product disposal/destruction to ensure that it complies with Acerta 
Pharma’s requirements.  If the site cannot meet Acerta Pharma’s requirements for 
disposal/destruction, arrangements will be made between the site and Acerta Pharma 
or its designee, for return of unused investigational product.  Before 
disposal/destruction, final drug accountability and reconciliation must be performed by 
the monitor. 
All study supplies and associated documentation will be regularly reviewed and 
verified by the monitor. 

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7.7 
RECORD RETENTION 
The investigator and other appropriate study staff are responsible for maintaining all 
documentation relevant to the study.  Mandatory documentation includes copies of 
study protocols and amendments, each Form FDA 1572, IRB/IEC approval letters, 
signed ICFs, drug accountability records, SAE information transmitted to Acerta 
Pharma, subject files (source documentation) that substantiate entries in CRFs, all 
relevant correspondence and other documents pertaining to the conduct of the study. 
An investigator shall retain records for a period of at least 2 years after the date the 
last marketing application is approved for the drug for the indication for which it is 
being investigated; or, if no application is to be filed or if the application is not 
approved for such indication, until 2 years after the investigation is discontinued and 
regulatory authorities have been notified.  The investigator must notify Acerta Pharma 
and obtain written approval from Acerta Pharma before destroying any clinical study 
records at any time.  Acerta Pharma will inform the investigator of the date that study 
records may be destroyed or returned to Acerta Pharma. 
Acerta Pharma must be notified in advance of, and Acerta Pharma must provide 
express written approval of, any change in the maintenance of the foregoing 
documents if the investigator wishes to move study records to another location or 
assign responsibility for record retention to another party.  If the investigator cannot 
guarantee the archiving requirements set forth herein at his or her study site for all 
such documents, special arrangements must be made between the investigator and 
Acerta Pharma to store such documents in sealed containers away from the study 
site so that they can be returned sealed to the investigator for audit purposes. 
7.8 
PROTOCOL AMENDMENTS 
Acerta Pharma will initiate any change to the protocol in a protocol amendment 
document.  The amendment will be submitted to the IRB/IEC together with, if 
applicable, a revised model ICF.  If the change in any way increases the risk to the 
subject or changes the scope of the study, then written documentation of IRB/IEC 
approval must be received by Acerta Pharma before the amendment may take effect. 
Additionally under this circumstance, information on the increased risk and/or change 
in scope must be provided to subjects already actively participating in the study, and 
they must read, understand, and sign any revised ICF confirming willingness to 
remain in the trial. 

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7.9 
PUBLICATION OF STUDY RESULTS 
Authorship, in general, will follow the recommendations of the International 
Committee of Medical Journal Editors (International Committee of Medical Journal 
Editors 2014). 
7.10 CLINICAL TRIAL INSURANCE 
Clinical trial insurance has been undertaken according to the laws of the countries 
where the study will be conducted.  An insurance certificate will be made available to 
the participating sites at the time of study initiation. 
7.11 GENERAL INVESTIGATOR RESPONSIBILITIES 
The principal investigator must ensure that: 
1. He or she will conduct or supervise the study. 
2. His or her staff and all persons who assist in the conduct of the study clearly 
understand their responsibilities and have their names included in the Study 
Personnel Responsibility/Signature Log. 
3. The study is conducted according to the protocol and all applicable 
regulations. 
4. The protection of each subject’s rights and welfare is maintained. 
5. Signed and dated informed consent and, when applicable, permission to use 
protected health information are obtained from each subject before conducting 
nonstandard of care study procedures.  If a subject or subject’s legal guardian 
withdraws permission to use protected health information, the investigator will 
obtain a written request from the subject or subject’s legal guardian and will 
ensure that no further data be collected from the subject. 
6. The consent process is conducted in compliance with all applicable 
regulations and privacy acts. 
7. The IRB/IEC complies with applicable regulations and conducts initial and 
ongoing reviews and approvals of the study. 
8. Any amendment to the protocol is submitted promptly to the IRB/IEC. 
9. Any significant protocol deviations are reported to Acerta Pharma and the 
IRB/IEC according to the guidelines at each study site. 
10. CRF pages are completed promptly. 
11. All IND Safety Reports/SUSAR Reports are submitted promptly to the 
IRB/IEC. 
12. All SAEs are reported to Acerta Pharma Drug Safety/Designee within 24 hours 
of knowledge via the clinical database and to the IRB/IEC per their 
requirements. 

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8.0 
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Michowitz M, Shimoni A, Nagler A. Phase I safety and pharmacokinetic study of CT-
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Boorjian SA, Sheinin Y, Crispen PL, et al. T-cell coregulatory molecule expression in 
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Bradshaw JM. The Src, Syk, and Tec family kinases: distinct types of molecular 
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Byrd JC, Harrington B, O’Brien S, et al.  Acalabrutinib (ACP-196) in relapsed chronic 
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Fuxe J, Karlsson MC. TGF-β-induced epithelial-mesenchymal transition: a link 
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Gartrell BA, Sonpavde G. Emerging drugs for urothelial carcinoma. Expert Opin 
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Hallek M, Cheson BD, Catovsky D, et al.  Guidelines for the diagnosis and treatment 
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targeted therapy. Leukemia 2013;27:2311-2321. 
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2013;2:662-673. Int J Surgery 2013;11:749-753. 
Meyer C, Cagnon L, Costa-Nunes CM, et al. Frequencies of circulating MDSC 
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9.0 
APPENDICES 
 
 
 
 
 
 

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Appendix 1. Performance Status Scores  
Grade 
ECOG 
0 
Fully active, able to carry on all pre-disease performance 
without restriction 
1 
Restricted in physically strenuous activity but ambulatory and 
able to carry out work of a light or sedentary nature, eg, light 
house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out 
any work activities. Up and about more than 50% of waking 
hours 
3 
Capable of only limited self-care, confined to bed or chair more 
than 50% of waking hours 
4 
Completely disabled. Cannot carry on any self-care. Totally 
confined to bed or chair 
5 
Dead 
As published in Am J Clin Oncol: 
Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., 
Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative Oncology 
Group. Am J Clin Oncol 5:649-655, 1982. 
Credit: Eastern Cooperative Oncology Group Chair: Robert Comis, MD 
Available at: http://www.ecog.org/general/perf_stat.html.  Accessed 23 August 2013. 
 
 
 
 

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Appendix 2.  Known Strong in Vivo Inhibitors or Inducers of CYP3A 
 
Strong Inhibitors of CYP3Aa 
Strong Inducers of CYP3Ae 
boceprevir 
carbamazepinef 
clarithromycinb 
phenytoinf 
conivaptinb 
rifampinf 
grapefruit juicec 
St John's wortf  
indinavir 
 
itraconazoleb 
 
ketoconazoleb 
 
lopinavir/ritonavirb (combination drug) 
 
mibefradild 
 
nefazodone 
 
nelfinavir 
 
posaconazole 
 
ritonavirb 
 
saquinavir 
 
telaprevir 
 
telithromycin 
 
voriconazole 
 
Source: 
FDA Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers . Web 
link Accessed 21 January 2015: 
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsL
abeling/ucm093664.htm#inVivo 
Note: The list of drugs in these tables is not exhaustive.  Any questions about drugs not on this list 
should be addressed to the medical monitor of the protocol. 
a. 
A strong inhibitor for CYP3A is defined as an inhibitor that increases the AUC of a substrate for 
CYP3A by ≥ 5-fold. 
b. 
In vivo inhibitor of P-glycoprotein. 
c. 
The effect of grapefruit juice varies widely among brands and is concentration-, dose-, and 
preparation-dependent. Studies have shown that it can be classified as a “strong CYP3A inhibitor” 
when a certain preparation was used (eg, high dose, double strength) or as a “moderate CYP3A 
inhibitor” when another preparation was used (eg, low dose, single strength). 
d. 
Withdrawn from the United States market because of safety reasons. 
e. 
A strong inducer for CYP3A is defined as an inducer that results in ≥ 80% decrease in the AUC of a 
substrate for CYP3A. 
f. 
In vivo inducer of P-glycoprotein.   
 
 
 
 

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Appendix 3.  Adverse Event Assessment of Causality 
 
Is there a reasonable possibility that the event may have been caused by study 
drugs?  No___ Yes___ 
The descriptions provided below will help guide the principal investigator in making 
the decision to choose either “yes” or “no”: 
No = There is no reasonable possibility that the event may have been caused by 
study drugs. 
The adverse event: 
• 
may be judged to be due to extraneous causes such as disease or 
environment or toxic factors 
• 
may be judged to be due to the subject’s clinical state or other therapy being 
administered 
• 
is not biologically plausible 
• 
does not reappear or worsen when study drug is re-administered 
• 
does not follow a temporal sequence from administration of study drug 
Yes = There is a reasonable possibility that the event may have been caused by 
study drugs. 
The adverse event: 
• 
follows a temporal sequence from administration of study drug 
• 
is a known response to the study drug based on clinical or preclinical data 
• 
could not be explained by the known characteristics of the subject’s clinical 
state, environmental or toxic factors, or other therapy administered to the 
subject 
• 
disappears or decreases upon cessation or reduction of dose of study drug 
• 
reappears or worsens when study drug is re-administered 
 

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Appendix 4.  Schedule of Assessments – Treatment Arms 1 and 2 
 
Treatment Phase (Weeks)b 
Safety 
Follow 
Visitc 
Follow-up 
Phased 
Study Weeks 
Screeninga 
1 
2 
3 
4 
5s 
6 
7 
8 
≥ 10 
(Q3W) 
ET 
+30 days 
after last 
dose  
Q12W 
Study Window 
-28 days 
 
± 3 days 
± 3 days 
+ 3 days 
+ 7 days 
± 10 days 
Informed consent 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm eligibility 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
x 
 
 
 
 
 
 
 
 
 
 
 
 
PEe/Vital signsf/Weight 
x 
x 
x 
x 
x 
x 
 
x 
 
x 
x 
x 
 
ECOG status 
x 
x 
x 
x 
x 
x 
 
x 
 
x 
 
 
 
ECGg 
x 
x 
x 
 
x 
x 
 
x 
 
Q6W 
x 
x 
 
Lab assessments: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy testh 
x 
xq 
 
 
x 
 
 
x 
 
x 
x 
x 
 
 
Hematologyi 
x 
xq 
x 
x 
x 
x 
 
x 
 
x 
x 
x 
 
 
Coagulation 
x 
 
 
 
 
 
 
x 
 
 
 
 
 
 
Serum chemistryj 
x 
xq 
x 
x 
x 
x 
 
x 
 
x 
x 
x 
 
 
Serum lipase/amylase 
x 
xq 
 
 
x 
x 
 
x 
 
x 
x 
x 
 
 
Thyroid panelk 
x 
xq 
 
 
 
 
 
x 
 
Week 13 then 
Q6W 
x 
x 
 
 
Urinalysisl 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
T/B/NK cell countm 
x 
xq 
 
 
 
 
 
xq 
 
Week 10 then 
Q3M 
 
 
 
 
Serum Ign 
 
xq 
 
 
 
 
 
xq 
 
Week 10 then 
Q3M 
 
 
 
 
Hepatitis serologyt 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
HBV PCRu 
x 
 
 
 
x 
 
 
 
x 
Week 12 then 
Q4W 
 
 
Q4W 
HCV PCRv 
x 
 
 
 
 
 
 
 
 
Week 13 and 
25 
 
 
 
 
Pharmacokineticsr 
 
x 
 
x 
 
 
 
x 
 
 
 
 
 
 
PD/Biomarkers 
Tumor 
sampleo 
xq 
xq 
xq 
xq 
 
 
xq 
 
Week 10 and 
13 onlyq 
 
 
 
Arm 1 
Pembrolizumab 200 mg Q3W 
 
x 
 
 
x 
 
 
x 
 
x 
 
 
 
Arm 2 
Acalabrutinib 100 mg BID 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
 
Pembrolizumab 200 mg Q3W 
 
x 
 
 
x 
 
 
x 
 
x 
 
 
 
Study drug compliance 
 
x 
x 
x 
x 
x 
 
x 
 
x 
 
 
 

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Tumor assessmentp 
x 
 
 
 
 
 
 
x 
 
Week 13 and 
19 then every 
12 weeks 
 
 
 
Concomitant medications 
x 
x 
x 
x 
x 
x 
 
x 
 
x 
x 
x 
 
Adverse events 
 
x 
x 
x 
x 
x 
 
x 
 
x 
x 
x 
 
Survival 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
Abbreviations: BID = twice per day; ECG = electrocardiogram, ECOG = Eastern Cooperative Oncology Group, ET = early termination; HBV = hepatitis B virus; Ig = 
immunoglobulin; PCR = polymerase chain reaction; PE = physical exam; Q3M = every 3 months; Q12W = every 12 weeks; Q3W = every 3 weeks; Q4W = every 
4 weeks; Q6W = every 6 weeks. 
Note:  Visits to the sites are not required on Week 6 and 8, but subjects will continue to take acalabrutinib 100 mg BID during those weeks. 
Footnotes for ACE-ST-005 Schedule of Study Activities: 
a.  Screening tests should be performed within 28 days before the first administration of study drug, unless otherwise indicated. 
b. 
Treatment may be stopped earlier for confirmed CR as described in the protocol. 
c. 
A 30-day (+ 7 days) safety follow-up visit is required when subjects discontinue study drug unless they start another anticancer therapy within that timeframe. 
d. 
Subjects who discontinue study therapy will be followed for survival unless they withdraw consent or are lost to follow-up or the sponsor ends the study.  Subjects who 
discontinue study drug for any reason other than disease progression, death, lost to follow-up, or withdrawal of consent will be followed for tumor assessment until disease 
progression or initiation of any other anticancer therapies, whichever comes first. 
e. 
The screening physical examination will include, at a minimum, the general appearance of the subject, height (screening only) and weight, and examination of the skin, 
eyes, ears, nose, throat, lungs, heart, abdomen, extremities, musculoskeletal system, lymphatic system, and nervous system.  Symptom-directed physical exams, including 
tumor assessments by palpation, are done thereafter.   
f. 
Vital signs (blood pressure, pulse, respiratory rate, and temperature) will be assessed after the subject has rested in the sitting position.   
g. 
Subjects should be in supine position and resting for ≥ 10 minutes before study-related ECGs.  On Day 1, Week 1 ECGs will be done in triplicate ≥ 1 minute apart.  At all 
other visits the single ECGs will be done at any time during the visit. 
h. 
Women of childbearing potential must have a negative urine or serum pregnancy testing within 72 hours prior to receiving the first dose of study medication.  If the urine test 
is positive or cannot be confirmed as negative, a serum pregnancy test is required.   
i. 
Hematology includes complete blood count with differential and platelet and reticulocyte counts. Week 1 hematology does not need to be repeated if screening hematology 
was done within 7 days. 
j. 
Serum chemistry: albumin, alkaline phosphatase, alanine transaminase (ALT), aspartate aminotransferase (AST), bicarbonate, blood urea nitrogen (BUN), bone-specific 
alkaline phosphatase, calcium, chloride, creatinine, glucose, lactate dehydrogenase (LDH), magnesium, phosphate, potassium, sodium, total bilirubin, total protein, and uric 
acid. Week 1 serum chemistry does not need to be repeated if screening serum chemistry was within 7 days. 
k. 
Thyroid panel:  total triiodothyronine (T3), free thyroxine (T4), and thyroid stimulating hormone (TSH).  Week 1 thyroid panel does not need to be repeated if screening 
thyroid panel was within 7 days. 
l. 
Urinalysis: pH, ketones, specific gravity, bilirubin, blood, and glucose.  
m. T/B/NK cell count (ie, CD3, CD4, CD8, CD14, CD19, CD16/56).  Week 1 cell count does not need to be repeated if screening cell count was within 7 days. 
n. 
Serum immunoglobulin: IgG, IgM, IgA.   
o. 
Provide tissue sections from either an archived or newly obtained tumor sample (most recent biopsy) for biomarker analysis 
p. 
A pretreatment computed tomography (CT) scan with contrast (unless contraindicated) is required of the chest, abdomen, and pelvis and any other disease sites (eg, neck) 
within 30 days before the first dose of study drug. CT scans will be done for tumor assessments at Week 7, 13, 19 (± 7 days) and then every 12 weeks (± 10 days) or more 
frequently at the investigator’s discretion.  
q. 
The indicated samples at this timepoint must be drawn predose. 
r. 
Only subjects in Arm 2 will have PK sampling.  The first 6 subjects in Arm 2 will have PK samples drawn at Week 1 (Day 1 and Day 2), Week 3 and Week 7.  All other 
subjects in Arm 2 will only have PK samples drawn at Week 3.  Refer to Section 4.1.19 complete instructions on the PK sampling timepoints. 
s. 
The Week 5 visit is only required for subjects who will contribute to the DLT assessment. 
t. 
Hepatitis serology must include hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), hepatitis B core antibody (anti-HBc), and hepatitis C (HCV) 
antibody.  In addition, any subjects testing positive for any hepatitis serology, must have PCR testing (see exclusion criterion #16). 

Product: Acalabrutinib (ACP-196) 
Date: 23 May 2016 
Protocol: ACE-ST-005 
 
 
 
Acerta Pharma 
Confidential 
Page 108 of 162 
u. 
Subjects who are hepatitis B core antibody positive (or have a known history of HBV infection) should have a quantitative PCR test for HBV DNA during screening and 
monthly thereafter.  Monitoring should continue Q4W (± 7 days) until 12 months after last dose of study drug(s).  Any subject with a rising viral load (above lower limit of 
detection) should discontinue study drug(s) and have antiviral therapy instituted and a consultation with a physician with expertise in managing hepatitis B. 
v. 
Subjects with a known history of hepatitis C or who are hepatitis C antibody positive should have quantitative PCR testing for HCV DNA performed during screening and at 
Weeks 13 and 25.  No further testing beyond Week 25 is necessary if, PCR results are negative.    
 
 

Product: Acalabrutinib (ACP-196) 
Date: 23 May 2016 
Protocol: ACE-ST-005 
 
 
 
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Confidential 
Page 109 of 162 
Appendix 5.  Schedule of Assessments – Crossover 
Treatment Phase (Weeks) 
Weeks After Crossovera,b 
0 
1 
2 
3 
≥ 4 
Study Window 
± 3 days 
Vital signs 
Refer to Schedule of 
Assessments in Appendix 4 
x 
x 
Refer to Schedule of 
Assessments in Appendix 4 
Refer to Schedule of Assessments in 
Appendix 4 
Lab assessments: 
 
 
Hematologyc 
x 
x 
Serum chemistryd 
x 
x 
Study drug compliance 
x 
x 
Concomitant medications 
x 
x 
Adverse events 
x 
x 
Acalabrutinib 100 mg BIDb 
x 
x 
x 
x 
Pembrolizumab 200 mg Q3W 
x 
 
 
x 
Abbreviations: BID = twice per day; Q3W = every 3 weeks. 
Footnotes for ACE-ST-005 Schedule of Study Activities - Crossover: 
a. 
Subjects are to complete assessments as shown in the 2 weeks following crossover.  (Eg, if a subject crosses over to receive acalabrutinib and pembrolizumab at Week 10, 
assessments will be performed as listed for Week 10 in Appendix 4.  During Weeks 11 and 12, assessments will be performed as listed above for Weeks 1 and 2 after 
Crossover.  During Week 13, assessments will be performed as listed in Week 13 in Appendix 4; assessments will be performed as listed in Appendix 4 for all subsequent 
weeks). 
b. 
Subjects who cross over to receive acalabrutinib in addition to pembrolizumab should start acalabrutinib treatment at the next visit in which they are scheduled to receive 
pembrolizumab. 
c. 
Hematology includes complete blood count with differential and platelet and reticulocyte counts.  
d. 
Serum chemistry: albumin, alkaline phosphatase, alanine transaminase (ALT), aspartate aminotransferase (AST), bicarbonate, blood urea nitrogen (BUN), bone-specific 
alkaline phosphatase, calcium, chloride, creatinine, glucose, lactate dehydrogenase (LDH), magnesium, phosphate, potassium, sodium, total bilirubin, total protein, and uric 
acid.  

Product: Acalabrutinib (ACP-196) 
Date: 23 May 2016 
Protocol: ACE-ST-005 
 
 
 
Acerta Pharma 
Confidential 
Page 110 of 162 
Appendix 6.  KEYTRUDA Package Insert 
 
 
 

HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use 
KEYTRUDA safely and effectively. See full prescribing 
information for KEYTRUDA.
KEYTRUDA® (pembrolizumab) for injection, for intravenous use 
KEYTRUDA® (pembrolizumab) injection, for intravenous use
Initial U.S. Approval: 2014
---------------------------RECENT MAJOR CHANGES ---------------------------
Indications and Usage (1.1)
12/2015
Indications and Usage (1.2)
10/2015
Dosage and Administration (2.1, 2.3)
10/2015
Dosage and Administration (2.4)
01/2015
Warnings and Precautions (5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7)
12/2015
----------------------------INDICATIONS AND USAGE----------------------------
KEYTRUDA is a programmed death receptor-1 (PD-1)-blocking 
antibody indicated for the treatment of:

patients with unresectable or metastatic melanoma. (1.1)

patients with metastatic NSCLC whose tumors express PD-L1 as 
determined by an FDA-approved test and who have disease 
progression on or after platinum-containing chemotherapy. 
Patients with EGFR or ALK genomic tumor aberrations should 
have disease progression on FDA-approved therapy for these 
aberrations prior to receiving KEYTRUDA.
This indication is approved under accelerated approval based on 
tumor response rate and durability of response. An improvement 
in survival or disease-related symptoms has not yet been
established. Continued approval for this indication may be 
contingent upon verification and description of clinical benefit in 
the confirmatory trials. (1.2)
----------------------- DOSAGE AND ADMINISTRATION -----------------------

Administer 2 mg/kg as an intravenous infusion over 30 minutes 
every 3 weeks. (2.2)

Dilute prior to intravenous infusion. (2.4)
---------------------DOSAGE FORMS AND STRENGTHS ---------------------

For injection: 50 mg lyophilized powder in single-use vial for 
reconstitution (3)

Injection: 100 mg/4 mL (25 mg/mL) solution in a single-use vial (3)
-------------------------------CONTRAINDICATIONS-------------------------------
None. (4)
----------------------- WARNINGS AND PRECAUTIONS------------------------

Immune-mediated Pneumonitis: Withhold for moderate, and 
permanently discontinue for severe, life-threatening or recurrent 
moderate pneumonitis. (5.1)

Immune-mediated Colitis: Withhold for moderate or severe, and 
permanently discontinue for life-threatening colitis. (5.2)

Immune-mediated Hepatitis: Monitor for changes in hepatic 
function. Based on severity of liver enzyme elevations, withhold or 
discontinue. (5.3)

Immune-mediated Endocrinopathies (5.4): 
o
Hypophysitis: Withhold for moderate and withhold or 
permanently discontinue for severe or life-threatening 
hypophysitis. 
o
Thyroid disorders: Monitor for changes in thyroid function. 
Withhold or permanently discontinue for severe or life-
threatening hyperthyroidism. 
o
Type 1 diabetes mellitus: Monitor for hyperglycemia. 
Withhold KEYTRUDA in cases of severe hyperglycemia. 

Immune-mediated nephritis: Monitor for changes in renal function. 
Withhold for moderate, and permanently discontinue for severe or 
life-threatening nephritis. (5.5)

Infusion-related reactions: Stop infusion and permanently 
discontinue KEYTRUDA for severe or life-threatening infusion 
reactions. (5.7)

Embryofetal toxicity: KEYTRUDA can cause fetal harm. Advise 
females of reproductive potential of the potential risk to a fetus. 
(5.8)
------------------------------ ADVERSE REACTIONS ------------------------------
Most common adverse reactions (reported in ≥20% of patients) with:

melanoma included fatigue, pruritus, rash, constipation, diarrhea, 
nausea, and decreased appetite. (6.1)

NSCLC included fatigue, decreased appetite, dyspnea and 
cough. (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Merck 
Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-877-
888-4231 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
----------------------- USE IN SPECIFIC POPULATIONS -----------------------
Lactation: Discontinue nursing or discontinue KEYTRUDA. (8.2)
See 17 for PATIENT COUNSELING INFORMATION and Medication 
Guide.
Revised: 12/2015
FULL PRESCRIBING INFORMATION: CONTENTS*
1
INDICATIONS AND USAGE
1.1
Melanoma
1.2
Non-Small Cell Lung Cancer
2
DOSAGE AND ADMINISTRATION
2.1
Patient Selection
2.2
Recommended Dosing
2.3
Dose Modifications
2.4
Preparation and Administration
3
DOSAGE FORMS AND STRENGTHS
4
CONTRAINDICATIONS
5
WARNINGS AND PRECAUTIONS
5.1
Immune-Mediated Pneumonitis
5.2
Immune-Mediated Colitis
5.3
Immune-Mediated Hepatitis
5.4
Immune-Mediated Endocrinopathies
5.5
Immune-Mediated Nephritis and Renal Dysfunction
5.6
Other Immune-Mediated Adverse Reactions
5.7
Infusion-Related Reactions
5.8
Embryofetal Toxicity
6
ADVERSE REACTIONS
6.1
Clinical Trials Experience
6.2
Immunogenicity
7
DRUG INTERACTIONS
8
USE IN SPECIFIC POPULATIONS
8.1
Pregnancy
8.2
Lactation
8.3
Females and Males of Reproductive Potential
8.4
Pediatric Use
8.5
Geriatric Use
8.6
Renal Impairment
8.7
Hepatic Impairment
10
OVERDOSAGE
11
DESCRIPTION
12
CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
12.3 Pharmacokinetics
13
NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
13.2 Animal Toxicology and/or Pharmacology
14
CLINICAL STUDIES
14.1 Melanoma
14.2 Non-Small Cell Lung Cancer
16
HOW SUPPLIED/STORAGE AND HANDLING
17
PATIENT COUNSELING INFORMATION
*Sections or subsections omitted from the full prescribing information 
are not listed.

2
FULL PRESCRIBING INFORMATION
1
INDICATIONS AND USAGE
1.1
Melanoma
KEYTRUDA® (pembrolizumab) is indicated for the treatment of patients with unresectable or metastatic 
melanoma [see Clinical Studies (14.1)].
1.2
Non-Small Cell Lung Cancer
KEYTRUDA is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC)
whose tumors express PD-L1 as determined by an FDA-approved test with disease progression on or 
after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should 
have disease progression on FDA-approved therapy for these aberrations prior to receiving KEYTRUDA 
[see Clinical Studies (14.2)].
This indication is approved under accelerated approval based on tumor response rate and durability of 
response. An improvement in survival or disease-related symptoms has not yet been established. 
Continued approval for this indication may be contingent upon verification and description of clinical 
benefit in the confirmatory trials. 
2
DOSAGE AND ADMINISTRATION
2.1
Patient Selection
Select patients for second line or greater treatment of metastatic NSCLC with KEYTRUDA based on the 
presence of positive PD-L1 expression [see Clinical Studies (14.2)]. Information on FDA-approved tests 
for the detection of PD-L1 expression in NSCLC is available at: 
http://www.fda.gov/CompanionDiagnostics.
2.2
Recommended Dosing
The recommended dose of KEYTRUDA is 2 mg/kg administered as an intravenous infusion over 
30 minutes every 3 weeks until disease progression or unacceptable toxicity.
2.3
Dose Modifications
Withhold KEYTRUDA for any of the following:

Grade 2 pneumonitis [see Warnings and Precautions (5.1)] 

Grade 2 or 3 colitis [see Warnings and Precautions (5.2)] 

Grade 3 or 4 endocrinopathies [see Warnings and Precautions (5.4)]

Grade 2 nephritis [see Warnings and Precautions (5.5)] 

Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) greater than 3 and up to 
5 times upper limit of normal (ULN) or total bilirubin greater than 1.5 and up to 3 times ULN

Any other severe or Grade 3 treatment-related adverse reaction [see Warnings and Precautions 
(5.6)]
Resume KEYTRUDA in patients whose adverse reactions recover to Grade 0-1.
Permanently discontinue KEYTRUDA for any of the following:

Any life-threatening adverse reaction (excluding endocrinopathies controlled with hormone 
replacement therapy)

Grade 3 or 4 pneumonitis or recurrent pneumonitis of Grade 2 severity [see Warnings and 
Precautions (5.1)]

Grade 3 or 4 nephritis [see Warnings and Precautions (5.5)]

AST or ALT greater than 5 times ULN or total bilirubin greater than 3 times ULN
o
For patients with liver metastasis who begin treatment with Grade 2 AST or ALT, if AST or ALT 
increases by greater than or equal to 50% relative to baseline and lasts for at least 1 week

Grade 3 or 4 infusion-related reactions [see Warnings and Precautions (5.7)]

3

Inability to reduce corticosteroid dose to 10 mg or less of prednisone or equivalent per day within 
12 weeks

Persistent Grade 2 or 3 adverse reactions (excluding endocrinopathies controlled with hormone 
replacement therapy) that do not recover to Grade 0-1 within 12 weeks after last dose of 
KEYTRUDA

Any severe or Grade 3 treatment-related adverse reaction that recurs [see Warnings and 
Precautions (5.6)]
2.4
Preparation and Administration
Reconstitution of KEYTRUDA for Injection (Lyophilized Powder)

Add 2.3 mL of Sterile Water for Injection, USP by injecting the water along the walls of the vial and 
not directly on the lyophilized powder (resulting concentration 25 mg/mL).

Slowly swirl the vial. Allow up to 5 minutes for the bubbles to clear. Do not shake the vial.
Preparation for Intravenous Infusion

Visually inspect the solution for particulate matter and discoloration prior to administration. The 
solution is clear to slightly opalescent, colorless to slightly yellow. Discard the vial if visible particles 
are observed.

Dilute KEYTRUDA injection (solution) or reconstituted lyophilized powder prior to intravenous 
administration.

Withdraw the required volume from the vial(s) of KEYTRUDA and transfer into an intravenous (IV) 
bag containing 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP. Mix diluted 
solution by gentle inversion. The final concentration of the diluted solution should be between 
1 mg/mL to 10 mg/mL.

Discard any unused portion left in the vial.
Storage of Reconstituted and Diluted Solutions
The product does not contain a preservative.
Store the reconstituted and diluted solution from the KEYTRUDA 50 mg vial either: 

At room temperature for no more than 6 hours from the time of reconstitution. This includes room 
temperature storage of reconstituted vials, storage of the infusion solution in the IV bag, and the 
duration of infusion.

Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the time of 
reconstitution. If refrigerated, allow the diluted solution to come to room temperature prior to 
administration.
Store the diluted solution from the KEYTRUDA 100 mg/4 mL vial either: 

At room temperature for no more than 6 hours from the time of dilution. This includes room 
temperature storage of the infusion solution in the IV bag, and the duration of infusion.

Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the time of dilution. 
If refrigerated, allow the diluted solution to come to room temperature prior to administration.
Do not freeze.
Administration

Administer infusion solution intravenously over 30 minutes through an intravenous line containing a 
sterile, non-pyrogenic, low-protein binding 0.2 micron to 5 micron in-line or add-on filter.

Do not co-administer other drugs through the same infusion line.
3
DOSAGE FORMS AND STRENGTHS

For injection: 50 mg lyophilized powder in a single-use vial for reconstitution

Injection: 100 mg/4 mL (25 mg/mL) solution in a single-use vial

4
4
CONTRAINDICATIONS
None.
5
WARNINGS AND PRECAUTIONS
5.1
Immune-Mediated Pneumonitis
Immune-mediated pneumonitis, including fatal cases, occurred in patients receiving KEYTRUDA. Monitor 
patients for signs and symptoms of pneumonitis. Evaluate patients with suspected pneumonitis with 
radiographic imaging and administer corticosteroids (initial dose of 1 to 2 mg/kg/day prednisone or 
equivalent followed by a taper) for Grade 2 or greater pneumonitis. Withhold KEYTRUDA for moderate 
(Grade 2) pneumonitis, and permanently discontinue KEYTRUDA for severe (Grade 3), life-threatening 
(Grade 4), or recurrent moderate (Grade 2) pneumonitis [see Dosage and Administration (2.3) and 
Adverse Reactions (6.1)].
Melanoma
Pneumonitis occurred in 32 (2.0%) of 1567 patients receiving KEYTRUDA in Trials 1, 2, and 6, including 
Grade 1 (0.8%), Grade 2 (0.8%), and Grade 3 (0.4%) pneumonitis. The median time to development of 
pneumonitis was 4.3 months (range: 2 days to 19.3 months). The median duration was 2.6 months
(range: 2 days to 15.1 months). Twelve (38%) of the 32 patients received corticosteroids, with 9 of the 12 
receiving high-dose systemic corticosteroids for a median duration of 8 days (range: 1 day to 1.1 months)
followed by a corticosteroid taper. Pneumonitis led to discontinuation of KEYTRUDA in 9 (0.6%) patients. 
Pneumonitis completely resolved in 21 (66%) of the 32 patients. 
NSCLC
Pneumonitis occurred in 19 (3.5%) of 550 patients with NSCLC, including Grade 2 (1.1%), Grade 3 
(1.3%), Grade 4 (0.4%), or Grade 5 (0.2%) pneumonitis in patients receiving KEYTRUDA in Trial 1. The 
median time to development of pneumonitis was 1.7 months (range: 4 days to 12.9 months). In patients 
receiving KEYTRUDA 10 mg/kg every 14 days, the median time to development of pneumonitis was 
shorter (1.5 months) compared with patients receiving 10 mg/kg every 21 days (3.5 months). Sixteen of 
the 19 patients (84%) received corticosteroids, with 14 of the 19 (74%) requiring high-dose systemic 
corticosteroids (greater than or equal to 40 mg prednisone or equivalent per day). The median starting 
dose of high-dose corticosteroid treatment for these fourteen patients was 60 mg/day with a median 
duration of treatment of 8 days (range: 1 day to 4.2 months). The median duration of pneumonitis was 
1.2 months (range: 5 days to 12.4 months). Pneumonitis occurred more frequently in patients with a 
history of asthma/chronic obstructive pulmonary disease (5.4%) than in patients without a history of these 
diseases (3.1%). Pneumonitis occurred more frequently in patients with a history of prior thoracic 
radiation (6.0%) than in patients who did not receive prior thoracic radiation (2.6%). Pneumonitis led to 
discontinuation of KEYTRUDA in 12 (2.2%) patients. Pneumonitis completely resolved in 9 patients. 
Pneumonitis was reported as ongoing in 9 patients and one patient with ongoing pneumonitis died within 
30 days of the last dose of KEYTRUDA.
5.2
Immune-Mediated Colitis
Immune-mediated colitis occurred in patients receiving KEYTRUDA. Monitor patients for signs and 
symptoms of colitis. Administer corticosteroids (initial dose of 1 to 2 mg/kg/day prednisone or equivalent 
followed by a taper) for Grade 2 or greater colitis. Withhold KEYTRUDA for moderate (Grade 2) or severe 
(Grade 3) colitis, and permanently discontinue KEYTRUDA for life-threatening (Grade 4) colitis [see 
Dosage and Administration (2.3) and Adverse Reactions (6.1)].
Melanoma
Colitis occurred in 31 (2.0%) of 1567 patients receiving KEYTRUDA in Trials 1, 2, and 6, including 
Grade 2 (0.5%), Grade 3 (1.1%), and Grade 4 (0.1%) colitis. The median time to onset of colitis was 
3.4 months (range: 10 days to 9.7 months). The median duration of colitis was 1.4 months (range: 1 day
to 7.2 months). Twenty-one (68%) of the 31 patients received corticosteroids, all of whom required high-
dose systemic corticosteroids for a median duration of 6 days (range: 1 day to 5.3 months) followed by a 

5
corticosteroid taper. Colitis led to discontinuation of KEYTRUDA in 14 (0.9%) patients. Colitis resolved in 
27 (87%) of the 31 patients. 
NSCLC
Colitis occurred in 4 (0.7%) of 550 patients, including Grade 2 (0.2%) or Grade 3 (0.4%) colitis in patients 
receiving KEYTRUDA in Trial 1. The median time to onset of colitis was 1.6 months (range: 28 days to 
2.2 months) and the median duration was 16 days (range: 7 days to 1.3 months). Two patients were 
started on high-dose corticosteroids (greater than or equal to 40 mg prednisone or equivalent per day) 
and two patients were started on low dose corticosteroids. One patient (0.2%) discontinued KEYTRUDA 
due to colitis. Three patients with colitis experienced complete resolution of the event.
5.3
Immune-Mediated Hepatitis
Immune-mediated hepatitis occurred in patients receiving KEYTRUDA. Monitor patients for changes in 
liver function. Administer corticosteroids (initial dose of 0.5 to 1 mg/kg/day [for Grade 2 hepatitis] and 1 to 
2 mg/kg/day [for Grade 3 or greater hepatitis] prednisone or equivalent followed by a taper) and, based 
on severity of liver enzyme elevations, withhold or discontinue KEYTRUDA [see Dosage and 
Administration (2.3) and Adverse Reactions (6.1)].
Melanoma
Hepatitis occurred in 16 (1.0%) of 1567 patients receiving KEYTRUDA in Trials 1, 2, and 6, including 
Grade 2 (0.1%), Grade 3 (0.7%), and Grade 4 (0.1%) hepatitis. The time to onset was 26 days (range: 
8 days to 21.4 months). The median duration was 1.2 months (range: 8 days to 4.7 months). Eleven 
(69%) of the 16 patients received corticosteroids, with 10 of the 11 receiving high-dose systemic 
corticosteroids for a median duration of 5 days (range: 1 to 14 days) followed by a corticosteroid taper. 
Hepatitis led to discontinuation of KEYTRUDA in 6 (0.4%) patients. Hepatitis resolved in 14 (88%) of the 
16 patients.
5.4
Immune-Mediated Endocrinopathies
Hypophysitis
Hypophysitis occurred in patients receiving KEYTRUDA. Monitor for signs and symptoms of hypophysitis 
(including hypopituitarism and adrenal insufficiency). Administer corticosteroids and hormone 
replacement as clinically indicated. Withhold KEYTRUDA for moderate (Grade 2) hypophysitis and 
withhold or discontinue KEYTRUDA for severe (Grade 3) or life-threatening (Grade 4) hypophysitis [see
Dosage and Administration (2.3) and Adverse Reactions (6.1)].
Melanoma
Hypophysitis occurred in 13 (0.8%) of 1567 patients receiving KEYTRUDA in Trials 1, 2, and 6 including 
Grade 2 (0.3%), Grade 3 (0.3%), and Grade 4 (0.1%) hypophysitis. The time to onset was 3.3 months 
(range: 1 day to 7.2 months). The median duration was 2.7 months (range: 12 days to 12.7 months). 
Twelve (92%) of the 13 patients received corticosteroids, with 4 of the 12 patients receiving high-dose
systemic corticosteroids. Hypophysitis led to discontinuation of KEYTRUDA in 4 (0.3%) patients. 
Hypophysitis resolved in 7 (54%) of the 13 patients.
NSCLC
In Trial 1, hypophysitis occurred in 1 (0.2%) of 550 patients, which was Grade 3 in severity. The time to 
onset was 3.7 months. The patient was treated with systemic corticosteroids and physiologic hormone 
replacement therapy. The patient did not discontinue KEYTRUDA due to hypophysitis.
Thyroid Disorders
Thyroid disorders can occur at any time during treatment. Monitor patients for changes in thyroid function 
(at the start of treatment, periodically during treatment, and as indicated based on clinical evaluation) and 
for clinical signs and symptoms of thyroid disorders.

6
Administer replacement hormones for hypothyroidism and manage hyperthyroidism with thionamides and 
beta-blockers as appropriate. Withhold or discontinue KEYTRUDA for severe (Grade 3) or life-threatening 
(Grade 4) hyperthyroidism [see Dosage and Administration (2.3) and Adverse Reactions (6.1)].
Melanoma
Hyperthyroidism occurred in 51 (3.3%) of 1567 patients receiving KEYTRUDA in Trials 1, 2, or 6, 
including Grade 2 (0.6%) and Grade 3 (0.1%) hyperthyroidism. The median time to onset was 1.4 months 
(range: 1 day to 21.9 months). The median duration was 1.7 months (range: 1 day to 12.8 months). 
Hyperthyroidism led to discontinuation of KEYTRUDA in 2 (0.1%) patients. Hyperthyroidism resolved in 
36 (71%) of the 51 patients.
Hypothyroidism occurred in 127 (8.1%) of 1567 patients receiving KEYTRUDA in Trials 1, 2, and 6 
including Grade 3 (0.1%) hypothyroidism. The median time to onset of hypothyroidism was 3.3 months 
(range: 5 days to 18.9 months). The median duration was 5.4 months (range: 6 days to 24.3 months). No 
patients discontinued KEYTRUDA due to hypothyroidism. Hypothyroidism resolved in 24 (19%) of the 
127 patients.
NSCLC
Hyperthyroidism occurred in 10 (1.8%) of 550 patients receiving KEYTRUDA in Trial 1, including Grade 2 
(0.7%) or Grade 3 (0.3%) hyperthyroidism. The median time to onset was 1.8 months (range: 2 days to 
3.4 months), and the median duration was 4.5 months (range: 4 weeks to 7.5 months). No patients 
discontinued KEYTRUDA due to hyperthyroidism. 
Hypothyroidism occurred in 38 (6.9%) of 550 patients receiving KEYTRUDA in Trial 1, including Grade 2 
(5.5%) or Grade 3 (0.2%) hypothyroidism. The median time to onset was 4.2 months (range: 20 days to 
11.2 months), and the median duration was 5.8 months (range: 11 days to 22.8 months). No patients 
discontinued KEYTRUDA due to hypothyroidism.
Type 1 Diabetes mellitus
Type 1 diabetes mellitus, including diabetic ketoacidosis, occurred in 3 (0.1%) of 2117 patients with 
melanoma or NSCLC receiving KEYTRUDA in Trials 1, 2, and 6. Monitor patients for hyperglycemia or 
other signs and symptoms of diabetes. Administer insulin for type 1 diabetes, and withhold KEYTRUDA 
and administer anti-hyperglycemics in patients with severe hyperglycemia [see Dosage and 
Administration (2.3) and Adverse Reactions (6.1)].
5.5
Immune-Mediated Nephritis and Renal Dysfunction
Immune-mediated nephritis occurred in patients receiving KEYTRUDA. Monitor patients for changes in 
renal function. Administer corticosteroids (initial dose of 1 to 2 mg/kg/day prednisone or equivalent 
followed by a taper) for Grade 2 or greater nephritis. Withhold KEYTRUDA for moderate (Grade 2), and 
permanently discontinue KEYTRUDA for severe (Grade 3) or life-threatening (Grade 4) nephritis [see 
Dosage and Administration (2.3) and Adverse Reactions (6.1)].
Melanoma
Nephritis occurred in 7 (0.4%) of 1567 patients receiving KEYTRUDA in Trials 1, 2, and 6, including 
Grade 2 (0.2%), Grade 3 (0.2%), and Grade 4 (0.1%) nephritis. The median time to onset of nephritis was 
5.1 months (range: 12 days to 12.8 months). The median duration was 1.1 months (range: 3 days to 
3.3 months). Six (86%) of the 7 patients received corticosteroids, with 5 of the 6 receiving high-dose 
systemic corticosteroids for a median duration of 15 days (range: 3 days to 1.6 months) followed by a 
corticosteroid taper. Nephritis led to discontinuation of KEYTRUDA in 2 (0.1%) patients. Nephritis 
resolved in 4 (57%) of the 7 patients.
5.6
Other Immune-Mediated Adverse Reactions
Other clinically important immune-mediated adverse reactions can occur.

7
For suspected immune-mediated adverse reactions, ensure adequate evaluation to confirm etiology or 
exclude other causes. Based on the severity of the adverse reaction, withhold KEYTRUDA and 
administer corticosteroids. Upon improvement to Grade 1 or less, initiate corticosteroid taper and 
continue to taper over at least 1 month. Based on limited data from clinical studies in patients whose 
immune-related adverse reactions could not be controlled with corticosteroid use, administration of other 
systemic immunosuppressants can be considered. Resume KEYTRUDA when the immune-mediated 
adverse reaction remains at Grade 1 or less following corticosteroid taper. Permanently discontinue
KEYTRUDA for any Grade 3 immune-mediated adverse reaction that recurs and for any life-threatening 
immune-mediated adverse reaction [see Dosage and Administration (2.3) and Adverse Reactions (6.1)].
Melanoma
The following clinically significant, immune-mediated adverse reactions occurred in less than 1% (unless 
otherwise indicated) of 1567 patients with melanoma treated with KEYTRUDA in Trials 1, 2, and 6: 
arthritis (1.6%), exfoliative dermatitis, bullous pemphigoid, uveitis, myositis, Guillain-Barré syndrome, 
myasthenia gravis, vasculitis, pancreatitis, hemolytic anemia, and partial seizures arising in a patient with 
inflammatory foci in brain parenchyma.
NSCLC
The following clinically significant, immune-mediated adverse reactions occurred in less than 1% of 
550 patients with NSCLC treated with KEYTRUDA in Trial 1: rash, vasculitis, hemolytic anemia, serum 
sickness, and myasthenia gravis.
5.7 
Infusion-Related Reactions
Severe and life-threatening infusion-related reactions have been reported in 3 (0.1%) of 2117 patients
receiving KEYTRUDA in Trials 1, 2, and 6. Monitor patients for signs and symptoms of infusion-related 
reactions including rigors, chills, wheezing, pruritus, flushing, rash, hypotension, hypoxemia, and fever. 
For severe (Grade 3) or life-threatening (Grade 4) infusion-related reactions, stop infusion and 
permanently discontinue KEYTRUDA [see Dosage and Administration (2.3)].
5.8
Embryofetal Toxicity
Based on its mechanism of action, KEYTRUDA can cause fetal harm when administered to a pregnant 
woman. Animal models link the PD-1/PD-L1 signaling pathway with maintenance of pregnancy through 
induction of maternal immune tolerance to fetal tissue. If this drug is used during pregnancy, or if the 
patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to a fetus. 
Advise females of reproductive potential to use highly effective contraception during treatment with 
KEYTRUDA and for 4 months after the last dose of KEYTRUDA [see Use in Specific Populations (8.1, 
8.3)].
6
ADVERSE REACTIONS
The following adverse reactions are discussed in greater detail in other sections of the labeling. 

Immune-mediated pneumonitis [see Warnings and Precautions (5.1)].

Immune-mediated colitis [see Warnings and Precautions (5.2)].

Immune-mediated hepatitis [see Warnings and Precautions (5.3)].

Immune-mediated endocrinopathies [see Warnings and Precautions (5.4)].

Immune-mediated nephritis and renal dysfunction [see Warnings and Precautions (5.5)].

Other immune-mediated adverse reactions [see Warnings and Precautions (5.6)].

Infusion-related reactions [see Warnings and Precautions (5.7)].
6.1
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in 
the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and 
may not reflect the rates observed in practice. 

8
The data described in the WARNINGS AND PRECAUTIONS section reflect exposure to KEYTRUDA in 
2117 patients in two randomized, open-label, active-controlled clinical trials, which enrolled 912 patients 
with unresectable or metastatic melanoma and one single-arm trial which enrolled 655 patients with 
metastatic melanoma and 550 patients with NSCLC. Across all studies, KEYTRUDA was administered at 
doses of 2 mg/kg intravenously every 3 weeks (19%), 10 mg/kg intravenously every 2 weeks (31%), or 
10 mg/kg intravenously every 3 weeks (50%). Among these 2117, 43% of the patients were exposed for 
6 months or more and 10% of the patients were exposed for 12 months or more.
The data described below were obtained in two randomized, open-label, active-controlled clinical trials 
(Trials 2 and 6), which enrolled 912 patients with unresectable or metastatic melanoma or in a single-arm 
trial (Trial 1), which enrolled 550 patients with metastatic non-small cell lung cancer (NSCLC). In these 
trials, KEYTRUDA was administered at 2 mg/kg every 3 weeks or 10 mg/kg every 2 or 3 weeks. 
Unresectable or Metastatic Melanoma
Ipilimumab-Naive Melanoma (Trial 6)
The safety of KEYTRUDA for the treatment of patients with unresectable or metastatic melanoma who 
had not received prior ipilimumab and who had received no more than one prior systemic therapy was 
investigated in Trial 6. Trial 6 was a multicenter, open-label, active-controlled trial where patients were 
randomized (1:1:1) and received KEYTRUDA 10 mg/kg every 2 weeks (n=278) or KEYTRUDA 10 mg/kg 
every 3 weeks (n=277) until disease progression or unacceptable toxicity or ipilimumab 3 mg/kg every 
3 weeks for 4 doses unless discontinued earlier for disease progression or unacceptable toxicity (n=256) 
[see Clinical Studies (14.1)]. Patients with autoimmune disease, a medical condition that required 
systemic corticosteroids or other immunosuppressive medication; a history of interstitial lung disease; or 
active infection requiring therapy, including HIV or hepatitis B or C, were ineligible. 
The median duration of exposure was 5.6 months (range: 1 day to 11.0 months) for KEYTRUDA and 
similar in both treatment arms. Fifty-one and 46% of patients received KEYTRUDA 10 mg/kg every 2 or 
3 weeks, respectively, for ≥6 months. No patients in either arm received treatment for more than one 
year.
The study population characteristics were: median age of 62 years (range: 18 to 89 years), 60% male, 
98% White, 32% had an elevated lactate dehydrogenase (LDH) value at baseline, 65% had M1c stage 
disease, 9% with history of brain metastasis, and approximately 36% had been previously treated with 
one or more lines of systemic therapy which included a BRAF inhibitor (15%), chemotherapy (13%), and 
immunotherapy (6%). 
In Trial 6, the adverse reaction profile was similar for the every 2 week and every 3 week schedule, 
therefore summary safety results are provided in a pooled analysis (n=555) of both KEYTRUDA arms. 
Adverse reactions leading to permanent discontinuation of KEYTRUDA occurred in 9% of patients. 
Adverse reactions leading to discontinuation of KEYTRUDA in more than one patient were colitis (1.4%), 
autoimmune hepatitis (0.7%), allergic reaction (0.4%), polyneuropathy (0.4%), and cardiac failure (0.4%). 
Adverse reactions leading to interruption of KEYTRUDA occurred in 21% of patients; the most common 
(≥1%) was diarrhea (2.5%). The most common adverse reactions (reported in at least 20% of patients) 
were fatigue and diarrhea. Table 1 and Table 2 summarize the incidence of selected adverse reactions
and laboratory abnormalities, respectively, that occurred in at least 10% of patients receiving 
KEYTRUDA.

9
Table 1: Selected* Adverse Reactions Occurring in ≥10% of Patients Receiving KEYTRUDA 
(Trial 6)
KEYTRUDA
10 mg/kg every 2 or 3 weeks
n=555
Ipilimumab
n=256
Adverse Reaction
All Grades†
(%)
Grade 3-4
(%)
All Grades
(%)
Grade 3-4
(%)
General Disorders and Administration Site Conditions
Fatigue
28
0.9
28
3.1
Skin and Subcutaneous Tissue Disorders
Rash‡
24
0.2
23
1.2
Vitiligo§
13
0
2
0
Musculoskeletal and Connective Tissue Disorders
Arthralgia
18
0.4
10
1.2
Back pain
12
0.9
7
0.8
Respiratory, Thoracic and Mediastinal Disorders
Cough
17
0
7
0.4
Dyspnea
11
0.9
7
0.8
Metabolism and Nutrition Disorders
Decreased appetite
16
0.5
14
0.8
Nervous System Disorders
Headache
14
0.2
14
0.8
*
Adverse reactions occurring at same or higher incidence than in the ipilimumab arm
†
Graded per NCI CTCAE v4.0
‡
Includes rash, rash erythematous, rash follicular, rash generalized, rash macular, rash maculo-
papular, rash papular, rash pruritic, and exfoliative rash.
§
Includes skin hypopigmentation
Other clinically important adverse reactions occurring in ≥10% of patients receiving KEYTRUDA were 
diarrhea (26%), nausea (21%), and pruritus (17%).
Table 2: Selected* Laboratory Abnormalities Worsened from Baseline Occurring in ≥20% of 
Melanoma Patients Receiving KEYTRUDA (Trial 6)
KEYTRUDA
10 mg/kg every 2 or 
3 weeks
Ipilimumab
Laboratory Test†
All Grades‡
%
Grades 3-4
%
All Grades
%
Grades 3-4
%
Chemistry
Hyperglycemia
45
4.2
45
3.8
Hypertriglyceridemia
43
2.6
31
1.1
Hyponatremia
28
4.6
26
7
Increased AST
27
2.6
25
2.5
Hypercholesterolemia
20
1.2
13
0
Hematology
Anemia
35
3.8
33
4.0
Lymphopenia
33
7
25
6
*
Laboratory abnormalities occurring at same or higher incidence than in ipilimumab arm
†
Each test incidence is based on the number of patients who had both baseline and at least one on-
study laboratory measurement available: KEYTRUDA (520 to 546 patients) and ipilimumab (237 to 
247 patients); hypertriglyceridemia: KEYTRUDA n=429 and ipilimumab n=183; hypercholesterolemia:
KEYTRUDA n=484 and ipilimumab n=205).
‡
Graded per NCI CTCAE v4.0
Other laboratory abnormalities occurring in ≥20% of patients receiving KEYTRUDA were increased 
hypoalbuminemia (27% all Grades; 2.4% Grades 3-4), increased ALT (23% all Grades; 3.1% Grades 3-
4), and increased alkaline phosphatase (21% all Grades, 2.0% Grades 3-4).

10
Ipilimumab-Refractory Melanoma (Trial 2)
The safety of KEYTRUDA in patients with unresectable or metastatic melanoma with disease progression 
following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor, was evaluated in Trial 2. 
Trial 2 was a multicenter, partially blinded (KEYTRUDA dose), randomized (1:1:1), active-controlled trial 
in which 528 patients received KEYTRUDA 2 mg/kg (n=178) or 10 mg/kg (n=179) every 3 weeks or 
investigator’s choice of chemotherapy (n=171), consisting of dacarbazine (26%), temozolomide (25%), 
paclitaxel and carboplatin (25%), paclitaxel (16%), or carboplatin (8%) [see Clinical Studies (14.1)]. The 
trial excluded patients with autoimmune disease, severe immune-related toxicity related to ipilimumab, 
defined as any Grade 4 toxicity or Grade 3 toxicity requiring corticosteroid treatment (greater than 
10 mg/day prednisone or equivalent dose) for greater than 12 weeks; medical conditions that required 
systemic corticosteroids or other immunosuppressive medication; a history of interstitial lung disease; or 
an active infection requiring therapy, including HIV or hepatitis B or C.
The median duration of exposure to KEYTRUDA 2 mg/kg every 3 weeks was 3.7 months (range: 1 day to 
16.6 months) and to KEYTRUDA 10 mg/kg every 3 weeks was 4.8 months (range: 1 day to 16.8 months). 
The data described below reflect exposure to KEYTRUDA 2 mg/kg in 36% of patients exposed to 
KEYTRUDA for ≥6 months and in 4% of patients exposed for ≥12 months. In the KEYTRUDA 10 mg/kg 
arm, 41% of patients were exposed to KEYTRUDA for ≥6 months and 6% of patients were exposed to 
KEYTRUDA for ≥12 months.
The study population characteristics were: median age of 62 years (range: 15 to 89 years), 61% male, 
98% White, 41% with an elevated LDH value at baseline, 83% with M1c stage disease, 73% received two 
or more prior therapies for advanced or metastatic disease (100% received ipilimumab and 25% a BRAF 
inhibitor), and 15% with history of brain metastasis. 
In Trial 2, the adverse reaction profile was similar for the 2 mg/kg dose and 10 mg/kg dose, therefore 
summary safety results are provided in a pooled analysis (n=357) of both KEYTRUDA arms. Adverse 
reactions resulting in permanent discontinuation occurred in 12% of patients receiving KEYTRUDA; the 
most common (≥1%) were general physical health deterioration (1%), asthenia (1%), dyspnea (1%), 
pneumonitis (1%), and generalized edema (1%). Adverse reactions leading to interruption of KEYTRUDA 
occurred in 14% of patients; the most common (≥1%) were dyspnea (1%), diarrhea (1%), and maculo-
papular rash (1%). The most common adverse reactions (reported in at least 20% of patients) of 
KEYTRUDA were fatigue, pruritus, rash, constipation, nausea, diarrhea, and decreased appetite.
Table 3 summarizes the incidence of adverse reactions occurring in at least 10% of patients receiving 
KEYTRUDA. 

11
Table 3: Selected* Adverse Reactions Occurring in ≥10% of Patients Receiving KEYTRUDA 
(Trial 2)
KEYTRUDA
2 mg/kg or 10 mg/kg 
every 3 weeks
n=357
Chemotherapy†
n=171
Adverse Reaction
All Grades‡
(%)
Grade 3-4
(%)
All Grades
(%)
Grade 3-4
(%)
General Disorders and Administration Site Conditions
Pyrexia
14
0.3
9
0.6
Asthenia
10
2.0
9
1.8
Skin and Subcutaneous Tissue Disorders
Pruritus
28
0
8
0
Rash§
24
0.6
8
0
Gastrointestinal Disorders
Constipation
22
0.3
20
2.3
Diarrhea
20
0.8
20
2.3
Abdominal pain
13
1.7
8
1.2
Respiratory, Thoracic and Mediastinal Disorders
Cough
18
0
16
0
Musculoskeletal and Connective Tissue Disorders
Arthralgia
14
0.6
10
1.2
*
Adverse reactions occurring at same or higher incidence than in chemotherapy arm
†
Chemotherapy : dacarbazine, temozolomide, carboplatin plus paclitaxel, paclitaxel, or carboplatin 
‡
Graded per NCI CTCAE v4.0
§ 
Includes rash, rash erythematous, rash generalized, rash macular, rash maculo-papular, rash 
papular, and rash pruritic
Other clinically important adverse reactions occurring in patients receiving KEYTRUDA were fatigue 
(43%), nausea (22%), decreased appetite (20%), vomiting (13%), and peripheral neuropathy (1.7%).
Table 4: Selected* Laboratory Abnormalities Worsened from Baseline Occurring in ≥20% of 
Melanoma Patients Receiving KEYTRUDA (Trial 2)
KEYTRUDA
2 mg/kg or 10 mg/kg every 
3 weeks
Chemotherapy
Laboratory Test†
All Grades‡
%
Grades 3-4
%
All Grades
%
Grades 3-4
%
Chemistry
Hyperglycemia
49
6
44
6
Hypoalbuminemia
37
1.9
33
0.6
Hyponatremia
37
7
24
3.8
Hypertriglyceridemia
33
0
32
0.9
Increased Alkaline Phosphatase 
26
3.1
18
1.9
Increased AST
24
2.2
16
0.6
Bicarbonate Decreased
22
0.4
13
0
Hypocalcemia 
21
0.3
18
1.9
Increased ALT
21
1.8
16
0.6
*
Laboratory abnormalities occurring at same or higher incidence than in chemotherapy arm.
†
Each test incidence is based on the number of patients who had both baseline and at least one on-study 
laboratory measurement available: KEYTRUDA (range: 320 to 325 patients) and chemotherapy (range: 154
to 161 patients); hypertriglyceridemia: KEYTRUDA n=247 and chemotherapy n=116; bicarbonate decreased:
KEYTRUDA n=263 and chemotherapy n=123).
‡
Graded per NCI CTCAE v4.0
Other laboratory abnormalities occurring in ≥20% of patients receiving KEYTRUDA were anemia (44% all 
Grades; 10% Grades 3-4) and lymphopenia (40% all Grades; 9% Grades 3-4).

12
NSCLC
Among the 550 patients with metastatic NSCLC enrolled in Trial 1, the median duration of therapy was 
2.8 months (range: 1 day to 25.6 months). Patients with NSCLC and autoimmune disease, a medical 
condition that required immunosuppression, or who had received more than 30 Gy of thoracic radiation 
within the prior 26 weeks were ineligible for Trial 1. The median age of patients was 64 years (range: 28 
to 93), 47% were age 65 years or older, 53% were male, 83% were White, and 67% received two or more 
prior systemic treatments. Disease characteristics were Stage III (4%), Stage IV (96%), and brain 
metastases (11%). Baseline ECOG performance status (PS) was 0 (35%) or 1 (65%).
KEYTRUDA was discontinued due to adverse reactions in 14% of patients. Serious adverse reactions 
occurred in 38% of patients receiving KEYTRUDA. The most frequent serious adverse reactions reported 
in at least 2% of patients were pleural effusion, pneumonia, dyspnea, pulmonary embolism, and 
pneumonitis. The incidence of adverse reactions, including serious adverse reactions, was similar 
between the two 10 mg/kg dosing schedules; therefore, these data were pooled. The majority of patients 
treated with KEYTRUDA 2 mg/kg every three weeks had shorter follow-up compared with patients treated 
with the 10 mg/kg schedules; therefore, comparisons of adverse reactions between doses were not 
appropriate.
Table 5 summarizes adverse reactions that occurred in at least 10% of patients. The most common 
adverse reactions (reported in at least 20% of patients) were fatigue, decreased appetite, dyspnea, and 
cough.

13
Table 5: Adverse Reactions in ≥10% of Patients with NSCLC (Trial 1)
KEYTRUDA
2 mg/kg every 3 weeks or 
10 mg/kg every 2 or 
3 weeks
n=550
Adverse Reaction
All Grades
(%)
Grade 3*
(%)
General Disorders and Administration Site Conditions
Fatigue†
44
4
Pyrexia
12
1
Peripheral Edema
10
0
Metabolism and Nutrition Disorders
Decreased appetite
25
1
Respiratory, Thoracic and Mediastinal Disorders
Dyspnea
23
4
Cough‡
29
<1
Gastrointestinal Disorders
Nausea
18
1
Diarrhea
15
1
Constipation
15
<1
Vomiting
12
1
Musculoskeletal and Connective Tissue Disorders
Arthralgia
15
1
Back pain
10
2
Blood and Lymphatic System Disorders
Anemia
12
2
Skin and Subcutaneous Tissue Disorders
Pruritus
12
0
Rash§
18
<1
*
Of the ≥10% adverse reactions, none was reported as Grade 4 or 5.
†
Includes the terms fatigue and asthenia
‡
Includes the terms cough, productive cough and hemoptysis
§
Includes the terms dermatitis, dermatitis acneiform, erythema multiforme, 
drug eruption, rash, rash generalized, rash pruritic, rash macular/maculo-
papular, papular
Table 6: Laboratory Abnormalities Worsened from 
Baseline in ≥20% of Patients with NSCLC (Trial 1)
KEYTRUDA
n=550
Laboratory Test
All Grades
%
Grades 3-4
%
Chemistry
Hyperglycemia
48
3*
Hyponatremia
38
6
Hypoalbuminemia
32
1
Increased alkaline 
phosphatase 
26
1
Hypertriglyceridemia
23
0
Increased aspartate 
aminotransferase 
20
1
Hypercholesterolemia
20
1*
Hematology
Anemia
36
2*
*
Grade 4 abnormalities in this table limited to hyperglycemia 
(n=4), hypercholesterolemia (n=3), and anemia (n=1).

14
6.2
Immunogenicity
As with all therapeutic proteins, there is the potential for immunogenicity. Trough levels of pembrolizumab 
interfere with the electrochemiluminescent (ECL) assay results; therefore, a subset analysis was 
performed in the patients with a concentration of pembrolizumab below the drug tolerance level of the 
anti-product antibody assay. In clinical studies in patients treated with pembrolizumab at a dose of
2 mg/kg every 3 weeks or 10 mg/kg every two or three weeks, 1 (0.3%) of 392 evaluable patients tested 
positive for treatment-emergent anti-pembrolizumab antibodies and confirmed positive in the neutralizing 
assay. 
The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. 
Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay 
may be influenced by several factors including assay methodology, sample handling, timing of sample 
collection, concomitant medications, and underlying disease. For these reasons, comparison of incidence 
of antibodies to KEYTRUDA with the incidences of antibodies to other products may be misleading.
7
DRUG INTERACTIONS
No formal pharmacokinetic drug interaction studies have been conducted with KEYTRUDA. 
8
USE IN SPECIFIC POPULATIONS
8.1
Pregnancy
Risk Summary
Based on its mechanism of action, KEYTRUDA can cause fetal harm when administered to a pregnant 
woman. In animal models, the PD-1/PD-L1 signaling pathway is important in the maintenance of 
pregnancy through induction of maternal immune tolerance to fetal tissue [see Data]. Human IgG4 
(immunoglobulins) are known to cross the placenta; therefore, pembrolizumab has the potential to be 
transmitted from the mother to the developing fetus. There are no available human data informing the risk
of embryo-fetal toxicity. Apprise pregnant women of the potential risk to a fetus.
In the U.S. general population, the estimated background risk of major birth defects and miscarriage in 
clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Data
Animal Data
Animal reproduction studies have not been conducted with KEYTRUDA to evaluate its effect on 
reproduction and fetal development, but an assessment of the effects on reproduction was provided. A 
central function of the PD-1/PD-L1 pathway is to preserve pregnancy by maintaining maternal immune 
tolerance to the fetus. Blockade of PD-L1 signaling has been shown in murine models of pregnancy to 
disrupt tolerance to the fetus and to result in an increase in fetal loss; therefore, potential risks of 
administering KEYTRUDA during pregnancy include increased rates of abortion or stillbirth. As reported 
in the literature, there were no malformations related to the blockade of PD-1 signaling in the offspring of 
these animals; however, immune-mediated disorders occurred in PD-1 knockout mice. Based on its 
mechanism of action, fetal exposure to pembrolizumab may increase the risk of developing immune-
mediated disorders or of altering the normal immune response.
8.2
Lactation
Risk Summary
It is not known whether KEYTRUDA is excreted in human milk. No studies have been conducted to 
assess the impact of KEYTRUDA on milk production or its presence in breast milk. Because many drugs 
are excreted in human milk, instruct women to discontinue nursing during treatment with KEYTRUDA and 
for 4 months after the final dose.
8.3
Females and Males of Reproductive Potential
Contraception

15
Based on its mechanism of action, KEYTRUDA can cause fetal harm when administered to a pregnant 
woman [see Warnings and Precautions (5.8) and Use in Specific Populations (8.1)]. Advise females of 
reproductive potential to use effective contraception during treatment with KEYTRUDA and for at least 
4 months following the final dose.
8.4
Pediatric Use
Safety and effectiveness of KEYTRUDA have not been established in pediatric patients.
8.5
Geriatric Use
Of the 2117 patients with melanoma or NSCLC treated with KEYTRUDA, 43% were 65 years and over. 
No overall differences in safety or efficacy were reported between elderly patients and younger patients.
8.6
Renal Impairment
Based on a population pharmacokinetic analysis, no dose adjustment is needed for patients with renal 
impairment [see Clinical Pharmacology (12.3)].
8.7
Hepatic Impairment
Based on a population pharmacokinetic analysis, no dose adjustment is needed for patients with mild 
hepatic impairment [total bilirubin (TB) less than or equal to ULN and AST greater than ULN or TB greater 
than 1 to 1.5 times ULN and any AST]. KEYTRUDA has not been studied in patients with moderate (TB 
greater than 1.5 to 3 times ULN and any AST) or severe (TB greater than 3 times ULN and any AST) 
hepatic impairment [see Clinical Pharmacology (12.3)].
10
OVERDOSAGE
There is no information on overdosage with KEYTRUDA.
11
DESCRIPTION
Pembrolizumab is a humanized monoclonal antibody that blocks the interaction between PD-1 and its 
ligands, PD-L1 and PD-L2. Pembrolizumab is an IgG4 kappa immunoglobulin with an approximate 
molecular weight of 149 kDa.
KEYTRUDA for injection is a sterile, preservative-free, white to off-white lyophilized powder in single-use 
vials. Each vial is reconstituted and diluted for intravenous infusion. Each 2 mL of reconstituted solution 
contains 50 mg of pembrolizumab and is formulated in L-histidine (3.1 mg), polysorbate 80 (0.4 mg), and 
sucrose (140 mg). May contain hydrochloric acid/sodium hydroxide to adjust pH to 5.5. 
KEYTRUDA injection is a sterile, preservative-free, clear to slightly opalescent, colorless to slightly yellow 
solution that requires dilution for intravenous infusion. Each vial contains 100 mg of pembrolizumab in 
4 mL of solution. Each 1 mL of solution contains 25 mg of pembrolizumab and is formulated in: L-histidine 
(1.55 mg), polysorbate 80 (0.2 mg), sucrose (70 mg), and Water for Injection, USP.
12
CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Binding of the PD-1 ligands, PD-L1 and PD-L2, to the PD-1 receptor found on T cells, inhibits T cell 
proliferation and cytokine production. Upregulation of PD-1 ligands occurs in some tumors and signaling 
through this pathway can contribute to inhibition of active T-cell immune surveillance of tumors. 
Pembrolizumab is a monoclonal antibody that binds to the PD-1 receptor and blocks its interaction with 
PD-L1 and PD-L2, releasing PD-1 pathway-mediated inhibition of the immune response, including the 
anti-tumor immune response. In syngeneic mouse tumor models, blocking PD-1 activity resulted in 
decreased tumor growth.
12.3 Pharmacokinetics
The pharmacokinetics of pembrolizumab was studied in 2195 patients who received doses of 1 to 
10 mg/kg every 2 weeks or 2 to 10 mg/kg every 3 weeks. Based on population pharmacokinetic analyses 

16
in patients with solid tumors, the geometric mean [% coefficient of variation (CV%)] for clearance, steady-
state volume of distribution, and terminal half-life were 202 mL/day (37%), 7.38 L (19%) and 27 days 
(38%), respectively.
Steady-state concentrations of pembrolizumab were reached by 19 weeks of repeated dosing with an 
every 3-week regimen and the systemic accumulation was 2.2-fold. The peak concentration (Cmax), trough 
concentration (Cmin), and area under the plasma concentration versus time curve at steady state (AUCss) 
of pembrolizumab increased dose proportionally in the dose range of 2 to 10 mg/kg every 3 weeks.
Specific Populations: The effects of various covariates on the pharmacokinetics of pembrolizumab were 
assessed in population pharmacokinetic analyses. The CL of pembrolizumab increased with increasing 
body weight; the resulting exposure differences were adequately addressed by the administration of a 
weight-based dose. The following factors had no clinically important effect on the CL of pembrolizumab: 
age (range: 15 to 94 years), gender, race, renal impairment, mild hepatic impairment, or tumor burden. 
Renal Impairment: The effect of renal impairment on the CL of pembrolizumab was evaluated by 
population pharmacokinetic analyses in patients with various solid tumors and mild (eGFR 60 to 
89 mL/min/1.73 m2; n=937), moderate (eGFR 30 to 59 mL/min/1.73 m2; n=201), or severe (eGFR 15 to 
29 mL/min/1.73 m2; n=4) renal impairment compared to patients with normal (eGFR greater than or equal 
to 90 mL/min/1.73 m2; n=1027) renal function. No clinically important differences in the CL of 
pembrolizumab were found between patients with renal impairment and patients with normal renal 
function [see Use in Specific Populations (8.6)].
Hepatic Impairment: The effect of hepatic impairment on the CL of pembrolizumab was evaluated by 
population pharmacokinetic analyses in patients with various solid tumors and mild hepatic impairment 
(TB less than or equal to ULN and AST greater than ULN or TB between 1 and 1.5 times ULN and any 
AST; n=269) compared to patients with normal hepatic function (TB and AST less than or equal to ULN; 
n=1871). No clinically important differences in the CL of pembrolizumab were found between patients with 
mild hepatic impairment and normal hepatic function. There is insufficient information to determine 
whether there are clinically important differences in the CL of pembrolizumab in patients with moderate or 
severe hepatic impairment [see Use in Specific Populations (8.7)].
13
NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No studies have been performed to test the potential of pembrolizumab for carcinogenicity or 
genotoxicity.
Fertility studies have not been conducted with pembrolizumab. In 1-month and 6-month repeat-dose 
toxicology studies in monkeys, there were no notable effects in the male and female reproductive organs; 
however, most animals in these studies were not sexually mature.
13.2 Animal Toxicology and/or Pharmacology
In animal models, inhibition of PD-1 signaling resulted in an increased severity of some infections and 
enhanced inflammatory responses. M. tuberculosis-infected PD-1 knockout mice exhibit markedly 
decreased survival compared with wild-type controls, which correlated with increased bacterial 
proliferation and inflammatory responses in these animals. PD-1 knockout mice have also shown 
decreased survival following infection with lymphocytic choriomeningitis virus (LCMV). Administration of 
pembrolizumab in chimpanzees with naturally occurring chronic hepatitis B infection resulted in two out of 
four animals with significantly increased levels of serum ALT, AST, and GGT, which persisted for at least 
1 month after discontinuation of pembrolizumab.

17
14
CLINICAL STUDIES
14.1 Melanoma
Ipilimumab-Naive Melanoma (Trial 6)
The safety and efficacy of KEYTRUDA were evaluated in Trial 6, a randomized (1:1:1), open-label, 
multicenter, active-controlled trial. Patients were randomized to receive KEYTRUDA at a dose of 
10 mg/kg every 2 weeks or 10mg/kg every 3 weeks as an intravenous infusion until disease progression 
or unacceptable toxicity or to ipilimumab 3 mg/kg every 3 weeks as an intravenous infusion for 4 doses 
unless discontinued earlier for disease progression or unacceptable toxicity. Patients with disease 
progression could receive additional doses of treatment unless disease progression was symptomatic, 
was rapidly progressive, required urgent intervention, occurred with a decline in performance status, or 
was confirmed at 4 to 6 weeks with repeat imaging. Randomization was stratified by line of therapy (0 vs. 
1), ECOG PS (0 vs. 1), and PD-L1 expression (≥1% of tumor cells [positive] vs. <1% of tumor cells 
[negative]) according to an investigational use only (IUO) assay. Key eligibility criteria were unresectable 
or metastatic melanoma with progression of disease; no prior ipilimumab; and no more than one prior 
systemic treatment for metastatic melanoma. Patients with BRAF V600E mutation-positive melanoma 
were not required to have received prior BRAF inhibitor therapy. Patients with autoimmune disease; a 
medical condition that required immunosuppression; previous severe hypersensitivity to other monoclonal 
antibodies; and HIV, hepatitis B or hepatitis C infection, were ineligible. Assessment of tumor status was 
performed at 12 weeks, then every 6 weeks through Week 48, followed by every 12 weeks thereafter. 
The major efficacy outcome measures were overall survival (OS) and progression-free survival (PFS; as 
assessed by blinded independent central review (BICR) using Response Evaluation Criteria in Solid 
Tumors [RECIST v1.1]). Additional efficacy outcome measures were overall response rate (ORR) and 
response duration.
A total of 834 patients were randomized: 277 patients to the KEYTRUDA 10 mg/kg every 3 weeks arm, 
279 to the KEYTRUDA 10 mg/kg every 2 weeks arm, and 278 to the ipilimumab arm. The study 
population characteristics were: median age of 62 years (range: 18 to 89 years), 60% male, 98% White, 
66% had no prior systemic therapy for metastatic disease , 69% ECOG PS of 0, 80% had PD-L1 positive 
melanoma, 18% had PD-L1 negative melanoma, and 2% had unknown PD-L1 status using the IUO 
assay, 65% had M1c stage disease, 68% with normal LDH, 36% with reported BRAF mutation-positive 
melanoma, and 9% with a history of brain metastases. Among patients with BRAF mutation-positive 
melanoma, 139 (46%) were previously treated with a BRAF inhibitor. 
The study demonstrated statistically significant improvements in OS and PFS for patients randomized to 
KEYTRUDA as compared to ipilimumab (Table 7 and Figure 1). 

18
Table 7: Efficacy Results in Trial 6
KEYTRUDA
10 mg/kg every 
3 weeks
n=277
KEYTRUDA
10 mg/kg every 
2 weeks
n=279
Ipilimumab
3 mg/kg every 
3 weeks
n=278
OS
Deaths (%)
92 (33%)
85 (30%)
112 (40%)
Hazard ratio* (95% CI)
0.69 (0.52, 0.90)
0.63 (0.47, 0.83)
---
p-Value (stratified log-rank)
0.004
<0.001
---
PFS by BICR
Events (%)
157 (57%)
157 (56%)
188 (68%)
Median in months (95% CI)
4.1 (2.9, 6.9)
5.5 (3.4, 6.9)
2.8 (2.8, 2.9)
Hazard ratio* (95% CI)
0.58 (0.47, 0.72)
0.58 (0.46, 0.72)
---
p-Value (stratified log-rank)
<0.001
<0.001
---
Best overall response by BICR
ORR % (95% CI)
33% (27, 39)
34% (28, 40)
12% (8, 16)
Complete response %
6%
5%
1%
Partial response %
27%
29%
10%
*
Hazard ratio (KEYTRUDA compared to ipilimumab) based on the stratified Cox proportional hazard 
model
Among the 91 patients randomized to KEYTRUDA 10 mg/kg every 3 weeks with an objective response, 
response durations ranged from 1.4+ to 8.1+ months. Among the 94 patients randomized to KEYTRUDA 
10 mg/kg every 2 weeks with an objective response, response durations ranged from 1.4+ to 8.2 months.
Figure 1: Kaplan-Meier Curve for Overall Survival in Trial 6 
0
2
4
6
8
10
12
14
16
18
Time in Months
0
10
20
30
40
50
60
70
80
90
100
Overall Survival (%)
              Treatment arm 
   
KEYTRUDA 10 mg/kg every 2 weeks
KEYTRUDA 10 mg/kg every 3 weeks
ipilimumab 
278
242
212
188
169
157
117
51
17
0
279
266
248
233
219
212
177
67
19
0
277
266
251
238
215
202
158
71
18
0
Number at Risk
KEYTRUDA 10 mg/kg every 2 weeks:
KEYTRUDA 10 mg/kg every 3 weeks:
ipilimumab:
Ipilimumab-Refractory Melanoma (Trial 2)
The safety and efficacy of KEYTRUDA were evaluated in Trial 2, a multicenter, randomized (1:1:1), 
active-controlled trial. Patients were randomized to receive one of two doses of KEYTRUDA in a blinded 
fashion or investigator’s choice chemotherapy. The treatment arms consisted of KEYTRUDA 2 mg/kg or 
10 mg/kg intravenously every 3 weeks or investigator’s choice of any of the following chemotherapy 
regimens: dacarbazine 1000 mg/m2 intravenously every 3 weeks (26%), temozolomide 200 mg/m2 orally 
once daily for 5 days every 28 days (25%), carboplatin AUC 6 intravenously plus paclitaxel 225 mg/m2
intravenously every 3 weeks for four cycles then carboplatin AUC of 5 plus paclitaxel 175 mg/m2 every 
3 weeks (25%), paclitaxel 175 mg/m2 intravenously every 3 weeks (16%), or carboplatin AUC 5 or 6 
intravenously every 3 weeks (8%). Randomization was stratified by ECOG performance status (0 vs. 1), 
LDH levels (normal vs. elevated [≥110% ULN]) and BRAF V600 mutation status (wild-type [WT] or 

19
V600E). The trial included patients with unresectable or metastatic melanoma with progression of 
disease; refractory to two or more doses of ipilimumab (3 mg/kg or higher) and, if BRAF V600 mutation-
positive, a BRAF or MEK inhibitor; and disease progression within 24 weeks following the last dose of 
ipilimumab. The trial excluded patients with uveal melanoma and active brain metastasis. Patients 
received KEYTRUDA until unacceptable toxicity; disease progression that was symptomatic, was rapidly 
progressive, required urgent intervention, occurred with a decline in performance status, or was 
confirmed at 4 to 6 weeks with repeat imaging; withdrawal of consent; or physician’s decision to stop 
therapy for the patient. Assessment of tumor status was performed at 12 weeks after randomization, then 
every 6 weeks through week 48, followed by every 12 weeks thereafter. Patients on chemotherapy who 
experienced progression of disease were offered KEYTRUDA. The major efficacy outcomes were 
progression-free survival (PFS) as assessed by BICR per RECIST v1.1 and overall survival (OS). 
Additional efficacy outcome measures were confirmed overall response rate (ORR) as assessed by BICR 
per RECIST v1.1 and duration of response.
The treatment arms consisted of KEYTRUDA 2 mg/kg (n=180) or 10 mg/kg (n=181) every 3 weeks or 
investigator’s choice chemotherapy (n=179). Among the 540 randomized patients, the median age was 
62 years (range: 15 to 89 years), with 43% age 65 or older; 61% male; 98% White; and ECOG 
performance score was 0 (55%) and 1 (45%). Twenty-three percent of patients were BRAF V600 
mutation positive, 40% had elevated LDH at baseline, 82% had M1c disease, and 73% had two or more 
prior therapies for advanced or metastatic disease. 
The study demonstrated a statistically significant improvement in PFS for patients randomized to 
KEYTRUDA as compared to control arm (Table 8). There was no statistically significant difference 
between KEYTRUDA 2 mg/kg and chemotherapy or between KEYTRUDA 10 mg/kg and chemotherapy 
in the interim OS analysis with 220 deaths (59% of required events for the final analysis). 

20
Table 8: Efficacy Results in Trial 2
KEYTRUDA
2 mg/kg every 
3 weeks
n=180
KEYTRUDA
10 mg/kg every 
3 weeks
n=181
Chemotherapy
n=179
Progression-Free Survival
Number of Events, n (%)
129 (72%)
126 (70%)
155 (87%)
Progression, n (%)
105 (58%)
107 (59%)
134 (75%)
Death, n (%)
24 (13%)
19 (10%)
21 (12%)
Median in months (95% CI)
2.9 (2.8, 3.8)
2.9 (2.8, 4.7)
2.7 (2.5, 2.8)
P Value (stratified log-rank)
<0.001
<0.001
---
Hazard ratio* (95% CI)
0.57 (0.45, 0.73)
0.50 (0.39, 0.64)
---
Objective Response Rate
ORR, n% (95% CI)
21% (15, 28)
25% (19, 32)
4% (2, 9)
Complete response %
2%
3%
0%
Partial response %
19%
23%
4%
*
Hazard ratio (KEYTRUDA compared to chemotherapy) based on the stratified Cox proportional hazard 
model
Figure 2: Kaplan-Meier Curve for Progression-Free Survival in Trial 2
0
2
4
6
8
10
12
14
Time in Months
0
10
20
30
40
50
60
70
80
90
100
Progression-Free Survival (%)
              Treatment arm         
KEYTRUDA 10 mg/kg every 3 weeks
KEYTRUDA 2 mg/kg every 3 weeks
Chemotherapy
179
128
43
22
15
4
2
1
180
153
74
53
26
9
4
2
181
158
82
55
39
15
5
1
Number at Risk
Chemotherapy:
KEYTRUDA 10 mg/kg:
KEYTRUDA 2 mg/kg:
Among the 38 patients randomized to KEYTRUDA 2 mg/kg with an objective response, response 
durations ranged from 1.3+ to 11.5+ months. Among the 46 patients randomized to KEYTRUDA 
10 mg/kg with an objective response, response durations ranged from 1.1+ to 11.1+ months.
14.2 Non-Small Cell Lung Cancer
The efficacy of KEYTRUDA was investigated in a sub-group of a cohort of 280 patients enrolled in a 
multicenter, open-label multi-cohort, activity-estimating study (Trial 1). The cohort consisted of patients 
with metastatic NSCLC that had progressed following platinum-containing chemotherapy, and if 
appropriate, targeted therapy for ALK or EGFR mutations and any evidence of PD-L1 expression by a 
clinical trial immunohistochemistry assay. Patients with autoimmune disease; a medical condition that 
required immunosuppression; or who had received more than 30 Gy of thoracic radiation within the prior 
26 weeks were ineligible.
A prospectively defined sub-group was retrospectively analyzed using an analytically validated test for 
PD-L1 expression tumor proportion score (TPS). This retrospectively identified sub-group of 61 patients 
accounts for 22% of the 280 patients in the cohort. Patients included in this sub-group had a PD-L1 

21
expression TPS of greater than or equal to 50% tumor cells as determined by the PD-L1 IHC 22C3 
pharmDx Kit. Patients received KEYTRUDA 10 mg/kg every 2 (n=27) or 3 (n=34) weeks until 
unacceptable toxicity or disease progression that was symptomatic, was rapidly progressive, required 
urgent intervention, occurred with a decline in performance status, or was confirmed at 4 to 6 weeks with 
repeat imaging. Assessment of tumor status was performed every 9 weeks. The major efficacy outcome 
measures were ORR according to RECIST 1.1 as assessed by BICR and duration of response.
Among the 61 patients with a TPS greater than or equal to 50%, the baseline characteristics were: 
median age 60 years (34% age 65 or older); 61% male; 79% White; and 34% and 64% with an ECOG PS
0 and 1, respectively. Disease characteristics were squamous (21%) and non-squamous (75%); M1 
(98%); brain metastases (11%); one (26%), two (30%), or three or more (44%) prior therapies; and the 
incidence of genomic aberrations was EGFR (10%) or ALK (0%).
Efficacy results are summarized in Table 9. The ORR and duration of response were similar regardless of 
schedule (every 2 weeks or every 3 weeks) and thus the data below are pooled.
Table 9: Efficacy Results
Endpoint
n=61
Overall Response Rate
ORR %, (95% CI)
41% (29, 54)
Complete Response
0%
Partial Response
41% 
Among the 25 responding patients, 21 (84%) patients had ongoing responses at the final analysis of 
ORR; 11 (44%) patients had ongoing responses of 6 months or longer.
In a separate subgroup of 25 patients with limited follow-up with PD-L1 expression TPS greater than or 
equal to 50% receiving KEYTRUDA at a dose of 2 mg/kg every 3 weeks in Trial 1, activity was also 
observed.
16
HOW SUPPLIED/STORAGE AND HANDLING
KEYTRUDA for injection (lyophilized powder): carton containing one 50 mg single-use vial (NDC 0006-
3029-02).
Store vials under refrigeration at 2°C to 8°C (36°F to 46°F).
KEYTRUDA injection (solution): carton containing one 100 mg/4 mL (25 mg/mL), single-use vial 
(NDC 0006-3026-02)
Store vials under refrigeration at 2°C to 8°C (36°F to 46°F) in original carton to protect from light. Do not 
freeze. Do not shake.
17
PATIENT COUNSELING INFORMATION
Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Inform patients of the risk of immune-mediated adverse reactions that may require corticosteroid 
treatment and interruption or discontinuation of KEYTRUDA, including: 

Pneumonitis: Advise patients to contact their healthcare provider immediately for new or 
worsening cough, chest pain, or shortness of breath [see Warnings and Precautions (5.1)].

Colitis: Advise patients to contact their healthcare provider immediately for diarrhea or severe 
abdominal pain [see Warnings and Precautions (5.2)]. 

Hepatitis: Advise patients to contact their healthcare provider immediately for jaundice, severe 
nausea or vomiting, or easy bruising or bleeding [see Warnings and Precautions (5.3)].

22

Hypophysitis: Advise patients to contact their healthcare provider immediately for persistent or 
unusual headache, extreme weakness, dizziness or fainting, or vision changes [see Warnings 
and Precautions (5.4)]. 

Hyperthyroidism and Hypothyroidism: Advise patients to contact their healthcare provider 
immediately for signs or symptoms of hyperthyroidism and hypothyroidism [see Warnings and 
Precautions (5.4)]. 

Type 1 Diabetes Mellitus: Advise patients to contact their healthcare provider immediately for 
signs or symptoms of type 1 diabetes [see Warnings and Precautions (5.4)].

Nephritis: Advise patients to contact their healthcare provider immediately for signs or symptoms 
of nephritis [see Warnings and Precautions (5.5)].

Advise patients to contact their healthcare provider immediately for signs or symptoms of infusion-
related reactions [see Warnings and Precautions (5.7)]. 

Advise patients of the importance of keeping scheduled appointments for blood work or other 
laboratory tests [see Warnings and Precautions (5.3, 5.4, 5.5)].

Advise women that KEYTRUDA can cause fetal harm. Instruct women of reproductive potential to 
use highly effective contraception during and for 4 months after the last dose of KEYTRUDA [see 
Warnings and Precautions (5.8) and Use in Specific Populations (8.1, 8.3)].

Advise nursing mothers not to breastfeed while taking KEYTRUDA and for 4 months after the final 
dose [see Use in Specific Populations (8.2)].
U.S. License No. 0002
For KEYTRUDA for injection, at:
Schering-Plough (Brinny) Co.,
County Cork, Ireland
For KEYTRUDA injection, at:
MSD Ireland (Carlow)
County Carlow, Ireland
For patent information: www.merck.com/product/patent/home.html
The trademarks depicted herein are owned by their respective companies.
Copyright © 2014-2015 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved.
uspi-mk3475-iv-1512r004

Product: Acalabrutinib (ACP-196) 
Date: 23 May 2016 
Protocol: ACE-ST-005 
 
 
 
Acerta Pharma 
Confidential 
Page 133 of 162 
Appendix 7. RECIST 1.1 Guidelines 
 

New response evaluation criteria in solid tumours:
Revised RECIST guideline (version 1.1)
E.A. Eisenhauera,*, P. Therasseb, J. Bogaertsc, L.H. Schwartzd, D. Sargente, R. Fordf,
J. Danceyg, S. Arbuckh, S. Gwytheri, M. Mooneyg, L. Rubinsteing, L. Shankarg, L. Doddg,
R. Kaplanj, D. Lacombec, J. Verweijk
aNational Cancer Institute of Canada – Clinical Trials Group, 10 Stuart Street, Queen’s University, Kingston, ON, Canada
bGlaxoSmithKline Biologicals, Rixensart, Belgium
cEuropean Organisation for Research and Treatment of Cancer, Data Centre, Brussels, Belgium
dMemorial Sloan Kettering Cancer Center, New York, NY, USA
eMayo Clinic, Rochester, MN, USA
fRadPharm, Princeton, NJ, USA
gDivision of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
hSchering-Plough, Kenilworth, NJ, USA
iEast Surrey Hospital, Redhill, Surrey, UK
jNational Cancer Research Network, Leeds, UK
kErasmus University Medical Center, Rotterdam, The Netherlands
A R T I C L E
I N F O
Article history:
Received 17 October 2008
Accepted 29 October 2008
Keywords:
Response criteria
Solid tumours
Guidelines
A B S T R A C T
Background: Assessment of the change in tumour burden is an important feature of the
clinical evaluation of cancer therapeutics: both tumour shrinkage (objective response)
and disease progression are useful endpoints in clinical trials. Since RECIST was published
in 2000, many investigators, cooperative groups, industry and government authorities have
adopted these criteria in the assessment of treatment outcomes. However, a number of
questions and issues have arisen which have led to the development of a revised RECIST
guideline (version 1.1). Evidence for changes, summarised in separate papers in this special
issue, has come from assessment of a large data warehouse (>6500 patients), simulation
studies and literature reviews.
Highlights of revised RECIST 1.1: Major changes include: Number of lesions to be assessed: based
on evidence from numerous trial databases merged into a data warehouse for analysis pur-
poses, the number of lesions required to assess tumour burden for response determination
has been reduced from a maximum of 10 to a maximum of ﬁve total (and from ﬁve to two
per organ, maximum). Assessment of pathological lymph nodes is now incorporated: nodes
with a short axis of P15 mm are considered measurable and assessable as target lesions.
The short axis measurement should be included in the sum of lesions in calculation of
tumour response. Nodes that shrink to <10 mm short axis are considered normal. Conﬁrma-
tion of response is required for trials with response primary endpoint but is no longer
required in randomised studies since the control arm serves as appropriate means of inter-
pretation of data. Disease progression is clariﬁed in several aspects: in addition to the previ-
ous deﬁnition of progression in target disease of 20% increase in sum, a 5 mm absolute
increase is now required as well to guard against over calling PD when the total sum is very
0959-8049/$ - see front matter  2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejca.2008.10.026
* Corresponding author: Tel.: +1 613 533 6430; fax: +1 613 533 2411.
E-mail address: eeisenhauer@ctg.queensu.ca (E.A. Eisenhauer).
E U R O P E A N J O U R N A L O F C A N C E R 4 5 ( 2 0 0 9 ) 2 2 8 –2 4 7
available at www.sciencedirect.com
journal homepage: www.ejconline.com

small. Furthermore, there is guidance offered on what constitutes ‘unequivocal progres-
sion’ of non-measurable/non-target disease, a source of confusion in the original RECIST
guideline. Finally, a section on detection of new lesions, including the interpretation of
FDG-PET scan assessment is included. Imaging guidance: the revised RECIST includes a
new imaging appendix with updated recommendations on the optimal anatomical assess-
ment of lesions.
Future work: A key question considered by the RECIST Working Group in developing RECIST
1.1 was whether it was appropriate to move from anatomic unidimensional assessment of
tumour burden to either volumetric anatomical assessment or to functional assessment
with PET or MRI. It was concluded that, at present, there is not sufﬁcient standardisation
or evidence to abandon anatomical assessment of tumour burden. The only exception to
this is in the use of FDG-PET imaging as an adjunct to determination of progression. As
is detailed in the ﬁnal paper in this special issue, the use of these promising newer
approaches requires appropriate clinical validation studies.
 2008 Elsevier Ltd. All rights reserved.
1.
Background
1.1.
History of RECIST criteria
Assessment of the change in tumour burden is an important
feature of the clinical evaluation of cancer therapeutics. Both
tumour shrinkage (objective response) and time to the devel-
opment of disease progression are important endpoints in
cancer clinical trials. The use of tumour regression as the
endpoint for phase II trials screening new agents for evi-
dence of anti-tumour effect is supported by years of evi-
dence suggesting that, for many solid tumours, agents
which produce tumour shrinkage in a proportion of patients
have a reasonable (albeit imperfect) chance of subsequently
demonstrating an improvement in overall survival or other
time to event measures in randomised phase III studies (re-
viewed in [1–4]). At the current time objective response car-
ries with it a body of evidence greater than for any other
biomarker supporting its utility as a measure of promising
treatment effect in phase II screening trials. Furthermore,
at both the phase II and phase III stage of drug development,
clinical trials in advanced disease settings are increasingly
utilising time to progression (or progression-free survival)
as an endpoint upon which efﬁcacy conclusions are drawn,
which is also based on anatomical measurement of tumour
size.
However, both of these tumour endpoints, objective re-
sponse and time to disease progression, are useful only if
based on widely accepted and readily applied standard crite-
ria based on anatomical tumour burden. In 1981 the World
Health Organisation (WHO) ﬁrst published tumour response
criteria, mainly for use in trials where tumour response was
the primary endpoint. The WHO criteria introduced the con-
cept of an overall assessment of tumour burden by summing
the products of bidimensional lesion measurements and
determined response to therapy by evaluation of change from
baseline while on treatment.5 However, in the decades that
followed their publication, cooperative groups and pharma-
ceutical companies that used the WHO criteria often ‘modi-
ﬁed’ them to accommodate new technologies or to address
areas that were unclear in the original document. This led
to confusion in interpretation of trial results6 and in fact,
the application of varying response criteria was shown to lead
to very different conclusions about the efﬁcacy of the same
regimen.7 In response to these problems, an International
Working Party was formed in the mid 1990s to standardise
and simplify response criteria. New criteria, known as RECIST
(Response Evaluation Criteria in Solid Tumours), were pub-
lished in 2000.8 Key features of the original RECIST include
deﬁnitions of minimum size of measurable lesions, instruc-
tions on how many lesions to follow (up to 10; a maximum
ﬁve per organ site), and the use of unidimensional, rather
than bidimensional, measures for overall evaluation of tu-
mour burden. These criteria have subsequently been widely
adopted by academic institutions, cooperative groups, and
industry for trials where the primary endpoints are objective
response or progression. In addition, regulatory authorities
accept
RECIST
as
an
appropriate
guideline
for
these
assessments.
1.2.
Why update RECIST?
Since RECIST was published in 2000, many investigators have
conﬁrmed in prospective analyses the validity of substituting
unidimensional for bidimensional (and even three-dimen-
sional)-based criteria (reviewed in [9]). With rare exceptions
(e.g. mesothelioma), the use of unidimensional criteria seems
to perform well in solid tumour phase II studies.
However, a number of questions and issues have arisen
which merit answers and further clarity. Amongst these
are whether fewer than 10 lesions can be assessed without
affecting the overall assigned response for patients (or the
conclusion about activity in trials); how to apply RECIST in
randomised phase III trials where progression, not response,
is the primary endpoint particularly if not all patients have
measurable disease; whether or how to utilise newer imag-
ing technologies such as FDG-PET and MRI; how to handle
assessment of lymph nodes; whether response conﬁrmation
is truly needed; and, not least, the applicability of RECIST in
trials of targeted non-cytotoxic drugs. This revision of the
RECIST guidelines includes updates that touch on all these
points.
E U R O P E A N J O U R N A L O F C A N C E R 4 5 ( 2 0 0 9 ) 2 2 8 –2 4 7
229

1.3.
Process of RECIST 1.1 development
The RECIST Working Group, consisting of clinicians with
expertise in early drug development from academic research
organisations, government and industry, together with imag-
ing specialists and statisticians, has met regularly to set the
agenda for an update to RECIST, determine the evidence
needed to justify the various changes made, and to review
emerging evidence. A critical aspect of the revision process
was to create a database of prospectively documented solid
tumour measurement data obtained from industry and aca-
demic group trials. This database, assembled at the EORTC
Data Centre under the leadership of Jan Bogaerts and Patrick
Therasse (co-authors of this guideline), consists of >6500 pa-
tients with >18,000 target lesions and was utilised to investi-
gate the impact of a variety of questions (e.g. number of
target lesions required, the need for response conﬁrmation,
and lymph node measurement rules) on response and pro-
gression-free survival outcomes. The results of this work,
which after evaluation by the RECIST Working Group led to
most of the changes in this revised guideline, are reported
in detail in a separate paper in this special issue.10 Larry Sch-
wartz and Robert Ford (also co-authors of this guideline) also
provided key databases from which inferences have been
made that inform these revisions.11
The publication of this revised guideline is believed to be
timely since it incorporates changes to simplify, optimise
and standardise the assessment of tumour burden in clinical
trials. A summary of key changes is found in Appendix I. Be-
cause the fundamental approach to assessment remains
grounded in the anatomical, rather than functional, assess-
ment of disease, we have elected to name this version RECIST
1.1, rather than 2.0.
1.4.
What about volumetric or functional assessment?
This raises the question, frequently posed, about whether it is
‘time’ to move from anatomic unidimensional assessment of
tumour burden to either volumetric anatomical assessment
or to functional assessment (e.g. dynamic contrast enhanced
MRI or CT or (18)F-ﬂuorodeoxyglucose positron emission
tomographic (FDG-PET) techniques assessing tumour metab-
olism). As can be seen, the Working Group and particularly
those involved in imaging research, did not believe that there
is at present sufﬁcient standardisation and widespread avail-
ability to recommend adoption of these alternative assess-
ment methods. The only exception to this is in the use of
FDG-PET imaging as an adjunct to determination of progres-
sion, as described later in this guideline. As detailed in paper
in this special issue12, we believe that the use of these prom-
ising newer approaches (which could either add to or substitute
for anatomical assessment as described in RECIST) requires
appropriate and rigorous clinical validation studies. This pa-
per by Sargent et al. illustrates the type of data that will be
needed to be able to deﬁne ‘endpoints’ for these modalities
and how to determine where and when such criteria/modal-
ities can be used to improve the reliability with which truly
active new agents are identiﬁed and truly inactive new agents
are discarded in comparison to RECIST criteria in phase II
screening trials. The RECIST Working Group looks forward
to such data emerging in the next few years to allow the
appropriate changes to the next iteration of the RECIST
criteria.
2.
Purpose of this guideline
This guideline describes a standard approach to solid tumour
measurement and deﬁnitions for objective assessment of
change in tumour size for use in adult and paediatric cancer
clinical trials. It is expected these criteria will be useful in all
trials where objective response is the primary study endpoint,
as well as in trials where assessment of stable disease, tu-
mour progression or time to progression analyses are under-
taken, since all of these outcome measures are based on an
assessment of anatomical tumour burden and its change on
study. There are no assumptions in this paper about the pro-
portion of patients meeting the criteria for any of these end-
points which will signal that an agent or treatment regimen is
active: those deﬁnitions are dependent on type of cancer in
which a trial is being undertaken and the speciﬁc agent(s) un-
der study. Protocols must include appropriate statistical sec-
tions which deﬁne the efﬁcacy parameters upon which the
trial sample size and decision criteria are based. In addition
to providing deﬁnitions and criteria for assessment of tumour
response,
this
guideline
also
makes
recommendations
regarding standard reporting of the results of trials that utilise
tumour response as an endpoint.
While these guidelines may be applied in malignant brain
tumour studies, there are also separate criteria published for
response assessment in that setting.13 This guideline is not in-
tended for use for studies of malignant lymphoma since
international guidelines for response assessment in lym-
phoma are published separately.14
Finally, many oncologists in their daily clinical practice fol-
low their patients’ malignant disease by means of repeated
imaging studies and make decisions about continued therapy
on the basis of both objective and symptomatic criteria. It is
not intended that these RECIST guidelines play a role in that
decision making, except if determined appropriate by the
treating oncologist.
3.
Measurability of tumour at baseline
3.1.
Deﬁnitions
At baseline, tumour lesions/lymph nodes will be categorised
measurable or non-measurable as follows:
3.1.1.
Measurable
Tumour lesions: Must be accurately measured in at least one
dimension (longest diameter in the plane of measurement is
to be recorded) with a minimum size of:
• 10 mm by CT scan (CT scan slice thickness no greater than
5 mm; see Appendix II on imaging guidance).
• 10 mm caliper measurement by clinical exam (lesions
which cannot be accurately measured with calipers should
be recorded as non-measurable).
• 20 mm by chest X-ray.
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Malignant lymph nodes: To be considered pathologically en-
larged and measurable, a lymph node must be P15 mm in
short axis when assessed by CT scan (CT scan slice thickness
recommended to be no greater than 5 mm). At baseline and in
follow-up, only the short axis will be measured and followed
(see Schwartz et al. in this Special Issue15). See also notes be-
low on ‘Baseline documentation of target and non-target le-
sions’ for information on lymph node measurement.
3.1.2.
Non-measurable
All other lesions, including small lesions (longest diameter
<10 mm or pathological lymph nodes with P10 to <15 mm
short axis) as well as truly non-measurable lesions. Lesions
considered truly non-measurable include: leptomeningeal dis-
ease, ascites, pleural or pericardial effusion, inﬂammatory
breast disease, lymphangitic involvement of skin or lung,
abdominal masses/abdominal organomegaly identiﬁed by
physical exam that is not measurable by reproducible imaging
techniques.
3.1.3.
Special considerations regarding lesion measurability
Bone lesions, cystic lesions, and lesions previously treated
with local therapy require particular comment:
Bone lesions:.
• Bone scan, PET scan or plain ﬁlms are not considered ade-
quate imaging techniques to measure bone lesions. How-
ever,
these
techniques
can
be
used
to
conﬁrm
the
presence or disappearance of bone lesions.
• Lytic bone lesions or mixed lytic-blastic lesions, with identi-
ﬁable soft tissue components, that can be evaluated by cross
sectional imaging techniques such as CT or MRI can be con-
sidered as measurable lesions if the soft tissue component
meets the deﬁnition of measurability described above.
• Blastic bone lesions are non-measurable.
Cystic lesions:.
• Lesions that meet the criteria for radiographically deﬁned
simple cysts should not be considered as malignant lesions
(neither measurable nor non-measurable) since they are, by
deﬁnition, simple cysts.
• ‘Cystic lesions’ thought to represent cystic metastases can
be considered as measurable lesions, if they meet the deﬁ-
nition of measurability described above. However, if non-
cystic lesions are present in the same patient, these are pre-
ferred for selection as target lesions.
Lesions with prior local treatment:.
• Tumour lesions situated in a previously irradiated area, or
in an area subjected to other loco-regional therapy, are usu-
ally not considered measurable unless there has been dem-
onstrated progression in the lesion. Study protocols should
detail the conditions under which such lesions would be
considered measurable.
3.2.
Speciﬁcations by methods of measurements
3.2.1.
Measurement of lesions
All measurements should be recorded in metric notation,
using calipers if clinically assessed. All baseline evaluations
should be performed as close as possible to the treatment
start and never more than 4 weeks before the beginning of
the treatment.
3.2.2.
Method of assessment
The same method of assessment and the same technique
should be used to characterise each identiﬁed and reported
lesion at baseline and during follow-up. Imaging based evalu-
ation should always be done rather than clinical examination
unless the lesion(s) being followed cannot be imaged but are
assessable by clinical exam.
Clinical lesions: Clinical lesions will only be considered mea-
surable when they are superﬁcial and P10 mm diameter as
assessed using calipers (e.g. skin nodules). For the case of skin
lesions, documentation by colour photography including a ru-
ler to estimate the size of the lesion is suggested. As noted
above, when lesions can be evaluated by both clinical exam
and imaging, imaging evaluation should be undertaken since
it is more objective and may also be reviewed at the end of the
study.
Chest X-ray: Chest CT is preferred over chest X-ray, particu-
larly when progression is an important endpoint, since CT is
more sensitive than X-ray, particularly in identifying new le-
sions. However, lesions on chest X-ray may be considered
measurable if they are clearly deﬁned and surrounded by aer-
ated lung. See Appendix II for more details.
CT, MRI: CT is the best currently available and reproducible
method to measure lesions selected for response assessment.
This guideline has deﬁned measurability of lesions on CT
scan based on the assumption that CT slice thickness is
5 mm or less. As is described in Appendix II, when CT scans
have slice thickness greater than 5 mm, the minimum size
for a measurable lesion should be twice the slice thickness.
MRI is also acceptable in certain situations (e.g. for body
scans). More details concerning the use of both CT and MRI
for assessment of objective tumour response evaluation are
provided in Appendix II.
Ultrasound: Ultrasound is not useful in assessment of lesion
size and should not be used as a method of measurement.
Ultrasound examinations cannot be reproduced in their en-
tirety for independent review at a later date and, because
they are operator dependent, it cannot be guaranteed that
the same technique and measurements will be taken from
one assessment to the next (described in greater detail in
Appendix II). If new lesions are identiﬁed by ultrasound in
the course of the study, conﬁrmation by CT or MRI is ad-
vised. If there is concern about radiation exposure at CT,
MRI may be used instead of CT in selected instances.
Endoscopy, laparoscopy: The utilisation of these techniques for
objective tumour evaluation is not advised. However, they
can be useful to conﬁrm complete pathological response
when biopsies are obtained or to determine relapse in trials
where recurrence following complete response or surgical
resection is an endpoint.
Tumour markers: Tumour markers alone cannot be used to as-
sess objective tumour response. If markers are initially above
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231

the upper normal limit, however, they must normalise for a
patient to be considered in complete response. Because
tumour markers are disease speciﬁc, instructions for their
measurement should be incorporated into protocols on a
disease speciﬁc basis. Speciﬁc guidelines for both CA-125
response (in recurrent ovarian cancer) and PSA response (in
recurrent prostate cancer), have been published.16–18 In addi-
tion, the Gynecologic Cancer Intergroup has developed CA125
progression criteria which are to be integrated with objective
tumour assessment for use in ﬁrst-line trials in ovarian
cancer.19
Cytology, histology: These techniques can be used to differenti-
ate between PR and CR in rare cases if required by protocol
(for example, residual lesions in tumour types such as germ
cell tumours, where known residual benign tumours can re-
main). When effusions are known to be a potential adverse
effect of treatment (e.g. with certain taxane compounds or
angiogenesis inhibitors), the cytological conﬁrmation of the
neoplastic origin of any effusion that appears or worsens dur-
ing treatment can be considered if the measurable tumour
has met criteria for response or stable disease in order to dif-
ferentiate between response (or stable disease) and progres-
sive disease.
4.
Tumour response evaluation
4.1.
Assessment of overall tumour burden and
measurable disease
To assess objective response or future progression, it is nec-
essary to estimate the overall tumour burden at baseline and
use this as a comparator for subsequent measurements.
Only patients with measurable disease at baseline should
be included in protocols where objective tumour response
is the primary endpoint. Measurable disease is deﬁned by
the presence of at least one measurable lesion (as detailed
above in Section 3). In studies where the primary endpoint
is tumour progression (either time to progression or propor-
tion with progression at a ﬁxed date), the protocol must
specify if entry is restricted to those with measurable disease
or whether patients having non-measurable disease only are
also eligible.
4.2.
Baseline documentation of ‘target’ and ‘non-target’
lesions
When more than one measurable lesion is present at baseline
all lesions up to a maximum of ﬁve lesions total (and a max-
imum of two lesions per organ) representative of all involved
organs should be identiﬁed as target lesions and will be re-
corded and measured at baseline (this means in instances
where patients have only one or two organ sites involved a
maximum of two and four lesions respectively will be re-
corded). For evidence to support the selection of only ﬁve tar-
get lesions, see analyses on a large prospective database in
the article by Bogaerts et al.10.
Target lesions should be selected on the basis of their size
(lesions with the longest diameter), be representative of all in-
volved organs, but in addition should be those that lend
themselves to reproducible repeated measurements. It may be
the case that, on occasion, the largest lesion does not lend it-
self to reproducible measurement in which circumstance the
next largest lesion which can be measured reproducibly
should be selected. To illustrate this point see the example
in Fig. 3 of Appendix II.
Lymph nodes merit special mention since they are normal
anatomical structures which may be visible by imaging even
if not involved by tumour. As noted in Section 3, pathological
nodes which are deﬁned as measurable and may be identi-
ﬁed as target lesions must meet the criterion of a short axis
of P15 mm by CT scan. Only the short axis of these nodes
will contribute to the baseline sum. The short axis of the
node is the diameter normally used by radiologists to judge
if a node is involved by solid tumour. Nodal size is normally
reported as two dimensions in the plane in which the image
is obtained (for CT scan this is almost always the axial plane;
for MRI the plane of acquisition may be axial, saggital or
coronal). The smaller of these measures is the short axis.
For example, an abdominal node which is reported as being
20 mm · 30 mm has a short axis of 20 mm and qualiﬁes as a
malignant, measurable node. In this example, 20 mm should
be recorded as the node measurement (See also the example
in Fig. 4 in Appendix II). All other pathological nodes (those
with short axis P10 mm but <15 mm) should be considered
non-target lesions. Nodes that have a short axis <10 mm
are considered non-pathological and should not be recorded
or followed.
A sum of the diameters (longest for non-nodal lesions, short
axis for nodal lesions) for all target lesions will be calculated
and reported as the baseline sum diameters. If lymph nodes
are to be included in the sum, then as noted above, only the
short axis is added into the sum. The baseline sum diameters
will be used as reference to further characterise any objective
tumour regression in the measurable dimension of the
disease.
All other lesions (or sites of disease) including pathological
lymph nodes should be identiﬁed as non-target lesions and
should also be recorded at baseline. Measurements are not re-
quired and these lesions should be followed as ‘present’, ‘ab-
sent’, or in rare cases ‘unequivocal progression’ (more details
to follow). In addition, it is possible to record multiple non-
target lesions involving the same organ as a single item on
the case record form (e.g. ‘multiple enlarged pelvic lymph
nodes’ or ‘multiple liver metastases’).
4.3.
Response criteria
This section provides the deﬁnitions of the criteria used to
determine objective tumour response for target lesions.
4.3.1.
Evaluation of target lesions
Complete Response (CR): Disappearance of all target lesions.
Any pathological lymph 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.
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Progressive Disease (PD): At least a 20% increase in the sum
of diameters of target 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 dem-
onstrate an absolute increase of at least 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.
4.3.2.
Special notes on the assessment of target lesions
Lymph nodes. Lymph nodes identiﬁed as target lesions should
always have the actual short axis measurement recorded (mea-
sured in the same anatomical plane as the baseline examina-
tion), even if the nodes regress to below 10 mm on study. This
means that when lymph nodes are included as target lesions,
the ‘sum’ of lesions may not be zero even if complete response
criteria are met, since a normal lymph node is deﬁned as having
a short axis of <10 mm. Case report forms or other data collec-
tion methods may therefore be designed to have target nodal le-
sions recorded in a separate section where, in order to qualify
for CR, each node must achieve a short axis <10 mm. For PR,
SD and PD, the actual short axis measurement of the nodes is
to be included in the sum of target lesions.
Target lesions that become ‘too small to measure’. While on
study, all lesions (nodal and non-nodal) recorded at baseline
should have their actual measurements recorded at each sub-
sequent evaluation, even when very small (e.g. 2 mm). How-
ever, sometimes lesions or lymph nodes which are recorded
as target lesions at baseline become so faint on CT scan that
the radiologist may not feel comfortable assigning an exact
measure and may report them as being ‘too small to measure’.
When this occurs it is important that a value be recorded on
the case report form. If it is the opinion of the radiologist that
the lesion has likely disappeared, the measurement should be
recorded as 0 mm. If the lesion is believed to be present and is
faintly seen but too small to measure, a default value of 5 mm
should be assigned (Note: It is less likely that this rule will be
used for lymph nodes since they usually have a deﬁnable size
when normal and are frequently surrounded by fat such as in
the retroperitoneum; however, if a lymph node is believed to
be present and is faintly seen but too small to measure, a de-
fault value of 5 mm should be assigned in this circumstance as
well). This default value is derived from the 5 mm CT slice
thickness (but should not be changed with varying CT slice
thickness). The measurement of these lesions is potentially
non-reproducible, therefore providing this default value will
prevent false responses or progressions based upon measure-
ment error. To reiterate, however, if the radiologist is able to
provide an actual measure, that should be recorded, even if
it is below 5 mm.
Lesions that split or coalesce on treatment. As noted in Appen-
dix II, when non-nodal lesions ‘fragment’, the longest diame-
ters of the fragmented portions should be added together to
calculate the target lesion sum. Similarly, as lesions coalesce,
a plane between them may be maintained that would aid in
obtaining maximal diameter measurements of each individ-
ual lesion. If the lesions have truly coalesced such that they
are no longer separable, the vector of the longest diameter
in this instance should be the maximal longest diameter for
the ‘coalesced lesion’.
4.3.3.
Evaluation of non-target lesions
Thissection provides the deﬁnitionsofthe criteriausedtodeter-
mine the tumour response for the group of non-target lesions.
While some non-target lesions may actually be measurable,
they need not be measured and instead should be assessed only
qualitatively at the time points speciﬁed in the protocol.
Complete Response (CR): Disappearance of all non-target le-
sions and normalisation of tumour marker level. All
lymph nodes must be non-pathological in size
(<10 mm short axis).
Non-CR/Non-PD: Persistence of one or more non-target le-
sion(s) and/or maintenance of tumour marker level
above the normal limits.
Progressive Disease (PD): Unequivocal progression (see com-
ments below) of existing non-target lesions. (Note:
the appearance of one or more new lesions is also
considered progression).
4.3.4.
Special notes on assessment of progression of non-
target disease
The concept of progression of non-target disease requires
additional explanation as follows:
When the patient also has measurable disease. In this setting,
to achieve ‘unequivocal progression’ on the basis of the
non-target disease, there must be an overall level of substan-
tial worsening in non-target disease such that, even in pres-
ence of SD or PR in target disease, the overall tumour
burden has increased sufﬁciently to merit discontinuation
of therapy (see examples in Appendix II and further details
below). A modest ‘increase’ in the size of one or more non-tar-
get lesions is usually not sufﬁcient to quality for unequivocal
progression status. The designation of overall progression so-
lely on the basis of change in non-target disease in the face of
SD or PR of target disease will therefore be extremely rare.
When the patient has only non-measurable disease.This circum-
stance arises in some phase III trials when it is not a criterion of
study entry to have measurable disease. The same general con-
cepts apply here as noted above, however, in this instance there
is no measurable disease assessment to factor into the inter-
pretation of an increase in non-measurable disease burden.
Because worsening in non-target disease cannot be easily
quantiﬁed (by deﬁnition: if all lesions are truly non-measur-
able) a useful test that can be applied when assessing patients
for unequivocal progression is to consider if the increase in
overall disease burden based on the change in non-measurable
disease is comparable in magnitude to the increase that would
berequiredtodeclarePDformeasurabledisease: i.e.anincrease
in tumour burden representing an additional 73% increase in
‘volume’ (which is equivalent to a 20% increase diameter in a
measurable lesion). Examples include an increase in a pleural
effusion from ‘trace’ to ‘large’, an increase in lymphangitic
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233

disease from localised to widespread, or may be described in
protocols as ‘sufﬁcient to require a change in therapy’. Some
illustrative examples are shown in Figs. 5 and 6 in Appendix II.
If ‘unequivocal progression’ is seen, the patient should be con-
sidered to have had overall PD at that point. While it would be
ideal to have objective criteria to apply to non-measurable dis-
ease, the very nature of that disease makes it impossible to do
so, therefore the increase must be substantial.
4.3.5.
New lesions
The appearance of new malignant lesions denotes disease
progression; therefore, some comments on detection of new
lesions are important. There are no speciﬁc criteria for the
identiﬁcation of new radiographic lesions; however, the ﬁnd-
ing of a new lesion should be unequivocal: i.e. not attributable
to differences in scanning technique, change in imaging
modality or ﬁndings thought to represent something other
than tumour (for example, some ‘new’ bone lesions may be
simply healing or ﬂare of pre-existing lesions). This is partic-
ularly important when the patient’s baseline lesions show
partial or complete response. For example, necrosis of a liver
lesion may be reported on a CT scan report as a ‘new’ cystic
lesion, which it is not.
A lesion identiﬁed on a follow-up study in an anatomical
location that was not scanned at baseline is considered a new
lesion andwill indicate diseaseprogression. An example of this
is the patient who has visceral disease at baseline and while on
study has a CTor MRI brain ordered which reveals metastases.
The patient’s brain metastases are considered to be evidence of
PD even if he/she did not have brain imaging at baseline.
If a new lesion is equivocal, for example because of its
small size, continued therapy and follow-up evaluation will
clarify if it represents truly new disease. If repeat scans con-
ﬁrm there is deﬁnitely a new lesion, then progression should
be declared using the date of the initial scan.
While FDG-PET response assessments need additional
study, it is sometimes reasonable to incorporate the use of
FDG-PET scanning to complement CT scanning in assessment
of progression (particularly possible ‘new’ disease). New le-
sions on the basis of FDG-PET imaging can be identiﬁed
according to the following algorithm:
a. Negative FDG-PET at baseline, with a positivel FDG-PET
at follow-up is a sign of PD based on a new lesion.
b. No FDG-PET at baseline and a positive FDG-PET at fol-
low-up:
If the positive FDG-PET at follow-up corresponds to a
new site of disease conﬁrmed by CT, this is PD.
If the positive FDG-PET at follow-up is not conﬁrmed as
a new site of disease on CT, additional follow-up CT
scans are needed to determine if there is truly progres-
sion occurring at that site (if so, the date of PD will be
the date of the initial abnormal FDG-PET scan).
If the positive FDG-PET at follow-up corresponds to a
pre-existing site of disease on CT that is not progress-
ing on the basis of the anatomic images, this is not PD.
4.4.
Evaluation of best overall response
The best overall response is the best response recorded from
the start of the study treatment until the end of treatment
taking into account any requirement for conﬁrmation. On oc-
casion a response may not be documented until after the end
of therapy so protocols should be clear if post-treatment
assessments are to be considered in determination of best
overall response. Protocols must specify how any new therapy
introduced before progression will affect best response desig-
nation. The patient’s best overall response assignment will
depend on the ﬁndings of both target and non-target disease
and will also take into consideration the appearance of new
lesions. Furthermore, depending on the nature of the study
and the protocol requirements, it may also require conﬁrma-
tory measurement (see Section 4.6). Speciﬁcally, in non-ran-
domised trials where response is the primary endpoint,
conﬁrmation of PR or CR is needed to deem either one the
‘best overall response’. This is described further below.
4.4.1.
Time point response
It is assumed that at each protocol speciﬁed time point, a re-
sponse assessment occurs. Table 1 on the next page provides
a summary of the overall response status calculation at each
time point for patients who have measurable disease at
baseline.
When patients have non-measurable (therefore non-tar-
get) disease only, Table 2 is to be used.
4.4.2.
Missing assessments and inevaluable designation
When no imaging/measurement is done at all at a particular
time point, the patient is not evaluable (NE) at that time point.
If only a subset of lesion measurements are made at an
assessment, usually the case is also considered NE at that
time point, unless a convincing argument can be made that
the contribution of the individual missing lesion(s) would
not change the assigned time point response. This would be
most likely to happen in the case of PD. For example, if a pa-
tient had a baseline sum of 50 mm with three measured le-
sions and at follow-up only two lesions were assessed, but
those gave a sum of 80 mm, the patient will have achieved
PD status, regardless of the contribution of the missing lesion.
4.4.3.
Best overall response: all time points
The best overall response is determined once all the data for the
patient is known.
Best response determination in trials where conﬁrmation of com-
plete or partial response IS NOT required: Best response in these
trials is deﬁned as the best response across all time points (for
example, a patient who has SD at ﬁrst assessment, PR at sec-
ond assessment, and PD on last assessment has a best overall
response of PR). When SD is believed to be best response, it
must also meet the protocol speciﬁed minimum time from
baseline. If the minimum time is not met when SD is other-
wise the best time point response, the patient’s best response
depends on the subsequent assessments. For example, a pa-
tient who has SD at ﬁrst assessment, PD at second and does
not meet minimum duration for SD, will have a best response
of PD. The same patient lost to follow-up after the ﬁrst SD
assessment would be considered inevaluable.
l A ‘positive’ FDG-PET scan lesion means one which is FDG avid
with an uptake greater than twice that of the surrounding tissue
on the attenuation corrected image.
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Best response determination in trials where conﬁrmation of com-
plete or partial response IS required: Complete or partial re-
sponses may be claimed only if the criteria for each are met
at a subsequent time point as speciﬁed in the protocol (gener-
ally 4 weeks later). In this circumstance, the best overall re-
sponse can be interpreted as in Table 3.
4.4.4.
Special notes on response assessment
When nodal disease is included in the sum of target lesions
and the nodes decrease to ‘normal’ size (<10 mm), they may
still have a measurement reported on scans. This measure-
ment should be recorded even though the nodes are normal
in order not to overstate progression should it be based on
increase in size of the nodes. As noted earlier, this means that
patients with CR may not have a total sum of ‘zero’ on the
case report form (CRF).
In trials where conﬁrmation of response is required, re-
peated ‘NE’ time point assessments may complicate best re-
sponse determination. The analysis plan for the trial must
address how missing data/assessments will be addressed in
determination of response and progression. For example, in
most trials it is reasonable to consider a patient with time
point responses of PR-NE-PR as a conﬁrmed response.
Patients with a global deterioration of health status requir-
ing discontinuation of treatment without objective evidence
of disease progression at that time should be reported as
‘symptomatic deterioration’. Every effort should be made to
document objective progression even after discontinuation
of treatment. Symptomatic deterioration is not a descriptor
of an objective response: it is a reason for stopping study ther-
apy. The objective response status of such patients is to be
determined by evaluation of target and non-target disease
as shown in Tables 1–3.
Conditions that deﬁne ‘early progression, early death and
inevaluability’ are study speciﬁc and should be clearly de-
scribed in each protocol (depending on treatment duration,
treatment periodicity).
In some circumstances it may be difﬁcult to distinguish
residual disease from normal tissue. When the evaluation of
complete response depends upon this determination, it is
recommended that the residual lesion be investigated (ﬁne
Table 3 – Best overall response when conﬁrmation of CR and PR required.
Overall response
Overall response
BEST overall response
First time point
Subsequent time point
CR
CR
CR
CR
PR
SD, PD or PRa
CR
SD
SD provided minimum criteria for SD duration met, otherwise, PD
CR
PD
SD provided minimum criteria for SD duration met, otherwise, PD
CR
NE
SD provided minimum criteria for SD duration met, otherwise NE
PR
CR
PR
PR
PR
PR
PR
SD
SD
PR
PD
SD provided minimum criteria for SD duration met, otherwise, PD
PR
NE
SD provided minimum criteria for SD duration met, otherwise NE
NE
NE
NE
CR = complete response, PR = partial response, SD = stable disease, PD = progressive disease, and NE = inevaluable.
a If a CR is truly met at ﬁrst time point, then any disease seen at a subsequent time point, even disease meeting PR criteria relative to baseline,
makes the disease PD at that point (since disease must have reappeared after CR). Best response would depend on whether minimum duration
for SD was met. However, sometimes ‘CR’ may be claimed when subsequent scans suggest small lesions were likely still present and in fact the
patient had PR, not CR at the ﬁrst time point. Under these circumstances, the original CR should be changed to PR and the best response is PR.
Table 1 – Time point response: patients with target (+/–
non-target) disease.
Target lesions
Non-target lesions
New
lesions
Overall
response
CR
CR
No
CR
CR
Non-CR/non-PD
No
PR
CR
Not evaluated
No
PR
PR
Non-PD or
not all evaluated
No
PR
SD
Non-PD or
not all evaluated
No
SD
Not all
evaluated
Non-PD
No
NE
PD
Any
Yes or No
PD
Any
PD
Yes or No
PD
Any
Any
Yes
PD
CR = complete response, PR = partial response, SD = stable disease,
PD = progressive disease, and NE = inevaluable.
Table 2 – Time point response: patients with non-target
disease only.
Non-target lesions
New lesions
Overall response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PDa
Not all evaluated
No
NE
Unequivocal PD
Yes or No
PD
Any
Yes
PD
CR = complete
response,
PD = progressive
disease,
and
NE = inevaluable.
a ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target
disease since SD is increasingly used as endpoint for assessment
of efﬁcacy in some trials so to assign this category when no
lesions can be measured is not advised.
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235

needle aspirate/biopsy) before assigning a status of complete
response. FDG-PET may be used to upgrade a response to a CR
in a manner similar to a biopsy in cases where a residual
radiographic abnormality is thought to represent ﬁbrosis or
scarring. The use of FDG-PET in this circumstance should be
prospectively described in the protocol and supported by dis-
ease speciﬁc medical literature for the indication. However, it
must be acknowledged that both approaches may lead to
false positive CR due to limitations of FDG-PETand biopsy res-
olution/sensitivity.
For equivocal ﬁndings of progression (e.g. very small and
uncertain new lesions; cystic changes or necrosis in existing
lesions), treatment may continue until the next scheduled
assessment. If at the next scheduled assessment, progression
is conﬁrmed, the date of progression should be the earlier
date when progression was suspected.
4.5.
Frequency of tumour re-evaluation
Frequency
of
tumour
re-evaluation
while
on
treatment
should be protocol speciﬁc and adapted to the type and sche-
dule of treatment. However, in the context of phase II studies
where the beneﬁcial effect of therapy is not known, follow-up
every 6–8 weeks (timed to coincide with the end of a cycle) is
reasonable. Smaller or greater time intervals than these could
be justiﬁed in speciﬁc regimens or circumstances. The proto-
col should specify which organ sites are to be evaluated at
baseline (usually those most likely to be involved with meta-
static disease for the tumour type under study) and how often
evaluations are repeated. Normally, all target and non-target
sites are evaluated at each assessment. In selected circum-
stances certain non-target organs may be evaluated less fre-
quently. For example, bone scans may need to be repeated
only when complete response is identiﬁed in target disease
or when progression in bone is suspected.
After the end of the treatment, the need for repetitive tu-
mour evaluations depends on whether the trial has as a goal
the response rate or the time to an event (progression/death).
If ‘time to an event’ (e.g. time to progression, disease-free
survival, progression-free survival) is the main endpoint of
the study, then routine scheduled re-evaluation of protocol
speciﬁed sites of disease is warranted. In randomised com-
parative trials in particular, the scheduled assessments
should be performed as identiﬁed on a calendar schedule
(for example: every 6–8 weeks on treatment or every 3–4
months after treatment) and should not be affected by delays
in therapy, drug holidays or any other events that might lead
to imbalance in a treatment arm in the timing of disease
assessment.
4.6.
Conﬁrmatory measurement/duration of response
4.6.1.
Conﬁrmation
In non-randomised trials where response is the primary end-
point, conﬁrmation of PR and CR is required to ensure re-
sponses identiﬁed are not the result of measurement error.
This will also permit appropriate interpretation of results in
the context of historical data where response has traditionally
required conﬁrmation in such trials (see the paper by Bogaerts
et al. in this Special Issue10). However, in all other circum-
stances, i.e. in randomised trials (phase II or III) or studies
where stable disease or progression are the primary endpoints,
conﬁrmation ofresponseis notrequiredsince itwillnotaddva-
lue to theinterpretationoftrial results.However, eliminationof
the requirement for response conﬁrmation may increase the
importance of central review to protect against bias, in partic-
ular in studies which are not blinded.
In the case of SD, measurements must have met the SD
criteria at least once after study entry at a minimum interval
(in general not less than 6–8 weeks) that is deﬁned in the
study protocol.
4.6.2.
Duration of overall response
The duration of overall response is measured from the time
measurement criteria are ﬁrst met for CR/PR (whichever is ﬁrst
recorded) until the ﬁrst date that recurrent or progressive dis-
ease is objectively documented (taking as reference for progres-
sive disease the smallest measurements recorded on study).
The duration of overall complete response is measured
from the time measurement criteria are ﬁrst met for CR until
the ﬁrst date that recurrent disease is objectively documented.
4.6.3.
Duration of stable disease
Stable disease is measured from the start of the treatment (in
randomised trials, from date of randomisation) until the crite-
ria for progression are met, taking as reference the smallest
sum on study (if the baseline sum is the smallest, this is the
reference for calculation of PD).
The clinical relevance of the duration of stable disease var-
ies in different studies and diseases. If the proportion of pa-
tients achieving stable disease for a minimum period of time
is an endpoint of importance in a particular trial, the protocol
should specify the minimal time interval required between
two measurements for determination of stable disease.
Note: The duration of response and stable disease as well as
theprogression-free survivalareinﬂuenced by thefrequencyof
follow-up after baseline evaluation. It is not in the scope of this
guideline to deﬁne a standard follow-up frequency. The fre-
quency should take into account many parameters including
disease types and stages, treatment periodicity and standard
practice. However, these limitations of the precision of the
measured endpoint should be taken into account if compari-
sons between trials are to be made.
4.7.
Progression-free survival/proportion progression-free
4.7.1.
Phase II trials
This guideline is focused primarily on the use of objective re-
sponse endpoints for phase II trials. In some circumstances, ‘re-
sponse rate’ may not be the optimal method to assess the
potential anticancer activity of new agents/regimens. In such
cases ‘progression-free survival’ (PFS) or the ‘proportion pro-
gression-free’ at landmark time points, might be considered
appropriate alternatives to provide an initial signal of biologic
effect of new agents. It is clear, however, that in an uncontrolled
trial, these measures are subject to criticism since an appar-
ently promising observation may be related to biological factors
such as patient selectionand not theimpactof theintervention.
Thus, phase II screening trials utilising these endpoints are best
designed with a randomised control. Exceptions may exist
236
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where the behaviour patterns of certain cancers are so consis-
tent (and usually consistently poor), that a non-randomised
trial is justiﬁable (see for example van Glabbeke et al.20). How-
ever, in these cases it will be essential to document with care
the basis for estimating the expected PFS or proportion progres-
sion-free in the absence of a treatment effect.
4.7.2.
Phase III trials
Phase III trials in advanced cancers are increasingly designed
to evaluate progression-free survival or time to progression as
the primary outcome of interest. Assessment of progression
is relatively straightforward if the protocol requires all pa-
tients to have measurable disease. However, restricting entry
to this subset of patients is subject to criticism: it may result
in a trial where the results are less likely to be generalisable if,
in the disease under study, a substantial proportion of pa-
tients would be excluded. Moreover, the restriction to entry
will slow recruitment to the study. Increasingly, therefore, tri-
als allow entry of both patients with measurable disease as
well as those with non-measurable disease only. In this cir-
cumstance, care must be taken to explicitly describe the ﬁnd-
ings which would qualify for progressive disease for those
patients without measurable lesions. Furthermore, in this set-
ting, protocols must indicate if the maximum number of re-
corded target lesions for those patients with measurable
disease may be relaxed from ﬁve to three (based on the data
found in Bogaerts et al.10 and Moskowitz et al.11). As found in
the ‘special notes on assessment of progression’, these guide-
lines offer recommendations for assessment of progression
in this setting. Furthermore, if available, validated tumour mar-
ker measures of progression (as has been proposed for ovarian
cancer) may be useful to integrate into the deﬁnition of pro-
gression. Centralised blinded review of imaging studies or of
source imaging reports to verify ‘unequivocal progression’
may be needed if important drug development or drug ap-
proval decisions are to be based on the study outcome. Finally,
as noted earlier, because the date of progression is subject to
ascertainment bias, timing of investigations in study arms
should be the same. The article by Dancey et al. in this special
issue21 provides a more detailed discussion of the assessment
of progression in randomised trials.
4.8.
Independent review of response and progression
For trials where objective response (CR + PR) is the primary end-
point, and in particular where key drug development deci-
sions are based on the observation of a minimum number of
responders, it is recommended that all claimed responses be
reviewed by an expert(s) independent of the study. If the study
is a randomised trial, ideally reviewers should be blinded to
treatment assignment. Simultaneous review of the patients’
ﬁles and radiological images is the best approach.
Independent review of progression presents some more
complex issues: for example, there are statistical problems
with the use of central-review-based progression time in
place of investigator-based progression time due to the poten-
tial introduction of informative censoring when the former
precedes the latter. An overview of these factors and other
lessons learned from independent review is provided in an
article by Ford et al. in this special issue.22
4.9.
Reporting best response results
4.9.1.
Phase II trials
When response is the primary endpoint, and thus all patients
must have measurable disease to enter the trial, all patients
included in the study must be accounted for in the report of
the results, even if there are major protocol treatment devia-
tions or if they are not evaluable. Each patient will be assigned
one of the following categories:
1. Complete response
2. Partial response
3. Stable disease
4. Progression
5. Inevaluable for response: specify reasons (for example: early
death, malignant disease; early death, toxicity; tumour
assessments not repeated/incomplete; other (specify)).
Normally, all eligible patients should be included in the
denominator for the calculation of the response rate for phase
II trials (in some protocols it will be appropriate to include all
treated patients). It is generally preferred that 95% two-sided
conﬁdence limits are given for the calculated response rate.
Trial conclusions should be based on the response rate for
all eligible (or all treated) patients and should not be based
on a selected ‘evaluable’ subset.
4.9.2.
Phase III trials
Response evaluation in phase III trials may be an indicator
of the relative anti-tumour activity of the treatments eval-
uated and is almost always a secondary endpoint. Ob-
served differences in response rate may not predict the
clinically relevant therapeutic beneﬁt for the population
studied. If objective response is selected as a primary end-
point for a phase III study (only in circumstances where a
direct relationship between objective tumour response and
a clinically relevant therapeutic beneﬁt can be unambigu-
ously demonstrated for the population studied), the same
criteria as those applying to phase II trials should be used
and all patients entered should have at least one measur-
able lesion.
In those many cases where response is a secondary end-
point and not all trial patients have measurable disease, the
method for reporting overall best response rates must be
pre-speciﬁed in the protocol. In practice, response rate may
be reported using either an ‘intent to treat’ analysis (all ran-
domised patients in the denominator) or an analysis where
only the subset of patients with measurable disease at
baseline are included. The protocol should clearly specify
how response results will be reported, including any subset
analyses that are planned.
The original version of RECIST suggested that in phase III
trials one could write protocols using a ‘relaxed’ interpreta-
tion of the RECIST guidelines (for example, reducing the num-
ber of lesions measured) but this should no longer be done
since these revised guidelines have been amended in such a
way that it is clear how these criteria should be applied for
all trials in which anatomical assessment of tumour response
or progression are endpoints.
E U R O P E A N J O U R N A L O F C A N C E R 4 5 ( 2 0 0 9 ) 2 2 8 –2 4 7
237

Appendix I. Summary of major changes RECIST 1.0 to RECIST 1.1
RECIST 1.0
RECIST 1.1
Rationale
Reference in special issue
(if applicable)
Minimum size measurable
lesions
CT: 10 mm spiral
CT 10 mm; delete reference to
spiral scan
Most scans used have 5 mm or less slice
thickness Clearer to give instruction based on
slice interval if it is greater than 5 mm
20 mm non-spiral
Clinical: 20 mm
Clinical: 10 mm (must be
measurable with calipers)
Caliper measurement will make this reliable
Lymph node: not mentioned
CT:
Since nodes are normal structure need to deﬁne
pathological enlargement. Short axis is most
sensitive
Schwartz et al.15
P15 mm short axis for target
P10–<15 mm for non-target
<10 mm is non-pathological
Special considerations on
lesion measurability
–
Notes included on bone
lesions, cystic lesions
Clarify frequently asked questions
Overall tumour burden
10 lesions (5 per organ)
5 lesions (2 per organ)
Data warehouse analysis shows no loss of
information if lesion number reduced from 10 to
5. A maximum of 2 lesions per organ yields
sufﬁcient representation per disease site
Bogaerts et al.10
Response criteria target
disease
CR lymph node not mentioned
CR lymph nodes must be
<10 mm short axis
In keeping with normal size of nodes
Schwartz et al.15
PD 20% increase over smallest sum on
study or new lesions
PD 20% increase over smallest
sum on study (including
baseline if that is smallest) and
at least 5 mm increase or new
lesions
Clariﬁcation that if baseline measurement is
smaller than any on study measurement, it is
reference against which PD is assessed
5 mm absolute increase to guard against over
calling PD when total sum is very small and 20%
increase is within measurement error
Response criteria non-target
disease
‘unequivocal progression’ considered as PD
More detailed description of
‘unequivocal progression’ to
indicate that it should not
normally trump target disease
status. It must be
representative of overall
disease status change, not a
single lesion increase
Confusion with RECIST 1.0 where some were
considering PD if ‘increase’ in any non-target
lesion, even when target disease is stable or
responding
New lesions
–
New section on New lesions
To provide guidance on when a lesion is
considered new (and thus PD)
Overall response
Table integrated target and non-target
lesions
Two tables: one integrating
target and non-target and the
other of non-target only
To account for the fact that RECIST criteria are
now being used in trials where PFS is the
endpoint and not all patients have measurable
(target) disease at baseline
Dancey et al.21
238
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RECIST 1.0
RECIST 1.1
Rationale
Reference in special issue
(if applicable)
Special notes:
Frequently asked questions on these topics
How to assess and measure
lymph nodes
CR in face of residual tissue
Discussion of ‘equivocal’
progression
Conﬁrmatory measure
For CR and PR: criteria
must be met again 4
weeks after initial
documentation
Retain this requirement ONLY
for
non-randomised trials with
primary endpoint of response
Data warehouse shows that response rates
rise when conﬁrmation is eliminated, but
the only circumstance where this is
important is in trials where there is no
concurrent comparative control and where
this measure is the primary endpoint
Bogaerts et al.10
Progression-free survival
General comments only
More speciﬁc comments on
use of PFS (or proportion
progression-free) as
phase II endpoint
Increasing use of PFS in phase III trials
requires guidance on assessment of PD in
patients with non-measurable disease
Dancey et al.21
Greater detail on PFS
assessment in phase III trials
Reporting of response
results
9 categories suggested for
reporting phase II results
Divided into phase II and phase
III
Simpliﬁes reporting and clariﬁes how to
report phase II and III data consistently
9 categories collapsed into 5
In phase III, guidance given
about reporting response
Response in phase III
trials
More relaxed guidelines
possible if protocol speciﬁed
This section removed and
referenced in section
above: no need to have
different criteria for phase II
and III
Simpliﬁcation of response assessment by
reducing number of lesions and eliminating
need for conﬁrmation in randomised
studies where response is not the primary
endpoint makes separate ‘rules’
unnecessary
Imaging appendix
Appendix I
Appendix II: updated with
detailed guidance on
use of MRI, PET/CT
Evolving use of newer modalities addressed.
Enhanced guidance in response to frequent
questions and from radiology review
experience
Other practical guidance
included
New appendices
Appendix I: comparison of
RECIST 1.0 and 1.1
Appendix III: frequently asked
questions
E U R O P E A N J O U R N A L O F C A N C E R 4 5 ( 2 0 0 9 ) 2 2 8 –2 4 7
239

Conﬂict of interest statement
None declared.
Acknowledgements
The RECIST Working Group would like to thank the following
organisations which made data bases available to us in order
to perform the analyses which informed decisions about
changes to this version of the criteria: Amgen; AstraZeneca;
Breast Cancer International Research Group (BCIRG); Bristol-
Myers
Squibb; European
Organisation for
Research and
Treatment of Cancer (EORTC) Breast Cancer Group and Gas-
trointestinal
Group;
Erasmus
University
Medical
Center,
Rotterdam, The Netherlands; Genentech; Pﬁzer; RadPharm;
Roche; SanoﬁAventis.
We would also like to thank the following individuals from
academic, government, and pharmaceutical organisations for
providing helpful comments on an earlierdraft of these revised
guidelines: Ohad Amit, Phil Murphy, Teri Crofts and Janet Be-
gun, GlaxoSmithKline, USA; Laurence H. Baker, Southwest
Oncology Group, USA; Karla Ballman, Mayo Clinic, USA;
Charles Baum, Darrel Cohen, and Mary Ashford Collier, Pﬁzer,
USA; Gary J. Becker, American Board of Radiology, Tucson,
USA; Jean-Yves Blay, University Claude Pertrand, Lyon France;
Renzo Canetta, Bristol-Myers Squibb, USA; David Chang, Am-
gen Inc., USA; Sandra Chica, Perceptive Informations Inc. (PAR-
EXEL),
USA;
Martin
Edelman,
University
of
Maryland
Greenbaum Cancer Centre, USA; Gwendolyn Fyfe, Genentech,
USA; Bruce Giantonio, Eastern Cooperative Oncology Group,
USA; Gary Gordon, Abbott Pharmaceuticals, USA; Ronald Gott-
lieb, Roswell Park Cancer Institute, USA; Simon Kao, University
of Iowa College of Medicine, USA; Wasaburo Koizumi, Kitasato
University, Japan; Alessandro Riva, Novartis Pharmaceuticals,
USA; Wayne Rackhoff, Ortho Biotech Oncology Research and
Development, USA; Nagahiro Saijo, President Japanese Society
of Medical Oncology, Japan; Mitchell Schnall American College
of Radiology Imaging Network, USA; Yoshik Shimamura, PAR-
EXEL International Inc., Japan; Rajeshwari Sridhara, Centre
for Drug Evaluation and Research, Food and Drug Administra-
tion, USA; Andrew Stone, Alan Barge, AstraZeneca, United
Kingdom; Orhan Suleiman, Centre for Drug Evaluation and Re-
search, Food and Drug Administration, USA; Daniel C. Sullivan,
Duke University Medical Centre, USA; Masakazu Toi, Kyoto
University, Japan; Cindy Welsh, Centre for Drug Evaluation
and Research, Food and Drug Administration, USA.
Finally, the RECIST Working Group would like to thank indi-
vidualswho were not permanent members of the group (which
are all acknowledged as co-authors) but who attended working
group meetings from time to time and made contributions to
the total process over the past 7 years: Richard Pazdur, Food
and Drug Administration, USA; Francesco Pignatti, European
Medicines Agency, London, UK.
Appendix II.
Speciﬁcations for standard
anatomical radiological imaging
These protocols for image acquisition of computed tomogra-
phy (CT) and magnetic resonance imaging (MRI) are recom-
mendations intended for patients on clinical trials where
RECIST assessment will be performed. Standardisation of
imaging requirements and image acquisition parameters is
ideal to allow for optimal comparability of subjects within a
study and results between studies. These recommendations
are designed to balance optimised image acquisition proto-
cols with techniques that should be feasible to perform glob-
ally at imaging facilities in all types of radiology practices.
These guidelines are not applicable to functional imaging
techniques or volumetric assessment of tumour size.
Scanner quality control is highly recommended and should
follow
standard
manufacturer
and
facility
maintenance
schedules using commercial phantoms. It is likely that for RE-
CIST unidimensional measurements this will be adequate to
produce reproducible measurements. Imaging quality control
for CT includes an analysis of image noise and uniformity and
CT number as well as spatial resolution. The frequency of
quality control analysis is also variable and should focus on
clinically relevant scanning parameters. Dose analysis is al-
ways important and the use of imaging should follow the
ALARA principle, ‘As Low As Reasonably Achievable’, which
refers to making every reasonable effort to maintain radiation
exposures as far below the dose limits as possible.
Speciﬁc.notes
Chest X-ray measurement of lesions surrounded by pulmon-
ary
parenchyma
is
feasible,
but
not
preferable
as
the
measurement represents a summation of densities. Further-
more, there is poor identiﬁcation of new lesions within the
chest on X-ray as compared with CT. Therefore, measure-
ments of pulmonary parenchymal lesions as well as medias-
tinal disease are optimally performed with CT of the chest.
MRI of the chest should only be performed in extenuating cir-
cumstances. Even if IV contrast cannot be administered (for
example, in the situation of allergy to contrast), a non-con-
trast CT of the chest is still preferred over MRI or chest X-ray.
CT scans: CT scans of the chest, abdomen, and pelvis should
be contiguous throughout all the anatomic region of interest.
As a general rule, the minimum size of a measurable lesion at
baseline should be no less than double the slice thickness and
also have a minimum size of 10 mm (see below for minimum
size when scanners have a slice thickness more than 5 mm).
While the precise physics of lesion size and partial volume
averaging is complex, lesions smaller than 10 mm may be dif-
ﬁcult to accurately and reproducibly measure. While this rule
is applicable to baseline scans, as lesions potentially decrease
in size at follow-up CT studies, they should still be measured.
Lesions which are reported as ‘too small to measure’ should
be assigned a default measurement of 5 mm if they are still
visible.
The most critical CT image acquisition parameters for opti-
mal tumour evaluation using RECIST are anatomic coverage,
contrast administration, slice thickness, and reconstruction interval.
a. Anatomic coverage: Optimal anatomic coverage for most
solid tumours is the chest, abdomen and pelvis. Cover-
age should encompass all areas of known predilection
for metastases in the disease under evaluation and
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should additionally investigate areas that may be
involved based on signs and symptoms of individual
patients. Because a lesion later identiﬁed in a body part
not scanned at baseline would be considered as a new
lesion representing disease progression, careful consid-
eration should begiven to the extent of imaging coverage
at baseline and at subsequent follow-up time points.
This will enable better consistency not only of tumour
measurements but also identiﬁcation of new disease.
b. IV contrast administration: Optimal visualisation and
measurement of metastases in solid tumours requires
consistent administration (dose and rate) of IV contrast
as well as timing of scanning. Typically, most abdomi-
nal imaging is performed during the portal venous
phase and (optimally) about the same time frame after
injection on each examination (see Fig. 1 for impact of
different phase of IV contrast on lesion measurement).
Most solid tumours may be scanned with a single
phase after administration of contrast. While triphasic
CT scans are sometimes performed on other types of
vascular tumours to improve lesion conspicuity, for
consistency and uniformity, we would recommend tri-
phasic
CT
for
hepatocellular
and
neuroendocrine
tumours for which this scanning protocol is generally
standard of care, and the improved temporal resolution
of the triphasic scan will enhance the radiologists’ abil-
ity to consistently and reproducibly measure these
lesions. The precise dose and rate of IV contrast is
dependent upon the CT scanning equipment, CT acqui-
sition protocol, the type of contrast used, the available
venous
access
and
the
medical
condition
of
the
patient. Therefore, the method of administration of
intravenous contrast agents is variable. Rather than
try to institute rigid rules regarding methods for
administering contrast agents and the volume injected,
it is appropriate to suggest that an adequate volume of
a suitable contrast agent should be given so that the
metastases are demonstrated to best effect and a con-
sistent method is used on subsequent examinations for
any given patient (ideally, this would be speciﬁed in
the protocol or for an institution). It is very important
that the same technique be used at baseline and on fol-
low-up examinations for a given patient. This will
greatly enhance the reproducibility of the tumour mea-
surements. If prior to enrolment it is known a patient is
not able to undergo CT scans with IV contrast due to
allergy
or
renal
insufﬁciency,
the
decision
as
to
whether a non-contrast CT or MRI (with or without IV
contrast) should be used to evaluate the subject at
baseline and follow-up should be guided by the tumour
type under investigation and the anatomic location of
the disease. For patients who develop contraindica-
tions to contrast after baseline contrast CT is done,
the decision as to whether non-contrast CT or MRI
(enhanced or non-enhanced) should be performed
should also be based on the tumour type, anatomic
location of the disease and should be optimised to
allow for comparison to the prior studies if possible.
Each case should be discussed with the radiologist to
determine if substitution of these other approaches is
possible and, if not, the patient should be considered
not evaluable from that point forward. Care must be
taken in measurement of target lesions on a different
modality and interpretation of non-target disease or
new lesions, since the same lesion may appear to have
a different size using a new modality (see Fig. 2 for a
comparison of CT and MRI of the same lesion). Oral
contrast is recommended to help visualise and differ-
entiate structures in the abdomen.
c. Slice thickness and reconstruction interval: RECIST measure-
ments may be performed at most clinically obtained
slice thicknesses. It is recommended that CT scans be
performed at 5 mm contiguous slice thickness or less
and indeed this guideline presumes a minimum 5 mm
thickness in recommendations for measurable lesion
deﬁnition. Indeed, variations in slice thickness can have
an impact on lesion measurement and on detection of
new lesions. However, consideration should also be
given for minimising radiation exposure. With these
parameters, a minimum 10 mm lesion is considered
measurable at baseline. Occasionally, institutions may
perform medically acceptable scans at slice thicknesses
greater than 5 mm. If this occurs, the minimum size of
measurable lesions at baseline should be twice the slice
Fig. 1 – Difference in measurement/visualisation with different phases of IV contrast administration. Hypervascular
metastases imaged in the arterial phase (left) and the portal venous phase (right). Note that the number of lesions visible
differs greatly between the two phases of contrast administration as does any potential lesion measurement. Consistent CT
scan acquisition, including phase of contrast administration, is important for optimal and reproducible tumour
E U R O P E A N J O U R N A L O F C A N C E R 4 5 ( 2 0 0 9 ) 2 2 8 –2 4 7
241

thickness of the baseline scans. Most contemporary CT
scanners are multidetector which have many imaging
options for these acquisition parameters.23 The equip-
ment vendor and scanning manual should be reviewed
if there are any speciﬁc system questions.
d. Alternative contrast agents: There are a number of other,
new contrast agents, some organ speciﬁc.24 They may
be used as part of patient care for instance, in liver
lesion assessment, or lymph node characterisation25,
but should not as yet be used in clinical trials.
FDG-PET has gained acceptance as a valuable tool for
detecting, staging and restaging several malignancies. Criteria
for incorporating (or substituting) FDG-PET into anatomical
assessment of tumour response in phase II trials are not yet
available, though much research is ongoing. Nevertheless,
FDG-PET is being used in many drug development trials both
as a tool to assess therapeutic efﬁcacy and also in assessment
of progression. If FDG-PET scans are included in a protocol, by
consensus, an FDG uptake period of 60 min prior to imaging
has been decided as the most appropriate for imaging of pa-
tients with malignancy.26 Whole-body acquisition is impor-
tant since this allows for sampling of all areas of interest
and can assess if new lesions have appeared thus determining
the possibility of interval progression of disease. Images from
the base of the skull to the level of the mid-thigh should be ob-
tained 60 min post injection. PET camera speciﬁcations are
variable and manufacturer speciﬁc, so every attempt should
be made to use the same scanner, or the same model scanner,
for serial scans on the same patient. Whole-body acquisitions
can be performed in either 2- or 3-dimensional mode with
attenuation correction, but the method chosen should be con-
sistent across all patients and serial scans in the clinical trial.
PET/CT scans: Combined modality scanning such as with
PET–CT is increasingly used in clinical care, and is a modal-
ity/technology that is in rapid evolution; therefore, the recom-
mendations in this paper may change rather quickly with
time. At present, low dose or attenuation correction CT por-
tions of a combined PET–CT are of limited use in anatomically
based efﬁcacy assessments and it is therefore suggested that
they should not be substituted for dedicated diagnostic con-
trast enhanced CT scans for anatomically based RECIST mea-
surements. However, if a site can document that the CT
performed as part of a PET–CT is of identical diagnostic qual-
ity to a diagnostic CT (with IV and oral contrast) then the CT
portion of the PET–CT can be used for RECIST measurements.
Note, however, that the PET portion of the CT introduces addi-
tional data which may bias an investigator if it is not routinely
or serially performed.
Ultrasound examinations should not be used in clinical trials
to measure tumour regression or progression of lesions be-
cause the examination is necessarily subjective and operator
dependent. The reasons for this are several: Entire examina-
tions cannot be reproduced for independent review at a later
date, and it must be assumed, whether or not it is the case,
that the hard-copy ﬁlms available represent a true and accu-
rate reﬂection of events. Furthermore, if, for example, the
only measurable lesion is in the para-aortic region of the
abdomen and if gas in the bowel overlies the lesion, the lesion
will not be detected because the ultrasound beam cannot
penetrate the gas. Accordingly, the disease staging (or restag-
ing for treatment evaluation) for this patient will not be
accurate.
While evaluation of lesions by physical examination is also
of limited reproducibility, it is permitted when lesions are
superﬁcial, at least 10 mm size, and can be assessed using
calipers. In general, it is preferred if patients on clinical trials
have at least one lesion that is measurable by CT. Other skin
or palpable lesions may be measured on physical examina-
tion and be considered target lesions.
Use of MRI remains a complex issue. MRI has excellent
contrast, spatial and temporal resolution; however, there
are many image acquisition variables involved in MRI, which
greatly impact image quality, lesion conspicuity and mea-
surement. Furthermore, the availability of MRI is variable
globally. As with CT, if an MRI is performed, the technical
speciﬁcations of the scanning sequences used should be
optimised for the evaluation of the type and site of disease.
Furthermore, as with CT, the modality used at follow-up
should be the same as was used at baseline and the lesions
should be measured/assessed on the same pulse sequence.
Generally, axial imaging of the abdomen and pelvis with T1
and T2 weighted imaging along with gadolinium enhanced
imaging should be performed. The ﬁeld of view, matrix,
number of excitations, phase encode steps, use of fat sup-
pression and fast sequences should be optimised for the spe-
Fig. 2 – CT versus MRI of same lesions showing apparent ‘progression’ due only to differing method of measurement.
242
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ciﬁc body part being imaged as well as the scanner utilised. It
is beyond the scope of this document or appendix to pre-
scribe speciﬁc MRI pulse sequence parameters for all scan-
ners, body parts and diseases. Ideally, the same type of
scanner should be used and the image acquisition protocol
should be followed as closely as possible to prior scans. Body
scans should be performed with breath-hold scanning tech-
niques if possible.
Selection of target lesions: In general, the largest lesions rep-
resentative of involved organs (up to a maximum of two per
organ and ﬁve total) are selected to follow as target lesions.
However, in some cases, the largest lesions may not be easily
measured and are not suitable for follow-up because of their
conﬁguration. In these cases, identiﬁcation of the largest most
reproducible lesions is advised. Fig. 3 provides an illustrative
example where the largest lesion is not the most reproducible
and another lesion is better to select and follow:
Measurement of lesions
The longest diameter of selected lesions should be measured
in the plane in which the images were acquired. For body CT,
this is the axial plane. In the event isotropic reconstructions
are performed, measurements can be made on these recon-
structed images; however, it should be cautioned that not
all radiology sites are capable of producing isotropic recon-
structions. This could lead to the undesirable situation of
measurements in the axial plane at one assessment point
and in a different plane at a subsequent assessment. There
are some tumours, for instance paraspinal lesions, which
are better measured in the coronal or sagittal plane. It would
be acceptable to measure these lesions in these planes if the
reconstructions in those planes were isotropic or the images
were acquired with MRI in those planes. Using the same plane
of evaluation, the maximal diameter of each target lesion
should always be measured at subsequent follow-up time
points even if this results in measuring the lesion at a differ-
ent slice level or in a different orientation or vector compared
with the baseline study. Software tools that calculate the
maximal diameter for a perimeter of a tumour may be em-
ployed and may even reduce variability.
The only exception to the longest diameter rule is lymph
node measurement. Because malignant nodes are identiﬁed
by the length of their short axis, this is the guide used to
determine not only whether they are pathological but is also
the dimension measured for adding into the sum of target le-
sions. Fig. 4 illustrates this point: the large arrow identiﬁes a
malignant node: the shorter perpendicular axis is P15 mm
and will be recorded. Close by (small arrow) there is a normal
node: note here the long axis is greater than 10 mm but the
short axis is well below 10 mm. This node should be consid-
ered non-pathological.
If a lesion disappears and reappears at a subsequent time
point it should continue to be measured. However, the pa-
tient’s response at the point in time when the lesion reap-
pears will depend upon the status of his/her other lesions.
For example, if the patient’s tumour had reached a CR status
and the lesion reappeared, then the patient would be consid-
ered PD at the time of reappearance. In contrast, if the tumour
status was a PR or SD and one lesion which had disappeared
then reappears, its maximal diameter should be added to the
sum of the remaining lesions for a calculated response: in
other words, the reappearance of an apparently ‘disappeared’
single lesion amongst many which remain is not in itself en-
Fig. 3 – Largest lesion may not be most reproducible: most reproducible should be selected as target. In this example, the
primary gastric lesion (circled at baseline and at follow-up in the top two images) may be able to be measured with thin
section volumetric CT with the same degree of gastric distention at baseline and follow-up. However, this is potentially
challenging to reproduce in a multicentre trial and if attempted should be done with careful imaging input and analysis. The
most reproducible lesion is a lymph node (circled at baseline and at follow-up in the bottom two images).
E U R O P E A N J O U R N A L O F C A N C E R 4 5 ( 2 0 0 9 ) 2 2 8 –2 4 7
243

ough to qualify for PD: that requires the sum of all lesions to
meet the PD criteria. The rationale for such a categorisation is
based upon the realisation that most lesions do not actually
‘disappear’ but are not visualised because they are beyond
the resolving power of the imaging modality employed.
The identiﬁcation of the precise boundary deﬁnition of a
lesion may be difﬁcult especially when the lesion is embed-
ded in an organ with a similar contrast such as the liver, pan-
creas, kidney, adrenal or spleen. Additionally, peritumoural
oedema may surround a lesion and may be difﬁcult to distin-
guish on certain modalities between this oedema and actual
tumour. In fact, pathologically, the presence of tumour cells
within the oedema region is variable. Therefore, it is most
critical that the measurements be obtained in a reproducible
manner from baseline and all subsequent follow-up time-
points. This is also a strong reason to consistently utilise
the same imaging modality.
When lesions ‘fragment’, the individual lesion diameters
should be added together to calculate the target lesion
sum. Similarly, as lesions coalesce, a plane between them
may be maintained that would aid in obtaining maximal
diameter measurements of each individual lesion. If the le-
sions have truly coalesced such that they are no longer sep-
arable, the vector of the longest diameter in this instance
should be the maximal longest diameter for the ‘merged
lesion’.
Progression of non-target lesions
To achieve ‘unequivocal progression’ there must be an overall
level of substantial worsening in non-target disease that is of
a magnitude that, even in the presence of SD or PR in target
disease, the treating physician would feel it important to
change therapy. Examples of unequivocal progression are
shown in Figs. 5 and 6.
Fig. 5 – Example of unequivocal progression in non-target lesions in liver.
Fig. 6 – Example of unequivocal progression in non-target lesion (nodes).
Fig. 4 – Lymph node assessment: large arrow illustrates a
pathological node with the short axis shown as a solid line
which should be measured and followed. Small arrow illus-
trates a non-pathological node which has a short axis
<10 mm.
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Appendix III. Frequently asked questions
Question
Answer
What should be done if several unique lesions at
baseline become conﬂuent at a follow-up
evaluation?
Measure the longest diameter of the conﬂuent mass and record to add into the sum of
the longest diameters
How large does a new lesion have to be to count
as progression? Does any small subcentimetre
lesion qualify, or should the lesion be at least
measurable?
New lesions do not need to meet ‘measurability criteria’ to be considered valid. If it is
clear on previous images (with the same technique) that a lesion was absent then its
deﬁnitive appearance implies progression. If there is any doubt (because of the
techniques or conditions) then it is suggested that treatment continue until next
scheduled assessment when, generally, all should be clear. Either it gets bigger and the
date of progression is the date of the ﬁrst suspicion, or it disappears and one may then
consider it an artefact with the support of the radiologists
How should one lesion be measured if on
subsequent exams it is split into two?
Measure the longest diameter of each lesion and add this into the sum
Does the deﬁnition of progression depend on
the status of all target lesions or only one?
As per the RECIST 1.1 guideline, progression requires a 20% increase in the sum of
diameters of all target lesions AND a minimum absolute increase of 5 mm in the sum
Are RECIST criteria accepted by regulatory
agencies?
Many cooperative groups and members of pharma were involved in preparing RECIST
1.0 and have adopted them. The FDA was consulted in their development and supports
their use, though they don’t require it. The European and Canadian regulatory
authorities also participated and the RECIST criteria are now integrated in the European
note for guidance for the development of anticancer agents. Many pharmaceutical
companies are also using them. RECIST 1.1 was similarly widely distributed before
publication
What is the criterion for a measurable lesion if
the CT slice thickness is >5 mm?
RECIST 1.1 recommends that CT scans have a maximum slice thickness of 5 mm and the
minimum size for a measurable lesion is twice that: 10 mm (even if slice thickness is
<5 mm). If scanners with slice thickness >5 mm are used, the minimum lesion size must
have a longest diameter twice the actual slice thickness
What should we record when target lesions
become so small they are below the 10 mm
‘measurable’ size?
Target lesion measurability is deﬁned at baseline. Thereafter, actual measurements,
even if <10 mm, should be recorded. If lesions become very small, some radiologists
indicate they are ‘too small to measure’. This guideline advises that when this occurs, if
the lesion is actually still present, a default measurement of 5 mm should be applied. If
in fact the radiologist believes the lesion has gone, a default measurement of 0 mm
should be recorded
If a patient has several lesions which have
decreased in size to meet PR criteria and one
has actually disappeared, does that patient have
PD if the ‘disappeared’ lesion reappears?
Unless the sum meets the PD criteria, the reappearance of a lesion in the setting of PR (or
SD) is not PD. The lesion should simply be added into the sum.
If the patients had had a CR, clearly reappearance of an absent lesion would qualify for
PD
When measuring the longest diameter of target
lesions in response to treatment, is the same
axis that was used initially used subsequently,
even if there is a shape change to the lesion that
may have produced a new longest diameter?
The longest diameter of the lesion should always be measured even if the actual axis is
different from the one used to measure the lesion initially (or at different time point
during follow-up)
The only exception to this is lymph nodes: as per RECIST 1.1 the short axis should
always be followed and as in the case of target lesions, the vector of the short axis may
change on follow-up
Target lesions have been selected at baseline
and followed but then one of these target
lesions then becomes non-evaluable (i.e.
different technique used)
What may be done in such cases is one of the following:
What is the effect this has on the other target
lesions and the overall response?
(a) If the patient is still being treated, call the centre to be sure that future evaluations are
done with the baseline technique so at least SOME courses are fully evaluable
(b) If that is not possible, check if there IS a baseline exam by the same technique which
was used to follow patients...in which case if you retrieve the baseline measures from
that technique you retrieve the lesion evaluability
(c) If neither (a) nor (b) is possible then it is a judgement call about whether you delete
the lesion from all forms or consider the impact of the lesion overall is so important that
its being non-evaluable makes the overall response interpretation inevaluable without
it. Such a decision should be discussed in a review panel
It is NOT recommended that the lesion be included in baseline sums and then excluded
from follow-up sums since this biases in favour of a response
(continued on next page)
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245

R E F E R E N C E S
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Appendix III – continued
Question
Answer
What if a single non-target lesion cannot be reviewed, for
whatever reason; does this negate the overall assessment?
Sometimes the major contribution of a single non-target lesion may be in
the setting of CR having otherwise been achieved: failure to examine one
non-target in that setting will leave you unable to claim CR. It is also
possible that the non-target lesion has undergone such substantial
progression that it would override the target disease and render patient
PD. However, this is very unlikely, especially if the rest of the measurable
disease is stable or responding
A patient has a 32% decrease in sum cycle 2, a 28% decrease cycle
4 and a 33% decrease cycle 6. Does conﬁrmation of PR have to
take place in sequential scans or is a case like this conﬁrmed PR?
It is not infrequent that tumour shrinkage hovers around the 30% mark.
In this case, most would consider PR to have been conﬁrmed looking at
this overall case. Had there been two or three non-PR observations
between the two time point PR responses, the most conservative
approach would be to consider this case SD
In the setting of a breast cancer neoadjuvant study, would
mammography not be used to assess lesions? Is CT preferred in
this setting?
Neither CT nor mammography are optimal in this setting. MRI is the
preferred modality to follow breast lesions in a neoadjuvant setting
A patient has a lesion measurable by clinical exam and by CT
scan. Which should be followed?
CT scan. Always follow by imaging if that option exists since it can be
reviewed and veriﬁed
A lesion which was solid at baseline has become necrotic in the
centre. How should this be measured?
The longest diameter of the entire lesion should be followed. Eventually,
necrotic lesions which are responding to treatment decrease in size. In
reporting the results of trials, you may wish to report on this
phenomenon if it is seen frequently since some agents (e.g. angiogenesis
inhibitors) may produce this effect
If I am going to use MRI to follow disease, what is minimum size
for measurability?
MRI may be substituted for contrast enhanced CT for some sites, but not
lung. The minimum size for measurability is the same as for CT (10 mm)
as long as the scans are performed with slice thickness of 5 mm and no
gap. In the event the MRI is performed with thicker slices, the size of a
measurable lesion at baseline should be two times the slice thickness. In
the event there are inter-slice gaps, this also needs to be considered in
determining the size of measurable lesions at baseline
Can PET–CT be used with RECIST?
At present, the low dose or attenuation correction CT portion of a
combined PET–CT is not always of optimal diagnostic CT quality for use
with RECIST measurements. However, if your site has documented that
the CT performed as part of a PET–CT is of the same diagnostic quality as
a diagnostic CT (with IV and oral contrast) then the PET–CT can be used
for RECIST measurements. Note, however, that the PET portion of the CT
introduces additional data which may bias an investigator if it is not
routinely or serially performed
246
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Passariello R. Optimizing radiation dose and image quality.
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system: new horizons. Contrast Media Mol Imaging
2006;1(6):230–45.
26. Shankar LK, Hoffman JM, Bacharach S, et al. National
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247

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Date: 23 May 2016 
Protocol: ACE-ST-005 
 
 
 
Acerta Pharma 
Confidential 
Page 154 of 162 
Appendix 8.  irRECIST Guidelines 
 

ADAPTATION OF THE  
IMMUNE-RELATED RESPONSE 
CRITERIA: irRECIST
Oliver Bohnsack, PAREXEL 
Katarina Ludajic, PAREXEL 
Axel Hoos, GSK
ESMO 2014 ABSTRACT 4958

RECIST 1.1 has its 
shortcomings for targeted 
immunotherapy in oncology. 
Using RECIST 1.1 in 
immunotherapy trials  
would lead to declaration  
of progressive disease  
(PD) too early, when the 
treatment effect is not yet 
fully evident. RECIST also 
neglects the importance  
of the ‘flare effect’ -  
pseudo-progression  
effect within the so-called 
flare time window. 
Immune related Response 
Criteria (irRC) based on  
WHO criteria were published 
with an aim to provide better 
assessment of the effect  
of immunotherapeutic 
agents. With this poster we 
introduce irRECIST based on 
RECIST 1.1, irRC and Nishino 
et al., 2013 findings. Our aim 
is to define criteria that 
better capture antitumor 
activity and reduce irRC 
criteria ambiguity. 
Consistent implementation 
of irRECIST by both 
investigators and blinded 
independent readers  
will help reduce site: 
central discordance.
AIM
2
Original irRC, Including WHO  
Criteria References
irRECIST  
Modifications and Clarifications
Rationale for Modification
At the baseline tumor assessment, the 
sum of the products of the two largest  
perpendicular diameters (SPD) of all 
index lesions (five lesions per organ, 
up to 10 visceral lesions and five 
cutaneous index lesions) is calculated.
1. 0 Baseline: Measurable Lesion  
Definitions and Target Lesion 
Selection
Follow the definitions from RECIST 1.1. 
Measurable lesions must be 
accurately measured in at least one 
dimension with a minimum size of:
î 10 mm in the longest diameter by 
CT or MRI scan (or no less than 
double the slice thickness) for non-
nodal lesions and ≥15 mm in short 
axis for nodal lesions
î 10 mm caliper measurement by  
clinical exam
î 20 mm by chest X-ray
Up to 5 target lesions may be selected  
at baseline. Lesions will be measured  
unidimensionally. The minimum target 
lesion size at baseline in irRECIST is 
aligned with RECIST 1.1, as outlined in 
Nishino et al., 2013. 
WHO 5.1.2
Unmeasurable Disease
There are many forms of 
unmeasurable disease, and only a few 
are mentioned as examples:
Lymphangitic pulmonary metastases.
Skin involvement in breast cancer.
Abdominal masses that can be 
palpated but not measured.
1.1. Baseline: Non-measurable  
Lesion Definitions  
Follow the definitions from RECIST 1.1 
 Non-target lesions will include:
î0HDVXUDEOHOHVLRQVQRWVHOHFWHGDV
target lesions
î$OOVLWHVRIQRQPHDVXUDEOHGLVHDVH
such as neoplastic masses that are too 
small to measure because their longest 
uninterrupted diameter is < 10 mm (or 
< two times the axial slice thickness), 
ie. the longest per-pendicular 
diameter is  ≥10 and < 15 mm.
î2WKHUW\SHVRIOHVLRQVWKDWDUH
confidently felt to represent 
neoplastic tissue, but are difficult to 
measure in a reproducible manner. 
These include bone metastases, 
leptomeningeal metastases, 
malignant ascites, pleural or 
pericardial effusions, ascites, 
inflammatory breast disease, 
lymphangitis cutis/pulmonis, cystic 
lesions, ill-defined abdominal 
masses, skin lesions, etc.
Although irRC does not specifically 
define non-target lesions, irRC is 
derived from WHO criteria and 
indicates accordance with the same 
for the purposes of definitions of  
non-target lesions. Further 
clarifications in alignment with  
RECIST 1.1 are provided.
Not specified.
1.2 Baseline: Target and Non-Target 
Lymph Node Lesion Definitions
Follow the definitions from RECIST 1.1
No change in definition of target  
and non-target lymph nodes from  
RECIST 1.1.
Not specified.
1.3 Baseline: Non-Target  
Lesion Selection
All lesions or sites of disease not  
recorded as target lesions should  
be recorded as non-target lesions  
at baseline. There is no limit to the 
number of non-target lesions that  
can be recorded at baseline.
In alignment with RECIST 1.1, all  
malignant lesions have to be selected 
at baseline. The excess of measurable 
lesions and all true non-measurable 
lesions will be selected as non-target 
lesions at baseline and followed at 
subsequent timepoints.
 Not specified.
1.4 Baseline: Bone Lesions
Follow the definitions from RECIST 1.1.
Regardless of the imaging modality 
blastic bone lesions will not be select-
ed as target lesions. Lytic or mixed 
lytic-blastic lesions with a measurable 
soft tissue component ≥10 mm can be 
selected as target lesions.
Bone lesions are to be handled the 
same as in RECIST 1.1.
Not specified.
1.5 Baseline: Brain Lesions detected 
on brain scans can be considered as 
both target or non-target lesions.
Brain lesions can be selected as target 
or non-target lesions at baseline,  
depending on the protocol definition, 
indication, and study design.

The adaptations from  
irRC and WHO criteria,  
as applicable in 
immunotherapy clinical 
studies, are documented in 
the “irRECIST Modifications 
and Clarifications” column  
in a comparative table 
format within our Blinded 
Independent Central  
Review (BICR) Charter. 
The modifications we 
introduce represent 
adaptations of published 
criteria based on radiology 
practice and clinical trial 
experience, and they provide 
more objective and 
reproducible response 
assessments for 
investigators and for  
the central independent 
image review.
METHODS
3
Original irRC, Including WHO  
Criteria References
irRECIST  
Modifications and Clarifications
Rationale for Modification
Not specified.
1.6 Baseline: Cystic and Necrotic 
Lesions as Target Lesions
Lesions that are partially cystic or 
necrotic can be selected as target 
lesions. The longest diameter of such 
a lesion will be added to the Total 
Measured Tumor Burden (TMTB) of  
all target lesions at baseline. If other 
lesions with a non-liquid/non-necrotic 
component are present, those should 
be preferred. 
RECIST 1.1 does not integrate viability 
of tumor tissue into the assessment, 
and that is carried over into irRECIST.
Not specified.
1.7 Baseline: Lesions With Prior  
Local Treatment
During target lesion selection the 
radiologist will consider information 
on the anatomical sites of previous 
intervention (e.g. previous irradiation, 
RF-ablation, TACE, surgery, etc.). 
Lesions undergoing prior intervention 
will not be selected as target lesions 
unless there has been a demon-
stration of progress in the lesion.
In order to minimize site vs. central 
discrepancy information about prior 
intervention needs to be available  
to both the investigators and 
independent reviewers. 
Not specified.
1.8 Baseline: No Disease at Baseline 
If a patient has no measurable and  
no non-measurable disease at  
baseline the radiologist will assign  
‘No Disease’ (irND) as the overall  
tumor assessment for any available 
follow-up timepoints unless new  
measurable lesions are identified and 
contribute to the TMTB.
irND is a valid assessment in studies 
with adjuvant setting where the  
protocol and study design allow to  
include patients with no visible  
disease. This had not been addressed 
at all in any prior immune-response 
related criteria but needs to be  
included to also allow for these  
patients to be assessed accurately.
At each subsequent tumor 
assessment, the SPD of the index 
lesions and of new, measurable 
lesions (≥5×5 mm; up to 5 new  
lesions per organ: 5 new cutaneous 
lesions and 10 visceral lesions) are 
added together to provide the total 
tumor burden:
SPDindex lesions + SPDnew measured lesion
2.0 Follow-up: Recording of  
Target and New Measureable  
Lesion Measurements
The longest diameters of non-nodal 
target and new non-nodal measurable 
lesions, and short axes of nodal target 
and new nodal measurable lesions will 
be recorded. Together they determine 
the Total Measured Tumor Burden 
(TMTB) at follow-up.
In alignment with Nishino et al., 2013,  
unidimensional measurements are 
used. Measurements of all measured 
lesions (baseline-selected target  
lesions and new measurble lesions) 
are combined into TMTB at follow-up.
2.1 Follow-up: Definition of  
Measurable New Lesions
In order to be selected as new mea-
surable lesions (≤ 2 lesions per organ, 
≤ 5 lesions total, per timepoint), new 
lesions must meet criteria as defined 
for baseline target lesion selection  
and meet the same minimum size  
requirements of 10 mm in long  
diameter and minimum 15 mm in 
short axis for new measurable lymph 
nodes. New measurable lesions shall 
be prioritized according to size, and 
the largest lesions shall be selected  
as new measured lesions. 
Proposed selection of up to 5 new 
measurable lesions of at least 10 mm  
each verus 10 new measurable lesions 
as suggested in the irRC criteria is due 
to the following: 5 new measurable 
lesions add up at least 50 mm to the 
TMTB. Since PD is determined by  
at least a 20% increase in TMTB 
compared to nadir, this would mean 
that for irPD assessment the nadir 
TMTB had to be 25 cm, or 10 cm for  
2 lesions in one organ, which is a 
significant tumor burden already for 
any cancer patient. That is why 
measuring up to 5 new lesions in total 
is sufficient and will not obstruct an 
irPD assessment. Measuring more 
than 5 new lesons is not needed.
Larger lesions must be preferred as  
new measurable over smaller lesions, 
because there will be a greater impact  
of the TMTB %-increase by these 
larger lesions for irPD, to support  
a most conservative approach.

4
irRECIST criteria are based 
on irRC criteria adapted for 
unidimensional measure-
ments, as outlined in Nishino 
et al., 2013. To further align 
the criteria with RECIST 1.1 
we outline the approach for 
the assessment of baseline-
selected non-target lesions 
and new non-measurable 
lesions, and discuss the 
impact of those lesions  
on the overall tumor 
response assessment. 
Guidelines for the evaluation 
of patients with non-target 
disease only and patients in 
adjuvant setting is provided.
RESULTS
Original irRC, Including WHO  
Criteria References
irRECIST  
Modifications and Clarifications
Rationale for Modification
Non-index lesions at follow-up 
timepoints contribute to defining irCR 
(complete disappearance required).
2.2 Follow-up: Non-Target 
 Lesion Assessment 
The RECIST 1.1 definitions for  
the assessment of non-target  
lesions apply.
The response of non-target lesions 
primarily contributes to the overall 
response assessments of irCR and 
irNon-CR/Non-PD (irNN). Non-target 
lesions do not affect irPR and irSD 
assessments. Only a massive and 
unequivocal worsening of non-target 
lesions alone, even without progress  
in the TMTB is indicative of irPD. 
Non-target lesions have a subordinate 
function. In the event that non-target 
lesions massively progress one cannot 
ignore such worsening and in these 
rare cases irPD based only on  
non-target lesions will be a valid 
assessment option. 
New, non-measurable lesions at 
follow-up timepoints do not define 
progression, they only preclude irCR.
2.3 Follow-up: New Non-Measurable 
Lesions Definition and Assessment
All new lesions not selected as new 
measurable lesions are considered  
new non-measurable lesions and are 
followed qualitatively. Only a massive  
and unequivocal progression of new 
non-measurable lesions leads to an 
overall assessment of irPD for the 
timepoint. Persisting new non-
measurable lesions prevent irCR.
When new non-measurable lesions 
substantially worsen in these rare 
cases irPD based only on new  
non-measurable lesions will be  
an assessment option. 
irRC Overall Tumor Assessments
irCR, complete disappearance of all  
lesions (whether measurable or not,  
and no new lesions) 
î  Confirmation by a repeat, 
consecutive assessment no  
less than 4 weeks from the date  
first documented 
irPR, decrease in tumor burden ≥50% 
relative to baseline
î Confirmed by a consecutive 
assessment at least 4 weeks after 
first documentation 
irSD, not meeting criteria for irCR or 
irPR, in absence of irPD 
irPD, increase in tumor burden ≥25% 
relative to nadir (minimum recorded  
tumor burden)
î Confirmation by a repeat, 
consecutive assessment no  
less than 4 weeks from the date  
first documented
2.4 irRC Overall Tumor Assessments
irCR, complete disappearance of  
all measurable and non-measurable 
lesions. Lymph nodes must decrease 
to < 10 mm in short axis. Confirmation 
of response is not mandatory. 
irPR, decrease of ≥ 30% in TMTB  
relative to baseline, non-target lesions 
are irNN, and no unequivocal progres-
sion of new non-measurable lesions. 
irSD, failure to meet criteria for irCR 
or irPR in the absence of irPD.
irNN, no target disease was identified 
at baseline and at follow-up the  
patient fails to meet criteria for  
irCR or irPD.
irPD, minimum 20% increase and  
minimum 5 mm absolute increase in  
TMTB compared to nadir, or irPD for 
non-target or new non-measurable  
lesions. Confirmation of progression is 
recommended minimum 4 weeks after 
the first irPD assessment. 
irNE, used in exceptional cases where  
insufficient data exists. 
irND, in adjuvant setting when no  
disease is detected.
The irRECIST overall tumor  
assessment is based on TMTB of  
measured target and new lesions, 
non-target lesion assessment and  
new non-measurable lesions. 
The thresholds for irPR and irPD  
assessment are aligned with  
RECIST 1.1, and confirmation of  
response is not required.
An irPD confirmation scan may be  
recommended for patients with a  
minimal TMTB %-increase over  
20% and especially during the flare 
time-window of the first 12 weeks  
of treatment, depending on the  
compound efficacy expectations, to 
account for expected delayed response.

5
irRECIST criteria as outlined here introduce the needed clarifications and adjustments to irRC 
criteria and Nishino et al., 2013 publication to allow for treatment evaluations that better meet both 
investigators’ and patients’ needs and with that better reflect sponsors’ demands for more reliable 
and reproducible study data in targeted immunotherapy in oncology studies. The main adaptation of 
the existing immune-response criteira lies in the assessment of all detected lesions. Unequivocal 
and substantial increase of non-target and new non-measurable lesions prevents irCR and may also 
lead to irPD. Reduction of the tumor burden in patients in an adjuvant setting may lead to irPR and 
such patients may therefore be enrolled in studies with response endpoints.
Clinical relevance of these adaptations needs to be confirmed.
CONCLUSIONS

6 
1.  TMTB: Baseline-selected target lesions and new measurable 
lesions should NOT be assessed separately. Measurements of 
those lesions should be combined into the Total Measured 
Tumor Burden (TMTB), and one combined assessment provided.
2.  New Measurable Lesions: According to irRC a measurable new 
lesion has to be at least 5 mm x 5 mm to be selected as an 
index lesion. For bidimensional measurements this threshold 
was acceptable. In irRECIST, criteria for unidimensional lesion 
measurment apply to both target and new measurable lesions: 
a minimum 10 mm in the longest diameter for non-nodal 
lesions, and a minimum 15 mm in short axis for lymph nodes. 
Smaller lesions contribute to the non-target or new non-
measurable tumor burden, but do not get measured.
3.  irPR if no Target Lesions: If new measurable lesions appear  
in patients with no target lesions at baseline, irPD will be 
assessed. That irPD timepoint will be considered a new 
baseline, and all subsequent timepoints will be compared  
to it for response assessment. irPR is possible if the TMTB  
of new measurable lesions decreases by ≥ 30% compared  
to the first irPD documentation. 
4.  irPR in Adjuvant Studies: irRECIST can be used in the adjuvant 
setting, in patients with no visible disease on CT/MRI scans. 
The appearance of new measurable lesion(s) automatically 
leads to an increase in TMTB by 100% and leads to irPD. These 
patients can achieve a response if the TMTB decreases at 
follow-up, as a sign of delayed response.  
 
Considering 3 and 4, sponsors may consider enrolling patients 
with no measurable disease and/or patients with no visible disease 
at all in studies with response related endpoints. 
 
 
 
 
5.  Non-Target Lesions: In alignment with RECIST 1.1, baseline 
selected non-target lesions can never convert to measurable 
lesions, not even if they increase in size at subsequent 
timepoints and become measurable. Only true new lesions  
can be measured and contribute to the TMTB.
6.  Example: A patient has multiple lung metastases, all smaller 
than 10 mm and selected as non-target lesions at baseline.  
If, at a subsequent timepoint some of these non-target lesions 
increase and become > 10 mm, and one new lesion >10 mm 
appears, only the new measurable lesion will contribute to  
the TMTB, and not the baseline selected non-target lesion  
that increased in size. Otherwise such an increase would  
make persisting non-target lesions switch into the new 
measurable lesion category which would be inaccurate,  
as the lesion existed at baseline.
7.  irPD Based on Non-Target Lesions: Unlike irRC that neglect 
non-target lesions for the assessment of irPD, in irRECIST a 
substantial and unequivocal increase of non-target lesions is 
indicative of progression. 
8.  irPD Based on New Non-Measurable Lesions: According to 
irRC, a patient with multiple new lesions of 9 mm would be 
considered non-PD, whereas a patient with just one new lesion 
of 10 mm may be assessed as irPD if the TMTB of such a 
patient increases ≥ 20% compared to nadir. According to 
irRECIST, the reviewer may assign irPD for the patient with 
multiple new lesions of 9 mm if they are considered to be a 
sign of unequivocal, massive worsening (see 2.3)
9.  irPD Confirmation: Progression confirmation no less than  
4 weeks after the initial irPD assessment is recommended 
especially in case of marginal disease growth and if the  
first irPD assessment is within the compound-specific  
tumor flare window.
SUMMARY AND ADDITIONAL GUIDANCE

 7
1)  JD Wolchok, A Hoos, O Bohnsack, et.al., Guidelines for the Evaluation of Immune Therapy  
Activity in Solid Tumors: Immune-Related Response Criteria, Clin Cancer Res 2009;15(23) 
December 1, 2009
2)  Nishino M et al. Developing a common language for tumor response to immunotherapy:  
immune-related response criteria using unidimensional measurements. Clin Cancer Res. 2013 
Jul 15;19(14):3936-43
3)  Therasse P, Arbuck SG, et al.: New Guidelines to Evaluate the Response to Treatment in Solid 
Tumors. Journal of the National Cancer Institute 2000 92(3):205-216]
4)  Eisenhauer EA, Therasse P, Bogaerts J, et al.: New response evaluation criteria in solid tumours: 
revised RECIST guideline (version 1.1). In: Eur. J. Cancer. 45, Nr. 2, Januar 2009, S. 228–47.
5)  Therasse P, Eisenhauer EA, Verweij J: RECIST revisited: a review of validation studies on tumour 
assessment. In: Eur. J. Cancer. 42, Nr. 8, Mai 2006, S. 1031–9.
6)  WHO handbook for reporting results of cancer treatment. Geneva (Switzerland): World Health 
Organization Offset Publication No. 48; 1979.
Oliver.Bohnsack@PAREXEL.com
PAREXEL International 
195 West Street 
Waltham, MA 02451 USA 
+ 1 781 487 9900 
www.PAREXEL.com
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