Phase 2, Single Arm, Historically Controlled Study Testing The Safety and Efficacy of Adjuvant Temozolomide Plus TTFields (Optune®) Plus Pembrolizumab in Patients With Newly Diagnosed Glioblastoma (2-THE-TOP)
Phase: PHASE2
Conditions: Glioblastoma, Glioblastoma, WHO Grade IV
Sponsor: University of Florida

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Phase 2, Single Arm, Historically Controlled Study Testing The Safety and Efficacy of 
Adjuvant Temozolomide Plus TTFields (Optune®) Plus Pembrolizumab in Patients with 
Newly Diagnosed Glioblastoma (2-THE-TOP) 
 
THERAPEUTIC PROTOCOL 
 
Protocol:  
 
 UF IRB201702270/OnCore 16397 
 
Version:   
 
10.1, June 9, 2023 
Coordinating Center:   University of Florida 
 
Principal Investigator:  Ashley Ghiaseddin, M.D. 
 
Phone: (352) 273-9000 
 
E-mail: ashley.ghiaseddin@neurosurgery.ufl.edu 
 
Sub-Investigators 
 
 
Institution 
 
 
Specialty 
 
 
 
 
1. David D. Tran, M.D., Ph.D. 
University of Southern 
Neuro-Oncology 
 
 
 
 
 
 
California (USC) 
2. Maryam Rahman, M.D.  
University of Florida  
Neurosurgery 
 
Protocol Manager:  
Debbie Sampson, BSN, RN 
 
 
 
 
Phone: (352) 273-9000 
 
 
 
Email: debbie.sampson@neurosurgery.ufl.edu 
 
Biostatistics Manager: Ji-Hyun Lee, PhD 
University of Florida Health Cancer Center  
& Department of Biostatistics Staff 
 
IND:  
 
 
137513 (Exempt) 
 
 
 
Sponsor:  
 
Novocure, Inc. 
 
 
 
 
 
CONFIDENTIAL:  The information in this document is regarded as confidential and, except 
to the extent necessary to obtain informed consent, may not be disclosed to another party unless 
aw or regulations require such disclosure.  Persons to whom the information is disclosed must 
be informed that the information is confidential and may not be further disclosed by them. 
 
 

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Phase 2, Single Arm, Historically Controlled Study Testing The Safety and Efficacy of 
Adjuvant Temozolomide Plus TTFields (Optune®) Plus Pembrolizumab in Patients with 
Newly Diagnosed Glioblastoma (2-THE-TOP) 
 
Protocol Revision History 
 
Version Date 
Protocol Version/Amendment Number 
8/28/2017 
Initial Protocol Release (SRMC Approval Only) 
11/06/2017 
Amendment #1 Version 2.0 (FDA determination) 
12/15/2017 
Amendment #2 Version 3.0 (IRB initial submission) 
01/05/2018 
Amendment #3 Version 4.0 
05/14/2018 
Amendment #4 Version 5.0 
08/07/2018 
Amendment #5 Version 6.0 
12/13/2018 
Amendment #6 Version 7.0 
3/29/2019 
Amendment #7 Version 8.0 
12/11/2019 
Amendment #8 Version 9.0 
03/20/2020 
Amendment #9 Version 9.1 
07/17/2020 
Amendment #10 Version 9.2 
3/17/2021 
Amendment #11 Version 9.3 
12/16/2021 
Amendment #12 Version 9.4 
1/28/2022 
Amendment #13 Version 9.5 
9/28/2022 
Amendment #14 Version 10.0 
6/09/2023 
Amendment #15 Version 10.1 
 
 
 
Glossary of Abbreviations 
 
AE 
Adverse Event 
ALT (SGPT) Alanine transaminase (serum glutamate pyruvic transaminase) 
ANC 
Absolute neutrophil count 
ANOVA 
Analysis of Variance 
AST (SGOT) Aspartate transaminase (serum glutamic oxaloacetic transaminase) 
B-HCG 
Beta human chorionic gonadotropin 
BUN 
Blood Urea Nitrogen 
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 

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CMP 
Comprehensive Metabolic Panel 
CNS 
Central nervous system 
Cr 
Serum Creatinine 
CR 
Complete Response 
CRF 
Case report form 
CT 
Computed tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
DISC 
Data Integrity and Safety Committee 
ECHO 
Echocardiography 
ECI 
Event of clinical interest 
EGFR 
Epidermal Growth Factor Receptor 
ELISA 
Enzyme-Linked Immunoabsorbent Assay 
EKG 
Electrocardiogram 
FDA 
Food and Drug Administration 
FLAIR 
Fluid Attenuated Inversion Recovery 
FWA 
Federal wide assurance 
GBM 
Glioblastoma multiforme 
GFR 
Glomerular Filtration Rate 
GLP 
Good Laboratory Practice 
HIV 
Human Immunodeficiency Virus 
IHC 
Immunohistochemistry 
IND 
Investigational New Drug 
INR 
International normalized ratio 
irAE 
Immune-related adverse event 
IRB 
Institutional Review Board 
IULN 
Institutional upper limits of normal 
IV 
Intravenous 
MRI 
Magnetic resonance imaging 
MTD 
Maximum tolerated dose 
NCI 
National Cancer Institute 
NIH 
National Institutes of Health 
NSCLC 
Non-small cell lung cancer 
OHRP 
Office of Human Research Protections 
OS 
Overall survival 
PFS 
Progression-free survival 
PI 
Principal Investigator 
PT 
Prothrombin time 
PTT 
Partial thromboplastic time 
iRANO 
immunotherapy Response Assessment in Neuro-Oncology 
RN 
Registered Nurse 
RR 
Radiographic Response 
RT 
Radiation Therapy 

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RTOG 
Radiation Therapy Oncology Group 
SAE 
Serious adverse event 
SD 
Stable Disease 
StD 
Standard Deviation 
SQ  
Subcutaneous 
SUSAR 
Suspected unexpected serious adverse reaction 
TIL 
Tumor-infiltrating lymphocytes 
TMZ 
Temozolomide 
TSH 
Thyroid stimulating hormone 
TTFields 
Tumor Treating Electric Fields  
UF 
University of Florida 
UPN 
Unique patient number 
WBI 
Whole Body Irradiation 
 
 

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SCHEMA 
 
 
 
 
R: Registration.  
 
 
 

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TABLE OF CONTENTS 
1. 
PROTOCOL SYNOPSIS .................................................................................................... 10 
2. 
BACKGROUND AND RATIONALE ............................................................................... 11 
2.1 
Glioblastoma Multiforme ............................................................................................... 11 
2.2 
Introduction to Electric Fields ........................................................................................ 11 
2.3 
Novocure’s Tumor Treating Electric Fields (TTFields) ................................................ 12 
2.4 
The Optune Device......................................................................................................... 12 
2.5 
Effect of Optune on Newly Diagnosed GBM patients - A Phase 3 Study ..................... 13 
2.6 
Immune Dysregulation ................................................................................................... 13 
2.7 
Pembrolizumab - Keytruda ............................................................................................ 13 
2.8 
Rationale for Pembrolizumab Dosing ............................................................................ 15 
2.9 
Study Rationale .............................................................................................................. 16 
2.10 
Correlative Study Background ....................................................................................... 18 
3. 
OBJECTIVES ...................................................................................................................... 19 
3.1 
Primary Objectives ......................................................................................................... 19 
3.2 
Secondary Objectives ..................................................................................................... 19 
3.3 
Exploratory Objectives ................................................................................................... 19 
4. 
PATIENT SELECTION ..................................................................................................... 20 
4.1 
Inclusion Criteria ............................................................................................................ 20 
4.2 
Exclusion Criteria ........................................................................................................... 21 
4.3 
Inclusion of Women and Minorities............................................................................... 22 
5. 
SUBJECT RECRUITMENT AND REGISTRATION PROCEDURES ....................... 22 
5.1 
Subject Registration in the University of Florida Cancer Center Database ................... 23 
6. 
TREATMENT PLAN ......................................................................................................... 23 
6.1 
Treatment with Optune................................................................................................... 24 
6.1.1 
Recommendations for Use of Optune ................................................................. 24 
6.1.2 
Skin Care Guidelines ........................................................................................... 24 
6.1.3 
Potential Adverse Events: Optune....................................................................... 25 
6.2 
Pembrolizumab Administration ..................................................................................... 25 
6.2.1 
Premedication Administration of Pembrolizumab .............................................. 25 
6.3 
Temozolomide Administration ...................................................................................... 25 
6.3.1 
Adjuvant Temozolomide Treatment ................................................................... 26 
6.4 
Follow-Up Evaluations During The 12 Cycles of Adjuvant TMZ ................................ 26 
6.5 
Evaluation After Adjuvant TMZ Until Treatment Termination .................................... 27 
6.6 
Post Treatment Evaluations ............................................................................................ 27 
7. 
CORRELATIVE STUDIES ............................................................................................... 27 
7.1 
Blood Specimens ............................................................................................................ 27 
7.1.1 
Collection of Specimens...................................................................................... 27 
7.1.2 
Handling of Specimens ....................................................................................... 28 
7.1.3 
Transport of Specimens ....................................................................................... 28 
7.2 
Tumor Tissue Specimens ............................................................................................... 29 

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7.2.1 
Collection of Specimens...................................................................................... 29 
7.2.2 
Handling of Specimens ....................................................................................... 29 
7.2.3 
Transport of Specimens ....................................................................................... 29 
7.3 
Urine Specimens ............................................................................................................ 29 
7.3.1 
Collection of Specimens...................................................................................... 29 
7.3.2 
Handling of Specimens ....................................................................................... 29 
7.3.3 
Transport of Specimens ....................................................................................... 30 
8. 
ADVERSE REACTIONS AND DOSE DELAYS/DOSE MODIFICATIONS .............. 30 
8.1 
Potential Adverse Events: Temozolomide ..................................................................... 30 
8.2 
Potential Adverse Events: Pembrolizumab .................................................................... 31 
8.2.1 
Supportive Care Guidelines for Infusion Reactions ............................................ 35 
8.3 
Additional Potential Risks .............................................................................................. 36 
8.3.1 
Disease progression ............................................................................................. 36 
8.3.2 
Cerebral Edema ................................................................................................... 36 
8.3.3 
Phlebotomy and/or Intravenous Catheter Insertion ............................................. 37 
8.3.4 
MRI ..................................................................................................................... 37 
8.3.5 
Allergic Reactions to Contrast Agents ................................................................ 37 
8.3.6 
Privacy/Confidentiality ....................................................................................... 37 
8.4 
Women of Childbearing Potential .................................................................................. 37 
9. 
REGULATORY AND REPORTING REQUIREMENTS .............................................. 38 
9.1 
Federal Regulations and Good Clinical Practice............................................................ 38 
9.2 
Institutional Review Board............................................................................................. 38 
9.3 
Compliance with Laws and Regulations ........................................................................ 38 
9.4 
Delegation of Investigator Responsibilities ................................................................... 39 
9.5 
Subject Information and Informed Consent ................................................................... 39 
9.6 
Privacy/Confidentiality .................................................................................................. 39 
9.7 
Protocol Amendments .................................................................................................... 40 
9.8 
Case Report Forms ......................................................................................................... 40 
9.9 
Record Retention ............................................................................................................ 40 
9.10 
Conflict of Interest ......................................................................................................... 41 
9.11 
Adverse Event Definitions, Reporting and Documentation ........................................... 41 
9.11.1 
Adverse Events (AEs) ..................................................................................... 41 
9.11.2 
Serious Adverse Event (SAE) ......................................................................... 41 
9.11.3 
Unexpected Adverse Experience ..................................................................... 42 
9.11.4 
Unanticipated Problems ................................................................................... 42 
9.11.5 
Noncompliance ................................................................................................ 42 
9.11.6 
Serious Noncompliance ................................................................................... 43 
9.11.7 
Protocol Exceptions ......................................................................................... 43 
9.12 
Grading of an Adverse Event ......................................................................................... 43 
9.13 
Determination of Causality of Adverse Events .............................................................. 43 
9.14 
Routine Adverse Event Reporting.................................................................................. 44 
9.15 
Unanticipated Adverse Device Effect Event (UADE) Reporting .................................. 44 
9.16 
Eliciting Adverse Event Information ............................................................................. 44 
9.17 
Adverse Event Reporting Period .................................................................................... 45 
9.18 
Follow-up of Unresolved Adverse Events ..................................................................... 45 

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9.19 
Adverse Event Reporting ............................................................................................... 45 
10. STATISTICAL CONSIDERATIONS: ............................................................................. 45 
10.1 
Primary Endpoint ........................................................................................................... 45 
10.2 
Secondary endpoints ...................................................................................................... 45 
10.3 
Sample Size Considerations ........................................................................................... 46 
10.4 
Data Analysis Considerations (Protocol v10.1) ............................................................. 46 
11. STUDY CALENDAR .......................................................................................................... 48 
12. DATA SUBMISSION SCHEDULE ................................................................................... 51 
13. RESPONSE EVALUATION .............................................................................................. 51 
13.1 
Criteria for Determining First Progression Depending on Time from Initial 
Chemoradiotherapy ................................................................................................................... 52 
13.2 
Disease Parameters ...................................................................................................... 53 
13.3 
Methods for Evaluation of Measurable Disease ........................................................ 53 
Brain FDG-PET or amino-acid PET coupled with head CT or brain MRI: This advanced 
metabolic imaging technique can be used as an adjunct test to determine response or disease 
status. However, it should be used as the primary or sole method of determining response or 
disease status. ............................................................................................................................ 54 
13.4 
Criteria for Immunotherapy Response Assessment in Neuro-Oncology Incorporating 
MRI and Clinical Factors (Adapted from [64]) with modifications ......................................... 54 
13.4.1 
Complete Response ......................................................................................... 54 
13.4.2 
Partial Response .............................................................................................. 54 
13.4.3 
Stable Disease .................................................................................................. 55 
13.4.4 
Progressive Disease ......................................................................................... 55 
13.5 
Modified iRANO Criteria .............................................................................................. 55 
13.6 
Response Evaluation after a Complete Resection .......................................................... 55 
13.6.1 
Complete Response ......................................................................................... 55 
13.6.2 
Partial Response .............................................................................................. 56 
13.6.3 
Stable Disease .................................................................................................. 56 
13.6.4 
Progressive Disease ......................................................................................... 56 
13.6.5 
Not Assessable ................................................................................................. 56 
14. QUALITY CONTROL AND QUALITY ASSURANCE ................................................ 56 
14.1 
Data and Safety Monitoring Plan ................................................................................... 56 
14.1.1 
Data Monitoring Plan ...................................................................................... 56 
14.1.2 
Data Safety Monitoring Board ........................................................................ 56 
14.2 
Audits ............................................................................................................................. 57 
14.3 
Data Management and Processing ................................................................................. 57 
14.3.1 
Study Documentation ...................................................................................... 57 
14.3.2 
Case Report Forms .......................................................................................... 58 
14.3.3 
Data Management and Procedures and Data Verifications ............................. 58 
15. REFERENCES .................................................................................................................... 59 
16. APPENDIX A: Karnofsky Performance Scale ................................................................. 64 
17. APPENDIX B:  RANO/iRANO Measurement Form....................................................... 65 

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18. APPENDIX C: GUIDANCE ON CONTRACEPTION ................................................... 67 
 
 
 

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1. PROTOCOL SYNOPSIS 
 
Title: 
 
Phase 2, Single Arm, Historically Controlled Study Testing The Safety 
and Efficacy of  Adjuvant Temozolomide plus TTFields (Optune®) plus 
Pembrolizumab in Patients with Newly Diagnosed Glioblastoma (2-THE-
TOP) 
Drug/Device 
Pembrolizumab, temozolomide, and TTFields (Optune®) 
Study Objectives:  
To determine whether the addition of pembrolizumab to the combination 
of TTFields (Optune®) and adjuvant temozolomide (Triple Combination) 
increases progression-free survival (PFS) in patients with newly 
diagnosed glioblastoma (GBM) as compared to historical control data in 
EF-14 study. 
Study Design:  
Open-labeled, historically controlled 
Study Hypothesis: 
The hypothesis of this study is that the addition of pembrolizumab to the 
combination of TTFields (Optune®) and adjuvant temozolomide (TMZ) 
will significantly increase the PFS of newly diagnosed GBM patients 
compared to a historical control. 
Sample Size: 
24 patients with newly diagnosed GBM 
Study Population: 
Patients 18 years and older with pathologic diagnosis of GBM WHO 
Grade IV who have undergone maximal resection or biopsy followed by 
radiation therapy with concomitant temozolomide (Stupp protocol) [1] 
Primary Endpoint: 
To determine whether the triple combination of pembrolizumab when 
added to TTFields (Optune®) and adjuvant temozolomide increases PFS 
in patients with newly diagnosed GBM as compared to historical control 
data in the EF-14 study. 
Secondary 
Endpoint: 
1. To determine toxicity and tolerability of the triple combination in 
newly diagnosed GBM patients 
2. To determine overall survival (OS) and radiographic response (RR) of 
the triple combination in newly diagnosed GBM as compared to 
historical data in EF-14 study 
3. To determine whether pembrolizumab augments TTFields-initiated 
glioma-specific immune reaction. 
Exploratory 
endpoints: 
1. Metabolomics signature of immune activation by TTFields and 
TTFields + pembrolizumab in serum and urine. 
2. To determine if mutation burden, when available from standard of care 
genomics analysis, in primary tumor samples correlates with response 
to pembrolizumab in the presence of TTFields. 
3. To determine if intratumoral expression of PD-L1 correlates with 
response to pembrolizumab in the presence of TTFields. 
Sponsor: 
Novocure Ltd. 
POB 15022 
MATAM Center  
Haifa, 31905, Israel 

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2. BACKGROUND AND RATIONALE 
 
2.1 
Glioblastoma Multiforme 
 
Glioblastoma is the most common primary malignant neoplasm of the central nervous system in 
adults with a median overall survival of 14.6 months and a 2 year survival rate of 28% with 
standard chemoradiation [2]. Tumor-treating fields are a novel loco-regional anti-mitotic treatment 
modality by interfering with formation of the spindle structure and other macromolecules during 
cell division [3]. In the planned interim analysis of 315 patients of the phase 3 EF-14 trial in newly 
diagnosed GBM comparing TTFields plus temozolomide to temozolomide alone adjuvant therapy, 
the addition of TTFields to adjuvant temozolomide significantly increased progression-free 
survival (PFS) (7.1 vs. 4.0 months; HR 0.62, p=0.001) and OS (20.5 vs. 15.6 months; HR 0.64; 
p=0.004) compared to temozolomide alone [4]. In the final analysis of all 695 patients, PFS for 
the combination vs. temozolomide alone was 6.7 vs. 4.0 months (hazard ratio [HR], 0.63 [95%CI 
0.52, 0.76] P=0.00005) and median survival for the combination vs. temozolomide alone was 20.9 
vs. 16 months (HR 0.63 [CI 0.53, 0.76] P=0.00006) [5]. These data establish TTFields plus 
adjuvant temozolomide as a new standard treatment for newly diagnosed GBM. 
 
2.2 
Introduction to Electric Fields 
 
In the laboratory setting and in clinical practice, alternating electric fields show a wide range of 
effects on living tissues. At very low frequencies (under 1 kHz), alternating electric fields stimulate 
excitable tissues through membrane depolarization [6]. The transmission of such fields by 
radiation is insignificant and therefore they are usually applied directly by contact electrodes, 
though some applications have also used insulated electrodes. Some well-known examples of such 
effects include nerve, muscle and heart stimulation by alternating electric fields [6, 7]. In addition, 
low frequency pulsed electric fields have been claimed to stimulate bone growth and accelerate 
fracture healing [8]. However, as the frequency of the alternating electric field increases above 1 
kHz, the stimulatory effect diminishes. Under these conditions although a greater fraction of the 
fields penetrates the cells, due to the parallel resistor-capacitor nature of all biological membranes, 
the stimulatory power greatly diminishes as the alternating cell membrane hyper–depolarization 
cycles are integrated such that the net effect is nulled. 
At very high frequencies (e.g. MHz), while the integration becomes even more effective, a 
completely different biological effect is observed. At these frequencies tissue heating becomes 
dominant due to dielectric losses. This effect becomes more intense as field intensity or tissue 
dissipation factor increase [9]. This phenomenon serves as the basis for some commonly used 
medical treatment modalities including diathermy and radio frequency tumor ablation, which can 
be applied through insulated electrodes [10]. 
Intermediate frequency electric fields (i.e., tens of kHz to MHz), alternate too fast for causing 
nerve-muscle stimulation and involve only minute dielectric losses (heating). Such fields, of low 
to moderate intensities, are commonly considered to have no biological effect [9]. However, a 
number of non-thermal effects, of minor biological consequence, have been reported even at low 
field intensities. These include microscopic particle alignment (i.e., the pearl chain effect [11]) and 
cell rotation [12, 13]. With pulsed relatively strong electric fields, > 103 V/cm and 100 ms pulse 

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length, reversible pore formation appears in the cell membrane, a phenomenon usually called 
electroporation [14]. 
 
2.3 
Novocure’s Tumor Treating Electric Fields (TTFields) 
 
Novocure has shown [15] that when properly tuned, very low intensity, intermediate frequency 
electric fields (TTFields) stunt the growth of tumor cells. This inhibitory effect was demonstrated 
in all proliferating cell types tested, whereas, non-proliferating cells and tissues were unaffected. 
Interestingly, different cell types showed specific intensity and frequency dependences of TTField 
inhibition. It has been shown that two main processes occur at the cellular level during exposure 
to TTFields: arrest of proliferation and dividing cell destruction. The damage caused by TTFields 
to these replicating cells was dependent on the orientation of the division process in relation to the 
field vectors, indicating that this effect is non-thermal. Indeed, temperature measurements made 
within culture dishes during treatment and on the skin above treated tumors in-vivo, showed no 
significant elevation in temperature compared to control cultures/mice. Also, TTFields caused the 
dividing cells to orient in the direction of the applied field in a manner similar to that described in 
cultured human corneal epithelial cells exposed to constant electric fields [16]. At the sub-cellular 
level it was found that TTFields disrupt the normal polymerization-depolymerization process of 
microtubules during mitosis. Indeed, the described abnormal mitotic configurations seen after 
exposure to TTFields are similar to the morphological abnormalities seen in cells treated with 
agents that interfere directly [17, 18] or indirectly [19-21] with microtubule polymerization (e.g., 
paclitaxel). 
 
2.4 
The Optune Device 
 
The Optune system (NovoTTFTM Therapy) is a portable battery operated device, which produces 
TTFields within the human body by means of surface transducer arrays [3, 4, 22]. The TTFields 
are applied to the patient by means of surface transducer arrays that are electrically insulated, so 
that resistively coupled electric currents are not delivered to the patient. The transducer arrays, 
which incorporate a layer of adhesive hydrogel and a layer of hypoallergenic medical tape, are 
placed on the patient’s shaved head.  The transducer arrays must be replaced every three to four 
days and the scalp re-shaved in order to maintain optimal capacitative coupling between the 
transducer arrays and the patient head. All the treatment parameters are pre-set by Novocure so 
there are no electrical output adjustments available to the patient. The patient must learn to change 
and recharge depleted service batteries and to connect to an external battery pack overnight. 
 
Optune is currently FDA-approved as a single modality treatment for recurrent GBM when both 
surgical and radiotherapy options have been exhausted as well as combination with adjuvant 
temozolomide for newly diagnosed GBM. In the pivotal EF-11 trial in recurrent GBM, overall 
survival of patients treated with the device was equivalent to those treated with standard 
chemotherapy alone [22]. Six-month progression-free survival (6PFS) analysis favored the 
TTFields arm compared to the chemotherapy arm, although not statistically significant. Safety and 
toxicity profile favored the Optune arm compared to the chemotherapy control arm. No device-
specific grade 3 and 4 toxicities were identified for hematologic, gastrointestinal, vascular, renal 
and respiratory disorders. There were also no increased grade 3 and 4 central nervous system 
adverse events. The most common device specific adverse event was skin rash due to the 

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transducer arrays.  
 
2.5 
Effect of Optune on Newly Diagnosed GBM patients - A Phase 3 Study 
 
Six hundred and ninety-five patients from 83 centers across the world were treated. All patients 
underwent surgery and radiotherapy for the primary tumor. All patients received temozolomide as 
adjuvant chemotherapy, and were then randomized to standard adjuvant TMZ chemotherapy (for 
6-12 cycles) with or without concomitant administration of TTFields. During a pre-specified 
interim and futility analysis after 315 randomized patients reached a minimum follow-up of 18 
months there was a 3.1 month PFS increase with a median PFS of 7.1 months compared to 4.0 
months in the control group [4].  
  
Increased PFS in the TTFields arm subsequently led to the recommendation from the independent 
data monitoring committee to terminate the trial early for success and allow standard of care 
patients to cross over to the TTFields group.  The percentage of patients alive at 2 years following 
enrollment was 43% in the TTFields plus temozolomide group compared to 29% in the 
temozolomide alone group.    
 
Overall survival results increased from 15.6 months in the temozolomide alone group to 20.5 
months in the TTFields plus adjuvant temozolomide group establishing a new standard treatment 
for newly diagnosed GBM [4]. 
 
2.6 
Immune Dysregulation 
 
Recent work has collectively demonstrated striking immune dysregulation in patients with GBM, 
including T cell lymphopenia and anergy, cytokine dysregulation, increased regulatory T cell 
(Treg) populations, and NK cell dysfunction, among others, which reflect immunologic 
compromise and functional impairment [23, 24]. However, a growing list of potential tumor 
antigens has been identified, suggesting that tumor cell-specific recognition by immune cells may 
be biologically relevant and therapeutically exploitable [25]. Therefore, given the immune 
dysfunction characterized in GBM patients, approaches that potentiate the anti-glioma immune 
response are particularly exciting. A priori, because the immune system has evolved to recognize 
a tremendous diversity of antigenic epitopes in vertebrates, immune-potentiating efforts may be 
especially effective at targeting the heterogeneity that defines GBM. Recently, the success of 
antibody-based therapies targeting immune checkpoints has generated field-wide enthusiasm that 
biological therapies may be broadly effect across many cancer types, including GBM [26-31]. Of 
these agents, those targeting the negative regulator proteins CTLA-4 and PD-1/PD-L1 have shown 
clinical efficacy but have not been studied widely in newly diagnosed GBM patients. 
 
2.7 
Pembrolizumab - Keytruda  
 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades [32]. Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in various 
malignancies [33-37]. In particular, the presence of CD8+ T-cells and the ratio of CD8+ effector 

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T-cells/Foxp3+ regulatory T-cells seem to correlate with improved prognosis and long-term 
survival in many solid tumors.  
 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune 
control. The normal function of PD-1, expressed on the cell surface of activated T-cells under 
healthy conditions, is to down-modulate unwanted or excessive immune responses, including 
autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig superfamily member related to 
CD28 and CTLA-4, which has been shown to negatively regulate antigen receptor signaling upon 
engagement of its ligands (PD-L1 and/or PD-L2) [38, 39]. The structure of murine PD-1 has been 
resolved [40]. PD-1 and family members are type I transmembrane glycoproteins containing an Ig 
Variable-type (V-type) domain responsible for ligand binding and a cytoplasmic tail which is 
responsible for the binding of signaling molecules. The cytoplasmic tail of PD-1 contains 2 
tyrosine-based signaling motifs, an immunoreceptor tyrosine-based inhibition motif (ITIM) and 
an immunoreceptor tyrosine-based switch motif (ITSM). Following T-cell stimulation, PD-1 
recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif within its cytoplasmic tail, 
leading to the dephosphorylation of effector molecules such as CD3ζ, PKCθ and ZAP70, which 
are involved in the CD3 T-cell signaling cascade [38, 41-43]. The mechanism by which PD-1 
down modulates T-cell responses is similar to, but distinct from that of CTLA-4 as both molecules 
regulate an overlapping set of signaling proteins [44, 45]. PD-1 has been shown to be expressed 
on activated lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, Tregs and Natural 
Killer cells [46, 47]. Expression has also been shown during thymic development on CD4-CD8- 
(double negative) T-cells as well as subsets of macrophages and dendritic cells [48]. The ligands 
for PD-1 (PD-L1 and PD-L2) are constitutively expressed or can be induced in a variety of cell 
types, including non-hematopoietic tissues as well as in various tumors [44, 49-51]. Both ligands 
are type I transmembrane receptors containing both IgV- and IgC-like domains in the extracellular 
region and contain short cytoplasmic regions with no known signaling motifs. Binding of either 
PD-1 ligand to PD-1 inhibits T-cell activation triggered through the T-cell receptor.  PD-L1 is 
expressed at low levels on various non-hematopoietic tissues, most notably on vascular 
endothelium, whereas PD-L2 protein is only detectably expressed on antigen-presenting cells 
found in lymphoid tissue or chronic inflammatory environments.  PD-L2 is thought to control 
immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen unwarranted T-
cell function in peripheral tissues [44]. Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor. PD-1 has 
been suggested to regulate tumor-specific T-cell expansion in subjects with melanoma [52]. This 
suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune evasion and should 
be considered as an attractive target for therapeutic intervention. 
 
Pembrolizumab is a potent and highly selective humanized monoclonal antibody (mAb) of the 
IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-
L1 and PD-L2. KeytrudaTM (pembrolizumab) has recently been approved in the United States for 
the treatment of patients with advanced and metastatic non-small cell lung cancer, recurrent or 
metastatic head and neck squamous cell carcinoma, locally advanced urothelial carcinoma, 
classical Hodgkin lymphoma, unresectable or metastatic melanoma or melanoma progression 
following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor, and any solid 
tumor with high microsatellite instability or mismatch repair deficiency.   
 

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2.8 
Rationale for Pembrolizumab Dosing  
 
An open-label Phase I trial was conducted to evaluate the safety and clinical activity of single 
agent pembrolizumab [53]. The dose escalation portion of this trial evaluated three dose levels, 1 
mg/kg, 3 mg/kg, and 10 mg/kg, administered every 2 weeks (Q2W) in subjects with advanced 
solid tumors. All three-dose levels were well tolerated and no dose-limiting toxicities 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 (1 mg/kg, 3 mg/kg and 10 mg/kg 
Q2W). No MTD was identified during the study date. Recent data from other clinical studies 
within the pembrolizumab program has shown that a lower dose of pembrolizumab and a less 
frequent schedule may be sufficient for target engagement and clinical activity [27, 29, 54]. 
 
PK data analysis of pembrolizumab administered Q2W and Q3W showed slow systemic clearance, 
limited volume of distribution, and a long half-life [55]. Pharmacodynamic data (IL-2 release 
assay) suggested that peripheral target engagement is durable (>21 days) [56, 57]. This early PK 
and pharmacodynamic data provides scientific rationale for testing a Q2W and Q3W dosing 
schedule. 
 
A population pharmacokinetic analysis has been performed using serum concentration time data 
from 476 patients. Within the resulting population PK model, clearance and volume parameters of 
pembrolizumab were found to be dependent on body weight. The relationship between clearance 
and body weight, with an allometric exponent of 0.58, is within the range observed for other 
antibodies and would support both body weight normalized dosing or a fixed dose across all body 
weights [58]. Pembrolizumab has been found to have a wide therapeutic range based on the 
melanoma indication [57]. The differences in exposure for a 200 mg fixed dose regimen relative 
to a 2 mg/kg Q3W body weight based regimen are anticipated to remain well within the established 
exposure margins of 0.5 – 5.0 for pembrolizumab in the melanoma indication. The exposure 
margins were based on the notion of similar efficacy and safety in melanoma at 10 mg/kg Q3W 
vs. the dose regimen of 200 mg Q3W (i.e. 5-fold higher dose and exposure). The population PK 
evaluation revealed that there was no significant impact of tumor burden on exposure. In addition, 
exposure was similar between the NSCLC and melanoma indications [28, 55, 58]. Therefore, there 
are no anticipated changes in exposure between different indication settings. 
 
An ongoing phase I and II study testing the safety and efficacy of pembrolizumab and laser ablation 
in recurrent high-grade gliomas (FDA IND 1250999; WUTSL IRB 201501072; PI: Jian Campian, 
M.D., Ph.D.) has completed the phase I trial with 9 patients in 3 dose cohorts. No dose limiting 
toxicity was observed. Pembrolizumab 200 mg IV Q3W (i.e. the highest dose in the study) was 
generally well-tolerated. One durable complete response and 4 patients with prolonged stable 
disease (range 5-21 months) were observed. 
 

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2.9 
Study Rationale  

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Radiographic responses to TTFields have been noted to be delayed, in many instances, for >4 
months after treatment initiation. In fact, most responders to TTFields experienced transient 
increases in enhancement, FLAIR and vasogenic edema within 2-4 months of treatment initiation, 
followed by a gradual decrease in enhancement and edema (EF-11 and Fig.1 and unpublished 
data) [4, 22]. These observations suggest a possibility that TTFields may induce an inflammatory 
reaction in the tumor. In 2 separate immunocompetent animal models of cancer including 1) 
syngeneic mice injected with the mouse melanoma cell line B16F10, and 2) New Zealand white 
rabbits implanted with VX-2 carcinoma within the renal capsule, TTFields therapy to the primary 
tumors in the abdomen significantly  reduced growth of distant lung metastasis, suggesting a 
systemic immune effect of TTFields. Within these primary tumors, TTFields induced a 
considerable increase in peri- and intra-tumoral immune cell infiltration, including both CD4+ and 
CD8+ lymphocytes, compared to sham-treated control tumors [59] (Fig. 2). Although the 
mechanism remains unclear, it is presumably through its anti-mitotic activities causing 

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immunogenic death of cancer cells, leading to an increase in cancer-associated antigen or 
neoantigen presentation and immune activation. These results also indicate that proliferating 
immune cells recruited to tumors were not susceptible to the anti-mitotic effect of the intermediate 
electrical field frequency of 100-200kHz used in TTFields. In fact, emerging data suggest that 
there appears to be an inverse correlation between cell size and intracellular electrical properties 
and the field frequency to which they are susceptible (data not shown). 
 
In addition, recent data indicate that TTFields may improve immunotherapy such as immune 
checkpoint inhibitors. In the Lewis lung carcinoma models in mice, the combination of TTFields 
and an anti-PD-1 monoclonal antibody resulted in improved tumor control compared to TTFields 
alone or anti-PD-1 antibody alone (Fig. 3). The improved tumor control by the combination was 
associated with higher tumor infiltration of various immune cells, especially antigen presenting 
cells and elevated expression of PD-L1 (Fig. 3). 
 
Taken together, these data support the notion that the early edema and delayed responses of GBM 
to TTFields may have an immunological basis and could be augmented if combined with an 
immune modulator. In this protocol, we propose to combine TTFields with pembrolizumab 
during the adjuvant temozolomide treatment phase for newly diagnosed GBM. We hypothesize 
that TTFields combined with temozolomide elicit anti-mitotic effects on proliferative cancer cells 
and also significantly augment recruitment of immune effector cells specific for glioma cells to 
the tumor microenvironment where pembrolizumab, a PD1 inhibitor, further potentiates the 
glioma-specific immune reaction to achieve a synergistic therapeutic effect.  
 
2.10 
Correlative Study Background 
 
Level of expression of PD-L1 on tumor cells has been associated with response to anti-PD-1/PD-
L1 checkpoint blockade therapy, although the association is not absolute [60]. Therefore, the 
degree of PD-L1 expression will be determined on tumor using IHC. RNA sequencing (RNAseq) 
can also be performed, if necessary, to determine if relative gene expression levels can serve as an 
alternative predictive biomarker as well as to determine the relative expression levels of other 
immune checkpoint pathways or immune responsive pathways (i.e. interferon-related genes) that 
may be associated with resistance or response to therapy.  
Mutational burden has also been associated with 
response to checkpoint blockade therapy. GBM is 
generally considered to have low mutation burden 
compared to other extracranial tumors [61]. 
However recent study suggests that TTFields may 
also target DNA repair mechanisms [62], which 
potentially could increase mutation burden in 
treated tumors over time and render them more 
sensitive 
to 
checkpoint 
inhibitors. 
Tumor 
mutational load will be assessed by DNA 
sequencing and obtained from routine clinical 
Foundation One or internal analysis on pre-
treatment tumor specimens. 

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The glioma-specific immune response, molecular, and genomic analysis will be assessed in 
peripheral blood. Pre- and post-treatment peripheral blood will be assessed by flow cytometry for 
markers of T cell activation and anergy as well as cytokine profiles. Furthermore, serum or plasma 
will be assessed for the presence and level of soluble immune checkpoint molecules, cytokines, 
and chemokines using commercially-available multiplex immunoassays.  
 
Recently immunometabolic markers of specific immune activation can be detected in the serum 
or urine and have been suggested as a non-invasive method to monitor vaccination reactions in 
real time [63]. We have applied this concept to monitoring the response of mice bearing a 
syngeneic GBM model to a PD-1 inhibitor and detected a clear shift of certain immunometabolic 
markers in both serum (Fig. 4) and urine (not shown). We will apply this technique to explore its 
utility in detecting and monitoring immune response to TTFields and to TTFields + 
pembrolizumab combination. 
 
3. OBJECTIVES 
 
This prospective, single-arm, open-label study will be conducted in patients with newly diagnosed 
GBM who have completed standard of care radiation therapy together with concomitant TMZ. In 
this protocol, we propose to combine TTFields (utilizing the Optune System) with 
pembrolizumab during the adjuvant TMZ treatment phase for newly diagnosed GBM. We 
hypothesize that TTFields combined with TMZ will elicit anti-mitotic effects on proliferative 
cancer cells and also significantly augment recruitment of immune effector cells specific for 
glioma cells to the tumor microenvironment where pembrolizumab, a PD1 inhibitor, further 
potentiates the glioma-specific immune reaction to achieve a synergistic therapeutic effect. 
 
3.1 
Primary Objectives 
 
To determine whether the triple combination (TTFields, temozolomide, pembrolizumab) increases 
PFS in patients with newly diagnosed GBM as compared to historical control data (TTFields, 
temozolomide) in the phase 3 registration EF-14 study.   
 
3.2 
Secondary Objectives 
1.  To determine toxicity and tolerability of the triple combination in newly diagnosed GBM 
patients 
2.  To determine OS and RR of the triple combination in newly diagnosed GBM as compared 
to historical data in the EF14 study. 
3.  To determine whether pembrolizumab augments TTFields-initiated glioma-specific 
immune reaction. 
 
3.3 
Exploratory Objectives 
1. Metabolomics signature of immune activation by TTFields and TTFields + pembrolizumab 
in serum and urine. 
2. To determine if mutation burden, when available from standard of care genomics analysis, 
in primary tumor samples correlates with response to pembrolizumab in the presence of 
TTFields. 
3. To determine if intratumoral expression of PD-L1 correlates with response to 
pembrolizumab in the presence of TTFields. 

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4. PATIENT SELECTION 
 
4.1 
Inclusion Criteria 
 
1) Histologic confirmation of glioblastoma, WHO Grade IV (GBM variants are allowed). 
 
2) MGMT methylation status if available (indeterminate methylation status will be considered 
unmethylated). 
 
3) Karnofsky performance status (KPS) ≥70%. 
 
4) Patients must be at least 18 years of age. 
 
5) Received maximal safe resection (biopsy only allowed) and radiotherapy concomitant with 
temozolomide: 
 
a. 
Gliadel wafers placement at the time of surgical resection is allowed. 
b. 
Any additional treatment directed at GBM will be considered exclusionary. 
c. 
Minimum dose for concomitant radiotherapy is 40 Gy. 
 
6) Candidate for adjuvant high dose temozolomide and Optune therapy. 
 
7) Life expectancy of at least 3 months. 
 
8) Adequate bone marrow and organ function as defined below: 
 
a. 
ANC ≥ 1,500/mcL 
b. 
Platelets ≥ 100,000/mcL 
c. 
Hemoglobin ≥ 9 g/dL or ≥ 5.6 mmol/L (transfusion is allowed) 
d. 
Serum creatinine ≤ 1.5 x IULN OR creatinine clearance by Cockcroft-Gault ≥ 60 mL/min 
for patients with serum creatinine > 1.5 x IULN 
e. 
Serum total bilirubin ≤ 1.5 x IULN OR direct bilirubin ≤ IULN for patients with total 
bilirubin > 1.5 x IULN 
f. 
AST (SGOT) and ALT (SGPT) ≤ 3 x IULN 
 
9) Participants of childbearing age must use effective contraception: 
• Women of childbearing potential (WOCBP) must be using a highly effective method of 
contraception to avoid pregnancy throughout the study and for at least 24 weeks after the 
last dose of study drug to minimize the risk of pregnancy.   Prior to study enrollment, 
women of childbearing potential must be advised of the importance of avoiding pregnancy 
during trial participation and the potential risk factors for an unintentional 
pregnancy.  Refer to Appendix D for guidance on highly effective contraceptive methods. 
• WOCBP include any woman who has experienced menarche and who has not undergone 
successful surgical sterilization (hysterectomy, bilateral tubal ligation or oophorectomy) or 
who is not post-menopausal. Post-menopause is defined as: 
 

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• Amenorrhea that has lasted for ≥ 12 consecutive months without another cause, or 
• For women with irregular menstrual periods who are taking hormone replacement therapy 
(HRT), a documented serum follicle-stimulating hormone (FSH) level of greater than 35 
mIU/mL. 
• Males with female partners of childbearing potential must agree to use physician-approved 
contraceptive methods (e.g., abstinence, condoms, vasectomy) throughout the study and 
should avoid conceiving children for 24 weeks following the last dose of study drug. 
 
10) Ability of the patient to understand and willingness to sign an IRB approved written informed 
consent document 
 
11) Steroid dose equivalent to dexamethasone dose of ≤ 4mg daily at the time of starting adjuvant 
treatment 
 
12) Optune and temozolomide treatment start date will be at least 4 weeks but not more than 6 
weeks from the later of last dose of concomitant temozolomide or radiotherapy. Although 
Optune and temozolomide should be started simultaneously, it is not required as long as both 
are started within this time frame. 
 
4.2 
Exclusion Criteria 
 
1. Prior treatment with anti-angiogenic agents including bevacizumab. 
 
2. History of other malignancy that, in the primary oncologist’s estimation, has a higher risk of 
recurrence or death than the study-related cancer at the time of study participation. 
 
3. Prior treatment with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or anti-cytotoxic T-
lymphocyte-associated antigen-4 (CTLA-4) antibody (including ipilimumab or any other 
antibody or drug specifically targeting T-cell co-stimulation or checkpoint pathways). 
 
4. Progressive disease (according to RANO criteria). Advanced imaging is allowed to further 
investigate suspected pseudoprogression if deemed necessary. 
 
5. Actively participating in another clinical treatment trial intended to treat GBM. 
 
6. Multifocal gliomas defined as distinct tumors that do not have overlapping T2/FLAIR signal. 
 
7. Presence of leptomeningeal metastases. 
 
8. Implanted pacemaker, programmable shunts, defibrillator, deep brain stimulator, other 
implanted electronic devices in the brain, or documented clinically significant arrhythmias. 
 
9. Tumor is entirely located in the infra-tentorial region. 
 
10. History of hypersensitivity reactions or allergies to hydrogels and/or compounds of similar 
chemical or biologic composition to Temozolomide and Pembrolizumab.  

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11. Steroid dose equivalent to > 4 mg dexamethasone at the time of starting adjuvant therapy. 
 
12. History of immunodeficiency or is receiving any form of immunosuppressive therapy within 
7 days prior to the first dose of trial treatment (with the exception of daily dexamethasone ≤ 
4 mg). 
 
13. Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, 
uncontrolled hypertension, or psychiatric illness/social situations that would limit compliance 
with study requirements. 
 
14. History of active autoimmune disease requiring systemic treatment within the past 2 years 
(i.e. with use of disease modifying agents, corticosteroids, or immunosuppressive drugs). 
Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement 
therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic 
treatment. 
 
15. History of (non-infectious) pneumonitis that required steroids or current pneumonitis. 
 
16. Pregnant and/or breastfeeding. Patient must have a negative serum or urine pregnancy test 
within 72 hours of study entry. 
 
17. Females or males of childbearing potential who are unwilling or unable to use an acceptable 
method to avoid pregnancy for the entire study period and for at least 24 weeks after the last 
dose of study drug.  
 
18. Known active hepatitis B (e.g., HBsAg reactive) or hepatitis C (e.g., HCV RNA [qualitative] 
is detected) infection. 
 
19. Known history of active TB (bacillus tuberculosis). 
 
20. Known history of HIV (HIV 1/2 antibodies). 
 
4.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial. 
 
5. SUBJECT RECRUITMENT AND REGISTRATION PROCEDURES 
 
Potential subjects will be recruited to this study from the outpatient clinic after confirmation of 
tumor pathology when patients are seen to discuss diagnosis, prognosis and treatment options 
which may include participation in a clinical trial.  If a patient is a potential candidate and interested 
in more information about a specific trial, the Physician-Investigator and/or the research 
coordinator will discuss the trial further as part of the consent process.  All potential subjects will 
be seen by a study investigator and will be required to sign a written informed consent prior to 

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being registered on this protocol. Every effort will be made to answer questions raised by the 
patient and their family or advocate regarding the protocol and alternative therapies prior to asking 
the patient to sign the consent form.   Subjects will be registered after the completion of radiation 
and concomitant TMZ.  MGMT status is not required to sign consent but should be confirmed 
prior to study registration if feasible (indeterminate methylation status will be considered 
unmethylated).  Both men and women and members of all races and ethnic groups are eligible for 
this trial.   
 
5.1  Subject Registration in the University of Florida Cancer Center Database 
 
All study subjects will be registered through OnCore at the University of Florida.  Each subject 
will be identified with a unique patient number (UPN) for this study and by first, middle, and 
last initials.  If the subject has no middle initial, a dash will be used on the case report forms 
(CRFs).  All data will be recorded with this UPN on the appropriate CRFs. 
 
6. TREATMENT PLAN 
Patients with newly-diagnosed GBM who undergo maximal safe resection (biopsy alone is 
eligible) followed by chemoradiation consisting of concomitant TMZ 75mg/m2 daily and RT with 
minimal RT dose of 40gy will be eligible for this trial.  MGMT methylation status will be recorded.  
Four weeks (+7/-14 days) after completing chemoradiation, patients will undergo baseline 
standard of care MRI.  Four to six weeks after finishing chemoradiation, patients will start monthly 
cycles of adjuvant TMZ.  A minimum of 6 and maximum of 12 cycles of adjuvant TMZ will be 
given depending on tolerability and toxicity.   
Treatment with Optune will start at approximately the same time as the first cycle of adjuvant TMZ 
and continue until second disease progression or a maximum of 2 years. Urine specimens will be 
collected as well as peripheral blood mononuclear cells (PBMC) will be obtained and cryo-
preserved at time points specified.  No sooner than 3 weeks after starting Optune therapy, patients 
will begin open-label treatment with pembrolizumab 200mg IV every 3 weeks until first disease 
progression or unacceptable toxicities or 2 years, whichever comes first.   
At first progression, patients will be allowed to continue with Optune therapy combined with any 
other therapy, which may include pembrolizumab, per standard of care at the discretion of the 
treating physician.  Surgical resection or biopsy of first recurrent tumor for confirmation of 
recurrence is allowed within the protocol.  
For correlative studies, flash frozen tumor tissues, where available, will be used to prime dendritic 
cells.  Intratumoral PD-1 expression will also be determined by IHC using FFPE slides. Research 
blood will be drawn prior to starting adjuvant therapy and within approximately 1 week before the 
first dose of pembrolizumab. Subsequently research blood will be drawn prior to the second dose 
of pembrolizumab, and at approximately 2-, 4-, 6-, 12-, and 24-months (+/- 2 weeks) post-
pembrolizumab dosing. Urine samples will be obtained at the same time points as research blood. 
If there is evidence of progression, however, a final research blood draw and urine sample will be 
obtained within 30 (+/- 7) days of progression and no further research blood draw and urine 
specimen will be performed (unless the patient continues on Optune therapy to second progression 
as detailed in the paragraph above). Research blood will also be collected before resection or 

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biopsy, when possible. Mutation burden, when available, will be obtained from next gene 
sequencing analysis per standard of care.  
 
 
6.1 
Treatment with Optune 
 
Patients will undergo 24-months of planned treatment with Optune therapy. Therapy will be given 
as per standard of care (see Section 6.1.1 for recommended use of Optune). 3D mapping and 
placement maps of recurrent tumors will be completed by the treating physician or Novocure. All 
device support services (including patients’ and families’ education of device operation, tips about 
scalp shaving and array placement, downloading and processing of technical and compliance data, 
and troubleshooting device malfunction) will be provided by device support specialists employed 
by Novocure. The goal of treatment compliance for this study is wearing the system for an average 
of no less than 75% of the time over a 4-week period for as many months as possible. Compliance 
reports with Optune will be obtained by Novocure’s DSS per usual procedures. If a patient’s 
compliance is below 50% over the first and second 4-week periods consecutively from the start of 
treatment, the patient will be trained on the importance of compliance and any barriers to 
compliance will be addressed. If a patient’s compliance is still below 50% in the third 4-week 
period, the patient will be removed from study and that subject should be considered non-evaluable 
for survival analysis and should be replaced.  This subject however should remain evaluable for 
the toxicity and tolerability endpoints as per end of treatment requirement detailed in section 6.6. 
At the discretion of treating investigators, patients can have an additional treatment break during 
each 4 week period of no more than 4 days as needed for personal reasons as long as it is estimated 
that the overall compliance for any 4 week period does not drop below 75% because of the 
additional break. 
 
6.1.1 Recommendations for Use of Optune 
All patients will be required to shave their heads to initiate array placement and Optune 
therapy. Array placement will be performed based on the transducer array map calculated 
during treatment planning. Optune is programmed by Novocure to deliver 200 kHz TTFields 
in two sequential, perpendicular field directions at a maximal intensity of 707mARMS. There 
will be no adjustments made to the device by investigators or patients/caregivers. 
 
It is recommended that patients replace the transducer arrays 2-3 times per week with the help 
of a caregiver. At each array replacement, it is recommended that the patient’s scalp be re-
shaved and skin treated according to the guidelines in section 6.1.2. 
 
There will be no dose adjustments to the device for adverse events.  
 
6.1.2 Skin Care Guidelines 
 
If the skin beneath the transducer arrays is inflamed, it is recommended that a prescription 
strength steroid ointment (e.g. 3% hydrocortisone or 0.05-0.1% Clobetasol) be prescribed to 
the patient. The patient or caregiver should apply the ointment after removing the arrays and 
cleaning the scalp with baby oil and gentle soap. The ointment should be left on the scalp for 

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at least 30 minutes prior to washing the skin with a mild shampoo and applying a new set of 
arrays.  
 
At each array replacement, it is recommended that the new set of arrays be shifted by 
approximately 2 cm compared to the previous layout so that the array discs are placed between 
the areas of skin irritation. At the next array replacement, the arrays should be shifted back to 
their original location.  
If the dermis is breached (ulcers, open sores, punctate lesions, cuts, etc.), it is recommended 
that an antibiotic ointment (e.g. bactroban) be prescribed and used in place of the steroid 
ointment. 
 
6.1.3 Potential Adverse Events: Optune 
 
Treatment with the Optune is not expected to cause any serious side effects. However, it is 
possible that treatment may cause any of the following: 
 
• Local warmth and tingling “electric” sensation beneath the transducer array 
• Allergic reaction to the adhesive or the gel 
• Skin irritation or skin breakdown 
• Infection at the sites of electrode contact with the skin 
• Transducer array overheating leading to pain and/or local skin burns 
• Headache 
• Fatigue 
 
6.2 
Pembrolizumab Administration 
 
Pembrolizumab 200 mg will be given intravenously every 3 weeks (+/- 4 days) beginning no 
sooner than 3 weeks after the start of Optune. Pembrolizumab will be given intravenously over the 
course of approximately 30 minutes on an outpatient basis. For subjects who receive 
pembrolizumab alone after the completion of TMZ or due to TMZ intolerance, pembrolizumab 
infusions may be administered per the treatment plan if absolute neutrophil count (ANC) is ≥ 1.0 
x 109/L, and the platelet count is ≥ 50 x 109/L, and if it is determined by the treating physician that 
the cytopenia was unlikely to be related to pembrolizumab treatment. 
 
6.2.1 Premedication Administration of Pembrolizumab 
 
No premeditations are required, but antiemetics may be given as per institutional practice if 
needed.  
 
6.3 
Temozolomide Administration 
 
Patients will begin treatment with adjuvant TMZ at least 4 weeks but no more than 6 weeks from 
last dose of concomitant temozolomide or radiation therapy (the latter of the two).  A minimum of 
6 and maximum of 12 cycles of adjuvant TMZ will be given depending on tolerability and toxicity. 
 

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6.3.1 Adjuvant Temozolomide Treatment 
 
• Adjuvant Phase Cycle 1 (4-6 weeks after chemoradiation): Dosage in Cycle 1 will be 
150 mg/m2 PO daily for 5 consecutive days per 28 (+7) day cycle. 
 
• Cycle 2 (up to Cycle 12): At the start of Cycle 2, the dose of TMZ will be increased to 
200 mg/m2 PO daily for 5 consecutive days per 28 (+7) day cycle, if the CTC non-
hematologic toxicity for Cycle one is Grade ≤ 2 (except for alopecia, nausea and vomiting), 
absolute neutrophil count (ANC) is ≥ 1.5 x 109/L, and the platelet count is ≥ 100 x 109/L. 
The TMZ dose will remain at 200 mg/m2 PO daily for 5 consecutive days per 28 (+7) day 
cycle for each subsequent cycle except if toxicity occurs (see section 8.1). If the dose is not 
increased at Cycle 2 due to toxicity, escalation should not occur in subsequent cycles; 
however, it is appropriate to decrease to cycle 1 dose in cycles 2-12 if toxicity occurs. 
 
6.4 
Follow-Up Evaluations During The 12 Cycles of Adjuvant TMZ 
 
All patients will be seen before Cycle 1 of TMZ, before starting the pembrolizumab, and every 3 
weeks (+/-4 days) before each subsequent pembrolizumab dose at an outpatient clinic until they 
complete all 12 cycles of adjuvant TMZ or discontinue TMZ due to toxicity or first progression. 
Optune compliance reports will be collected remotely or in the clinic setting approximately every 
4 (+/- 1) weeks. Contiguous data will be sufficient for Optune compliance reporting, per SOC for 
the Optune Device.  
 
At each visit the following will be performed except otherwise specified: 
• Physical exam and performance status (KPS) 
• Blood exams  
o CBC with differential - within 3 days prior to starting each cycle of temozolomide 
o Complete Metabolic Panel - prior to each cycle of pembrolizumab and prior to 
starting each cycle of temozolomide (+/- 7 days) 
o PT/PTT, INR – for patients receiving relevant anti-coagulants 
o TSH, Free T4 – prior to the first infusion of pembrolizumab and then prior to every 
other pembrolizumab infusion thereafter 
• Study lab as specified 
• Steroid dose 
• Concomitant Medications 
• Record of Adverse Events 
• TTF compliance report (only every 4 +/- 1 weeks) 
 
An MRI will be performed every 2 months (+/- 7 days) following the baseline MRI until second 
progression (when study treatment will be terminated). In the case of clinical progression an 
unscheduled MRI will be obtained within 1 week of the investigator becoming aware of the clinical 
progression. Contrast agent type and dose will be kept constant for each patient between scans. 
Disease will be assessed as per iRANO criteria [64] [65] with allowance for potential immune 
mediated effects at first appearance. No additional MRIs will be required by the study after second 
progression. Medical follow-up will continue for 30 (+/- 7) days after treatment termination in 

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order to capture treatment related toxicities. After this visit, mortality will be assessed based on 
telephone interviews with the patients or the patients' caregivers every 3 months. 
 
6.5 
Evaluation After Adjuvant TMZ Until Treatment Termination 
 
After 12 cycles of adjuvant TMZ, patients will be seen and examined before every three 
pembrolizumab doses.  Pembrolizumab and Optune can continue up to 2 years. Optune compliance 
reports will be collected remotely or in the clinic setting every 4 (+/- 1) weeks. Brain MRI and 
quality of life assessment will be performed every 2 months (+/- 7 days) until study termination or 
second progression, whichever comes first. In case of clinical progression an MRI will be 
performed within a week of the treating physician being made aware. Contrast agent type and dose 
will be kept constant for each patient between scans. Disease will be assessed as per iRANO 
criteria [64] [65]with allowance for potential immune mediated effects at first appearance. 
 
At each visit the following will be performed except for otherwise noted: 
• Physical exam and performance status (KPS) 
• Blood exams  
o CBC with differential - within 3 days prior to starting each cycle of temozolomide 
o Complete Metabolic Panel - prior to each dose of pembrolizumab and prior to 
starting each cycle of temozolomide (+/- 7 days) 
o PT/PTT, INR – for patients receiving relevant anti-coagulants 
o TSH, Free T4 – prior to the first infusion of pembrolizumab and then prior to every 
other pembrolizumab infusion thereafter 
• Study lab as specified 
• Steroid dose 
• Concomitant Medications 
• Record of Adverse Events 
• TTF compliance report (every 4 +/-1 weeks) 
 
6.6 
Post Treatment Evaluations 
 
Treatment will continue according to the protocol until toxicity, second progression or 24 months 
(the earlier of the three). After treatment termination the patient will be followed every three 
months via phone call or collected from clinic notes for survival follow up until death or for 5 
years, whichever occurs first.  
 
Subjects will be evaluable for survival analysis if they have received Optune treatment, AND have 
received at least one dose of pembrolizumab, AND have received adjuvant temozolomide. 
Subjects that are not evaluable for survival analysis will be replaced.   
 
7. CORRELATIVE STUDIES 
 
7.1 
Blood Specimens 
 
7.1.1 Collection of Specimens 
 

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Sixty milliliters of blood will be collected into 6 green top tubes (with heparin) for isolation of 
PBMCs at the following time points: 
 
• No more than two weeks prior to starting adjuvant therapy. 
• No more than one week prior to the first dose of pembrolizumab. 
• No more than one week prior to the second dose of pembrolizumab and then approximately 
2-, 4-, 6-, 12-, and 24-months after the first dose of pembrolizumab. 
• At the end-of-treatment with Pembrolizumab the research blood draw will be obtained at 
the next scheduled clinic visit. Clinic visits after treatment concludes shall be scheduled 
per standard care. 
o If study treatment is ended due to disease progression or toxicity prior to the 24 
months study term, a final research blood draw will be obtained within 30 (+/- 7) 
days of progression and no further research blood draws will be performed (unless 
the patient continues on Optune therapy to second progression as detailed in section 
6). 
o If the study treatment is ended at 24 months as stipulated by the protocol, the end-
of-treatment sample will be obtained at the next SOC visit and at the time of 
progression.  
• In the event of surgical resection or biopsy (refer to section 7.2.1), research labs will be 
collected as close to the date of surgery as possible, but not more than two weeks prior to 
surgery. 
 
7.1.2 Handling of Specimens 
 
One 10 mL vial will be used for isolation of plasma via centrifugation for cytokine analysis 
and NMR analysis for metabolic signatures of immune activation. The remaining vials will be 
used for isolation of peripheral mononuclear cells (PBMCs) using Ficoll and cryopreserved 
until ready for analysis per standard protocol [66, 67]. For the PBMC isolated from 40ml of 
blood obtained prior to the start of adjuvant therapy, all will be used to isolate monocytes per 
standard protocol [67]. The isolated monocytes will be incubated with IL-4 and GM-CSF to 
produce dendritic cells (DC)[67], which will then be cryopreserved for analysis of tumor-
specific functional activity of peripheral blood immune cells. To determine the phenotype of 
peripheral blood immune cells, following the 4-week interval, cryopreserved PBMC will be 
thawed and stained with labeled antibodies to CD4, CD8, CD45, CCR7, CD27, CD28, and 
CD62, markers of T cell hypofunctionality (e.g. PD-1, CTLA-4, LAG-3, TIM3, FoxP3, and 
ICOS), as well as MDSC (e.g. CD11b, CD33, CD14, CD15, Lin, HLA-DR). A subset of our 
analysis will be a comparison of CD8+PD-1+LAG-3+ T cells between before and after starting 
Optune and before and after starting pembrolizumab as this cell population has been shown to 
mark tumor-specific CD8+ T cells [68]. Cells will be assessed by flow cytometry in the Preston 
Wells, Jr. Center for Brain Tumor Therapy or by single cell genomics analysis for a comparison 
between before and after starting Optune and before and after starting pembrolizumab. 
 
7.1.3 Transport of Specimens 
 
Blood samples collected should be transported to Dr. Rahman’s lab to be processed at ambient 
temperature immediately after collection and processed immediately upon arrival. If a delay in 

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transport or processing of greater than 1 hour is anticipated, samples must be stored on ice. 
Samples should be processed within 4 hours of collection. 
 
7.2 
Tumor Tissue Specimens 
 
7.2.1 Collection of Specimens 
 
Any flash frozen tissue (from either surgical resection or biopsy) available after 
histopathologic diagnosis of GBM, that will be collected for research purposes, will be 
obtained for priming of DC. Fixed and paraffin embedded samples will be obtained from 
pathology or research tissue banks for IHC.  
 
7.2.2 Handling of Specimens 
 
Tissue and PBMC cryopreservation are per standard protocol. FFPE samples will be used to 
test for PD-L1 IHC to be performed in Dr. Rahman’s lab or the ICBR core lab. Flash frozen 
tumor samples will be minced and lysed into tumor lysate or treated with RNA buffer for total 
RNA isolation for DC priming. Parts of tissue will also be subjected to genomics analysis of 
the tissue to study the tumor immune microenvironment and correlate these findings with 
changes in immune systems related to Optune and Optune plus pembrolizumab. 
 
7.2.3 Transport of Specimens 
 
FFPE samples will be transported at room temperature. Frozen samples will be transported on 
dry ice or in liquid nitrogen to Dr. Rahman’s lab.  
 
Contact persons: Alexandra Calinescu (Alexandra.Calinescu@neurosurgery.ufl.edu) or 
Nagheme Thomas (thomasn@ufl.edu) 
 
Frozen samples will be kept at-80oC until ready for processing.  
 
7.3 
Urine Specimens 
 
7.3.1 Collection of Specimens 
 
Approximately twenty milliliters of clean-catch urine will be collected into a sterile plastic cup  
prior to starting adjuvant therapy and within approximately 1 week before the first dose of 
pembrolizumab. Subsequently research urine will be collected prior to the second dose of 
pembrolizumab, and at approximately 2-, 4-, 6-, 12-, and 24-months (+/- 2 weeks) post-
pembrolizumab. If study treatment is terminated due to disease progression or toxicity prior to 
the 24 months study term, a final urine sample will be obtained within 30 (+/- 7) days of 
progression. 
 
7.3.2 Handling of Specimens 
 

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Urine samples will be stored at -80oC until analysis. Samples will be analyzed using NMR 
technique to detect metabolomic signatures of immune activation by comparing the pre-
adjuvant/Optune samples to the post-adjuvant/Optune, but pre-pembrolizumab samples.  
These samples will be compared to the post-pembrolizumab samples. 
 
7.3.3 Transport of Specimens 
 
Urine samples will be transported to the Rahman Lab on ice within 1 hour of collection. 
 
8. ADVERSE REACTIONS AND DOSE DELAYS/DOSE MODIFICATIONS 
 
8.1 
Potential Adverse Events: Temozolomide 
 
Treatment with TMZ commonly (>10%) causes the following adverse reactions: alopecia, fatigue, 
nausea, vomiting, headache, constipation, anorexia, convulsions, rash, hemiparesis, diarrhea, 
asthenia, fever, dizziness, coordination abnormal, viral infection, amnesia, and insomnia. 
 
Treatment with TMZ commonly (>10%) causes the following adverse reactions: lymphopenia, 
thrombocytopenia, neutropenia and leukopenia. 
 
Adverse events and complications associated with the underlying GBM disease process, which are 
unlikely but unknown if related to treatment with Optune together with adjuvant TMZ include the 
following adverse events: 
 
• Seizure, including Status Epilepticus 
• Neurological and functional decline 
• Headaches, nausea and/or vomiting 
• Death 
 
Table 1: Temozolomide Dose Levels for Adjuvant Treatment 
 
Dose Level 
Dose (mg/m2/day) 
Remarks 
–1 
100 
Reduction for prior toxicity 
0 
150 
Dose during Cycle 1 
1 
200 
Dose during Cycles 2-12 in absence 
of toxicity 
 
Table 2: Temozolomide Dose Reduction or Discontinuation During Adjuvant Treatment 
 
Toxicity 
Reduce TMZ by 1 Dose Levela Discontinue TMZ 

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Absolute Neutrophil Count 
<1.0 x 109/L 
See footnote b 
Platelet Count 
<50 x 109/L 
 
See footnote b 
CTC Non-hematological Toxicity 
(Except for alopecia, nausea, 
vomiting) 
 
CTC Grade 3-4 
 
See footnote b 
a: TMZ dose levels are listed in table 1. 
b: TMZ is to be discontinued if dose reduction to <100 mg/m2 is required or if the same Grade 
3 non-hematological toxicity (except for alopecia, nausea, vomiting) recurs after dose 
reduction. 
TMZ = temozolomide; CTC = Common Toxicity Criteria. 
 
8.2 
Potential Adverse Events: Pembrolizumab 
 
AEs associated with pembrolizumab exposure may represent an immunologic etiology. These 
immune-related AEs (irAEs) may occur shortly after the first dose or several months after the last 
dose of pembrolizumab treatment and may affect more than on body system simultaneously. 
Therefore, early recognition and initiation of treatment is critical to reduce complications.  Based 
on existing clinical study data, most irAEs were reversible and could be managed with 
interruptions of pembrolizumab, administration of corticosteroids and/or other supportive care. 
For suspected irAEs, ensure adequate evaluation to confirm etiology or exclude other causes. 
Additional procedures or tests such as bronchoscopy, endoscopy, skin biopsy may be included as 
part of the evaluation. Based on the severity of irAEs, withhold or permanently discontinue 
pembrolizumab and administer corticosteroids. Dose modification and toxicity management 
guidelines for irAEs associated with pembrolizumab are provided in the Table 3 below. 
 

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Table 3: Pembrolizumab Dose Reduction or Discontinuation  
 
General instructions: 
1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 weeks. 
2. For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to Grade 1 or 0 and 
corticosteroid has been tapered. Pembrolizumab should be permanently discontinued if AE does not resolve within 12 weeks of last dose or 
corticosteroids cannot be reduced to ≤10 mg prednisone or equivalent per day within 12 weeks.  
3. For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other immunosuppressive treatment 
should be initiated if irAEs cannot be controlled by corticosteroids. 
 
Immune-related 
AEs 
Toxicity grade or 
conditions 
(CTCAEv4.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies  
Monitor and follow-up  
Pneumonitis  
Grade 2 
Withhold  
• Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
• 
Monitor participants for signs and 
symptoms of pneumonitis 
• 
Evaluate participants with suspected 
pneumonitis with radiographic imaging and 
initiate corticosteroid treatment 
• 
Add prophylactic antibiotics for 
opportunistic infections 
Grade 3 or 4, or 
recurrent Grade 2 
Permanently 
discontinue 
Diarrhea / Colitis  Grade 2 or 3 
Withhold 
• Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
• 
Monitor participants for signs and symptoms 
of enterocolitis (ie, diarrhea, abdominal 
pain, blood or mucus in stool with or 
without fever) and of bowel perforation 
(ie, peritoneal signs and ileus). 
• 
Participants with ≥ Grade 2 diarrhea 
suspecting colitis should consider GI 
consultation and performing endoscopy to 
rule out colitis.  
• 
Participants with 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. 
Grade 4 
Permanently 
discontinue 
AST / ALT 
elevation or 
Grade 2 
Withhold 
• Administer corticosteroids (initial 
dose of 0.5- 1 mg/kg prednisone or 
equivalent) followed by taper 
• 
Monitor with liver function tests (consider 
weekly or more frequently until liver 

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Increased 
bilirubin 
Grade 3 or 4  
Permanently 
discontinue 
• Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
enzyme value returned to baseline or is 
stable 
Type 1 diabetes 
mellitus (T1DM) 
or 
Hyperglycemia 
 
Newly onset 
T1DM or  
Grade 3 or 4 
hyperglycemia 
associated with 
evidence of β-cell 
failure 
Withhold 
• Initiate insulin replacement 
therapy for participants with 
T1DM  
• Administer anti-hyperglycemic in 
participants with hyperglycemia  
 
• 
Monitor participants for hyperglycemia or 
other signs and symptoms of diabetes. 
Hypophysitis 
Grade 2 
Withhold 
• Administer corticosteroids and 
initiate hormonal replacements as 
clinically indicated.   
 
• 
Monitor for signs and symptoms of 
hypophysitis (including hypopituitarism and 
adrenal insufficiency)  
Grade 3 or 4  
Withhold or 
permanently 
discontinue1  
Hyperthyroidism  
Grade 2 
Continue  
• Treat with non-selective beta-
blockers (eg, propranolol) or 
thionamides as appropriate  
• 
Monitor for signs and symptoms of thyroid 
disorders.  
 
Grade 3 or 4  
Withhold or  
permanently 
discontinue1 
Hypothyroidism 
Grade 2-4 
Continue  
• Initiate thyroid replacement 
hormones (eg, levothyroxine or 
liothyroinine) per standard of care 
• 
Monitor for signs and symptoms of thyroid 
disorders.  
 
Nephritis  with 
Renal 
dysfunction 
Grade 2 or 3 
Increased blood 
creatinine 
Withhold  
• Administer corticosteroids 
(prednisone 1-2 mg/kg or 
equivalent) followed by taper. 
• 
Monitor changes of renal function 
 
Grade 4  
Increased blood 
creatinine 
Permanently 
discontinue 
Exfoliative 
Dermatologic 
Conditions 
Suspected SJS, 
TEN, or DRESS 
Withhold 
• 
Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
• 
Monitor participants for increase in lesion 
size or frequency during corticosteroid 
course.   
 
Resume in patients with complete or partial 
resolution (Grades 0 to 1) after corticosteroid 
taper. Permanently discontinue if no complete or 
partial resolution within 12 weeks of initiating 
Confirmed SJS, 
TEN, or DRESS 
Permanently 
discontinue 

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steroids or inability to reduce prednisone to 10 
mg per day or less (or equivalent) within 12 
weeks of initiating steroids. 
Myocarditis 
Grade 1  
Withhold 
• Based on severity of AE 
administer corticosteroids 
• 
Ensure adequate evaluation to confirm 
etiology and/or exclude other causes 
 
Grade 2, 3, or 4 
Permanently 
discontinue 
All other 
immune-related 
AEs 
Intolerable/ 
persistent Grade 2 
Withhold 
• Based on type and severity of AE 
administer corticosteroids  
• 
Ensure adequate evaluation to confirm 
etiology and/or exclude other causes 
 
Grade 3 
Withhold or 
discontinue based 
on the type of 
event.  Events that 
require 
discontinuation 
include and not 
limited to:  
Gullain-Barre 
Syndrome, 
encephalitis 
Grade 4 or 
recurrent Grade 3  
Permanently 
discontinue 
1. Withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating physician.   
NOTE:  
For participants with Grade 3 or 4 immune-related endocrinopathy where withhold of pembrolizumab is required, pembrolizumab may be resumed 
when AE resolves to ≤ Grade 2 and is controlled with hormonal replacement therapy or achieved metabolic control (in case of T1DM).   
 
 

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8.2.1 Supportive Care Guidelines for Infusion Reactions 
 
Pembrolizumab may cause severe or life-threatening reactions including severe 
hypersensitivity or anaphylaxis.  Signs and symptoms usually develop during or shortly after 
drug infusion and generally resolve completely within 24 hours of completion of infusion. 
 
The table below shows treatment guidelines for patients who experience an infusion reaction 
associated with administration of pembrolizumab. 
 
Table 4. Supportive Care Guidelines for Infusion Reactions 
 
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 (e.g., 
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 (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.  
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 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 (i.e., not 
rapidly responsive to 
symptomatic medication 
and/or brief interruption 
of infusion); recurrence 
of symptoms following 
initial improvement; 
hospitalization indicated 
for other clinical sequelae 
(e.g., renal impairment, 
pulmonary infiltrates)  
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 

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Grade 4:  
Life-threatening; pressor 
or ventilator support 
indicated  
Appropriate resuscitation equipment should be available in the room and a physician readily available 
during the period of drug administration.  
 
8.3 
Additional Potential Risks  
 
8.3.1 Disease progression 
 
Adverse events and complications associated with the underlying GBM disease process, which 
are unlikely but unknown if related to treatment with Optune together with adjuvant 
temozolomide and pembrolizumab include the following adverse events: 
 
• Seizure, including Status Epilepticus 
• Neurological and functional decline 
• Headaches, nausea and/or vomiting 
• Death 
 
8.3.2 Cerebral Edema 
 
Cerebral edema may be secondary to the disease process itself, the surgical procedure, necrosis 
from previous radiation, or inflammation due to immune infiltration of the brain or destruction 
of tumor cells.  Symptoms may include, but are not limited to, severe headache, confusion, 
lethargy, unresponsiveness, coma, or focal neurological deficits.  Patients will be monitored 
throughout the course of the study and those patients with any signs or symptoms of cerebral 
edema may need their steroid doses increased, treatment with an osmotic diuretic and/or an, 
anti-angiogenic, or surgical decompression as per standard practice.  Edema that fails to 
respond to aggressive therapy may lead to permanent neurological impairment.  The 
probability of this risk can be predicted to some degree based upon tumor size, location, pre-
operative neurological impairment, and post-operative course prior to starting study treatment. 
Patients will be monitored throughout the course of the study. 
 
Cerebral edema toxicity exception: 
 
NCI CTCAE criteria categorize all cerebral edema as grade 4. 
 
Cerebral edema, with or without mass effect, normally presents in glioblastoma patients as part 
of the disease process and can be exacerbated by standard of care chemotherapy and radiation. 
Furthermore, an effective anti-tumor immune response may involve inflammatory response 
and edema in infiltrative tumor cells. Therefore, cerebral edema, for purposes of this protocol, 
although ranked grade IV by NCI CTCAE criteria, will be graded with the full range of 
toxicities in order to accurately capture the AE: (1) Mild (2) Moderate (3) Severe (4) Life 
Threatening (5) Fatal.   
 
 

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8.3.3 Phlebotomy and/or Intravenous Catheter Insertion 
 
Drawing blood or inserting an intravenous catheter into an arm vein may result in bruising or 
swelling in the area of the insertion, bleeding at the site of the needle puncture, light 
headedness, fainting and very rarely, local infection, which may be severe.  
 
8.3.4 MRI 
 
The risks and/or discomforts associated with the performance of MRI include the anxiety 
produced from being in a tight, enclosed space (claustrophobia).  In addition, the machine 
operates using a large and powerful magnet.  The magnetism of the machine attracts certain 
metals: therefore, people with these metals in their bodies (specifically pacemakers, infusion 
pumps, metal aneurysm clips, metal prostheses, joints, rods or plates) will be excluded from 
the study. Patients will also be checked to make sure that they do not bring any metal objects 
into the MRI facility.  Dental fillings are less affected by the magnetic fields generated and are 
therefore permitted.  It will be asked that patients let the physicians conducting this study know 
of any metal in their bodies other than dental fillings. 
 
8.3.5 Allergic Reactions to Contrast Agents 
 
During the MRI, patients will be given the contrast agent gadolinium.  The agent is given 
routinely to obtain enhanced MRI scans of the brain.  The agent is administered through the 
vein and requires the placement of an IV catheter.  The catheter placement is similar to drawing 
blood except that the catheter remains in the vein during the time the agent is actively delivered.  
The risks of a blood draw and insertion of a catheter are similar.  There have been a few, rare 
cases of allergies to the agent used in MRI contrast enhanced scans. Patients with any known 
severe allergies to contrast agents will be excluded from the study.  Patients with mild allergies 
(i.e., rash only) will be pretreated with Tylenol and Benadryl prior to injection of the contrast 
agent. 
 
8.3.6 Privacy/Confidentiality 
 
Participation in research may result in a loss of privacy should there be a breach in 
confidentiality.  All data will be coded to protect the patient’s identity so that risks are 
minimized; however, records will be made available to individuals involved with the study, 
the clinical staff administering the study, and regulatory representatives such as the IRB, FDA, 
and/or OHRP and the study sponsor. Any publications resulting from this study will not use 
patient identifying data. 
 
8.4 
Women of Childbearing Potential  
 
WOCBP include any woman who has experienced menarche and who has not undergone 
successful surgical sterilization (hysterectomy, bilateral tubal ligation or oophorectomy) or who is 
not post-menopausal. Post-menopause is defined as: 
 
• Amenorrhea that has lasted for ≥ 12 consecutive months without another cause, or 

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• For women with irregular menstrual periods who are taking hormone replacement therapy 
(HRT), a documented serum follicle-stimulating hormone (FSH) level of greater than 35 
mIU/mL. 
• Males with female partners of childbearing potential must agree to use physician-approved 
contraceptive methods (e.g., abstinence, condoms, vasectomy) throughout the study and 
should avoid conceiving children for 24 weeks following the last dose of study drug. 
 
WOCBP must use highly effective contraceptive methods as described in Appendix D. 
 
9. REGULATORY AND REPORTING REQUIREMENTS 
 
9.1 
Federal Regulations and Good Clinical Practice 
 
The study will be conducted in accordance with the protocol, the Declaration of Helsinki, FDA 
Regulations 21 CFR parts 50, 54, 56 and 312 (as applicable), HHS Regulations 45 CFR part 46 
(as applicable), the International Conference on Harmonization guidelines for Good Clinical 
Practice (ICH E6), and applicable institutional, local and state requirements. All personnel 
involved in the conduct of this study have completed human subjects protection and any other 
applicable research training in accordance with local institutional requirements. 
 
9.2 
Institutional Review Board 
 
The PI will obtain Institutional Review Board (IRB) approval of the protocol and protocol related 
documents including consent forms, subject recruitment materials/process (e.g., advertisements), 
and any other written information to be provided to subjects, prior to initiating the study.  The 
study may be initiated only after the Principal Investigator has received written and dated approval 
from the IRB. Amendments to the protocol must originate with the Protocol PI and be approved 
by the IRB prior to implementation.   
 
The Principal Investigator must submit and obtain approval from the IRB for all subsequent 
protocol amendments and changes to the informed consent form in accordance with 21 CFR 56 
and local policy prior to implementation except where necessary to eliminate apparent immediate 
hazard to the subject.  If a change is made to eliminate an apparent immediate hazard, the PI must 
notify the IRB in accordance with local policy.    The investigator will follow the requirements of 
the local IRB for periodic reporting of study progress, reporting of serious adverse events, 
unanticipated problems, and protocol deviations or violations, safety monitoring reports and study 
completion.  Protocol exceptions must have approval from the IRB prior to implementation. 
 
The Principal Investigator must obtain protocol re-approval as required by the IRB, but not less 
than once per year. 
 
9.3 
Compliance with Laws and Regulations 
 
In addition to the regulations, guidance and requirements outlined in Section 9.1, all UF Health 
investigator-initiated trials, meeting the criteria of the FDAAA’s applicable clinical trials, will be 
registered with ClinicalTrials.gov by the PI or assigned designee.  All studies must be registered 

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no later than 21 days after enrollment of the first participant.  The PI or designee will maintain the 
responsibility of updating trials registered with ClinicalTrials.gov; per the FDA’s updating 
requirements of information must be updated at least every twelve months and the registry must 
be updated within thirty days of any changes in recruitment status or completion of the study. 
 
9.4 
Delegation of Investigator Responsibilities 
 
The Principal Investigator will ensure that all persons assisting with the study are adequately 
informed about the protocol, any amendments to the protocol, the study treatments, and their study-
related duties and functions. The Principal Investigator will maintain a list of Co-Investigators and 
other appropriately qualified persons to whom significant study-related duties have been 
delegated.  
 
Study personnel involved in study conduct will be qualified by education, training, and experience 
to perform their respective tasks. 
 
9.5 
Subject Information and Informed Consent 
 
Informed consent will be obtained and documented in accordance with 21 CFR 50 and the 
requirements of the IRB.  The informed consent form must be written in a manner that is 
understandable to the subject population. Prior to its use, the informed consent form must be 
approved by the IRB. 
 
The Principal Investigator or authorized key personnel will discuss with the potential subject the 
purpose of the research, methods, potential risks and benefits, subject concerns, and other study-
related matters. This discussion will occur in a location that ensures subject privacy and in a 
manner that minimizes the possibility of coercion. Appropriate accommodations will be made 
available for potential subjects who cannot read or understand English or are visually impaired. 
Potential subjects will have the opportunity to contact the Principal investigator or authorized key 
personnel with questions, and will be given as much time as needed to make an informed decision 
about participation in the study. 
 
Before conducting any study-specific procedures, the Principal Investigator must obtain written 
informed consent from the subject. The original informed consent form will be maintained with 
the subject’s study records, and a copy of the informed consent form will be provided to the 
subject. The Principal Investigator is responsible for asking the subject whether the subject wishes 
to notify his/her primary care physician about participation in the study. If the subject agrees to 
such notification, the Principal Investigator will inform the subject’s primary care physician about 
the subject’s participation in the clinical study. 
 
9.6 
Privacy/Confidentiality 
 
The Principal Investigator will ensure that subject privacy and confidentiality of the subject’s data 
will be maintained. To protect privacy, every reasonable effort will be made to prevent undue 
access to subjects during the course of the study.  Prospective participants will be consented in an 
exam room where it is just the research staff, the patient and his family, if desired. For all future 

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visits, interactions with research staff (study doctor and study coordinators) regarding research 
activities will take place in a private exam room. All research related interactions with the 
participant will be conducted by qualified research staff who are directly involved in the conduct 
of the research study. 
 
To protect confidentiality, subject files in paper format will be stored in secure cabinets under lock 
and key accessible only by the research staff. After agreeing to participate, some patient identifiers 
will be collected, used and/or recorded, including, but not limited to name, date of birth, telephone 
number, address, dates from health records and a unique patient number. This information may be 
kept in patient binders as well as recorded in the respective eCRF. Images collected will be as de-
identified as possible. Only approved study personnel and those included in the HIPAA 
Authorization will have access to identified, partially identified, and/or coded data. Data and 
specimens will be collected, stored and transported with consideration for subject privacy and 
confidentiality. Electronic records of subject data will be maintained in a password-protected 
computer.  Access to electronic databases will be limited to the Principal Investigator and key 
study personnel.  Data stored on portable memory devices will be de-identified.   
Upon completion of the study, research records will be archived and handled per local policy.  
Subject names or identifiers will not be used in reports, presentations at scientific meetings, or 
publications in scientific journals. 
 
9.7 
Protocol Amendments 
 
All protocol amendments (including consent form changes and changes to other protocol 
documents) must be initiated by the PI and be approved by the IRB prior to implementation.    IRB 
approval is not required for protocol changes that occur to protect the safety of a subject from an 
immediate hazard. However, the Principal Investigator must inform the IRB per local policy.  
Deviations from the approved protocol will be recorded and reported to the IRB per policy. 
 
9.8 
Case Report Forms 
 
The Principal Investigator and/or his/her designee will prepare and maintain adequate and accurate 
participant case histories with observations and data pertinent to the study.  Study specific Case 
Report Forms (CRFs) will document safety and treatment outcomes for safety monitoring and data 
analysis.  All study data will be entered into OnCore® via standardized CRFs in accordance with 
the CTMS study calendar, using single data entry with a secure access account.   
 
Electronic case report form (eCRF) will be utilized for this trial and must be completed for each 
included subject.  
 
9.9 
Record Retention 
 
Study documentation includes all eCRFs, data correction forms or queries, source documents, 
Sponsor-Investigator correspondence, monitoring logs/letters, and regulatory documents (e.g., 
protocol and amendments, IRB correspondence and approval, signed subject consent forms). 
 
Source documents include all recordings of observations or notations of clinical activities and all 

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reports and records necessary for the evaluation and reconstruction of the clinical research study. 
 
The Principal Investigator will maintain study-related records in compliance with local record 
retention policies. 
 
UF Health Cancer Center requires that all study documentation be maintained for at least 6 years 
from the date of final study publication.  No study records may be destroyed without prior 
authorization from UF. 
 
9.10 
Conflict of Interest 
 
The Principal Investigator and Sub-Investigators must comply with applicable federal, state, and 
local regulations regarding reporting and disclosure of conflict of interest. Conflicts of interest 
may arise from situations in which financial or other personal considerations have the potential to 
compromise or bias professional judgment and objectivity. Conflicts of interest include but are not 
limited to royalty or consulting fees, speaking honoraria, advisory board appointments, publicly-
traded or privately-held equities, stock options, intellectual property, and gifts.  Investigators and 
key personnel must provide financial disclosures prior to trial participation and as interests change 
and complete any applicable institutional conflict of interest documentation per local policy. 
 
9.11 
Adverse Event Definitions, Reporting and Documentation 
 
 
 
9.11.1 Adverse Events (AEs) 
 
Definition:  An AE is any untoward medical occurrence associated with use of a drug, whether 
or not considered drug related. For this protocol, the definition of AE also includes worsening 
of any pre-existing medical condition. An AE can therefore be any unfavorable and unintended 
or worsening sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of the study drug, whether or not related to use of the study drug. 
Abnormal laboratory findings without clinical significance (based on the PI’s judgment) 
should not be recorded as AEs. But laboratory value changes that require therapy or adjustment 
in prior therapy are considered adverse events. 
 
An adverse drug reaction is any adverse event caused by a drug.  A suspected adverse reaction 
means any adverse event for which there is a reasonable possibility that the drug caused the 
adverse event. For the purposes of reporting, "reasonable possibility" means there is evidence 
to suggest a causal relationship between the drug and the adverse event. 
 
Grading:  the descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for all toxicity reporting.  A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP website. 
 
9.11.2 Serious Adverse Event (SAE)   
 
Definition: any adverse event that results in any of the following outcomes: 
  
• Death or life-threatening event 

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• Inpatient hospitalization or prolongation of existing hospitalization  
• A persistent or significant disability/incapacity (i.e., a substantial disruption of a 
person’s ability to conduct normal life functions)  
• A congenital anomaly/birth defect  
• Any other experience which, based upon appropriate medical judgment, may 
jeopardize the subject and may require medical or surgical intervention to prevent 
one of the outcomes listed above  
 
Important adverse events that may not result in death, may not be life-threatening, or do not 
require hospitalization may be considered serious when, based upon appropriate medical 
judgment, they may acutely jeopardize the patient without immediate medical intervention to 
prevent one of the outcomes listed above. Serious may also include any other event that the 
investigator or company judges to be serious.  The PI is responsible for reporting serious 
adverse events to their local IRB according to their institutional requirements. These SAEs will 
be captured in the CRFs as described for regular AEs. 
 
9.11.3 Unexpected Adverse Experience 
 
Definition:  any adverse drug experience, the specificity or severity of which is not consistent 
with the current investigator brochure (or risk information, if an IB is not required or available).  
 
9.11.4 Unanticipated Problems 
 
Definition: 
   
• Unexpected event (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document; and (b) the characteristics 
of the subject population being studied; 
• Related or possibly related to participation in the research (“possibly related” mean 
there is a reasonable possibility that the incident, experience, or outcome may have 
been caused by the procedures involved in the research)’ and 
• Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
 
Some SAEs may meet the definition of an unanticipated problem. 
 
9.11.5 Noncompliance  
 
Definition: failure to follow any applicable regulation or institutional policies that govern 
human subject’s research or failure to follow the determinations of the IRB. Noncompliance 
may occur due to lack of knowledge or due to deliberate choice to ignore regulations, 
institutional policies, or determinations of the IRB. 
 

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Events meeting the definition of noncompliance should be reported to the IRB in accordance 
with local policy.  
 
9.11.6 Serious Noncompliance  
 
Definition: noncompliance that materially increases risks, that results in substantial harm to 
subjects or others, or that materially compromises the rights or welfare of participants.  The 
IRB will determine if noncompliance is serious and/or continuing. 
 
9.11.7 Protocol Exceptions  
 
Definition: A planned deviation from the approved protocol that are under the research team’s 
control. Exceptions apply only to a single participant or a singular situation.  
 
Local IRB pre-approval of all protocol exceptions must be obtained prior to the event.  
 
9.12 
Grading of an Adverse Event 
 
The descriptions and grading scales found in the revised NCI Common Toxicity Criteria (CTC) 
version 4.0 will be utilized for assessing severity of adverse events. If the toxicity is not 
characterized adequately by the NCI toxicity scale, the investigator will use the adjectives MILD, 
MODERATE, SEVERE, LIFE-THREATENING or DEATH to describe the maximum intensity 
of the adverse event. For purposes of consistency, these intensity grades are defined as follows: 
 
Table 5: Grading of Adverse Events 
MILD 
Grade 1 
Asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
MODERATE 
Grade 2 
Minimal, local or noninvasive intervention indicated; 
limiting age-appropriate instrumental ADL. 
SEVERE 
Grade 3 
Severe or medically significant but not immediately life-
threatening; hospitalization or prolongation of 
hospitalization indicated; disabling; limiting self-care 
ADL. 
LIFE-
THREATENING 
Grade 4 
Urgent indication needed. 
DEATH 
Grade 5 
Death related to AE. 
9.13 
Determination of Causality of Adverse Events 
 
The relationship of the adverse event to the study treatment must be specified using the following 
definitions: 

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Table 6: Relationship of Adverse Event to the Study Treatment 
 
None: 
The event is clearly related to an event that may be due to environmental or 
accidental occurrence or other factors such as the subject’s clinical state, 
therapeutic interventions, or concomitant drugs administered to the subject. 
 
Unlikely 
The event is most likely produced by other factors such as the subject’s clinical 
condition, therapeutic interventions, or concomitant drugs administered to the 
subject, and does not follow a known response pattern to the study drug or device. 
 
 
 
Possible 
The event follows a reasonable temporal sequence from the time of drug 
administration or use of device, and/or follows a known response pattern to the 
study drug or device, but could have been produced by other factors such as the 
subject's clinical condition, therapeutic interventions, or concomitant drugs 
administered to the subject. 
 
 
Probable 
The event follows a reasonable temporal sequence from the time of drug 
administration or use of device, and follows a known response pattern to the study 
drug or device, and cannot be reasonably explained by other factors such as the 
subject's clinical condition, therapeutic interventions, or concomitant drugs 
administered to the subject. 
 
 
 
Definite 
The event follows a reasonable temporal sequence from the time of drug 
administration or use of device, and follows a known response pattern to the study 
drug or device, and cannot be reasonably explained by other factors such as the 
subject's clinical condition, therapeutic interventions, or concomitant drugs 
administered to the subject, and either occurs immediately following study drug 
administration or use of device or improves on stopping the study drug or device, 
or reappears on repeat exposure. 
 
9.14 
Routine Adverse Event Reporting 
 
All adverse events (as required by this protocol) must be reported in the source documentation and 
CRFs with appropriate information, including severity and rating of causality to the study 
drug/treatment. Adequate source documentation must be available to characterize the severity, 
duration and causality of each reported adverse event.  For purposes of this protocol, The adverse 
event-reporting period will begin immediately following initiation of treatment, with the adjuvant 
treatment with TMZ and the Optune device, and end at least 30-days following last study treatment 
(Pembrolizumab dose, Temozolomide dose, or wearing Optune, whichever comes last).  Any 
SAEs will be followed until stabilization. 
 
9.15 
Unanticipated Adverse Device Effect Event (UADE) Reporting 
 
Any potential unanticipated adverse device effect (UADE) will be reported to the local IRB and 
DISC per local reporting policy and FDA, as applicable.  
 
9.16 
Eliciting Adverse Event Information 
 

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The investigator is to report all directly observed adverse events and all adverse events 
spontaneously reported by the trial patient using concise medical terminology.  In addition, each 
trial patient will be questioned about adverse events at each clinic visit following initiation of 
treatment.  
 
9.17 
Adverse Event Reporting Period 
 
The adverse event-reporting period will begin immediately following initiation of treatment, with 
the adjuvant treatment with TMZ and the Optune device, and end at least 30-days following last 
study treatment (Pembrolizumab dose, Temozolomide dose, or wearing Optune, whichever comes 
last).  All adverse events that occur in trial patients during the adverse event reporting period must 
be reported on the CRFs, whether or not the event is considered study treatment-related.  In 
addition, any known untoward event that occurs beyond the adverse event-reporting period that 
the investigator assesses as possibly related to the investigational medication/product should also 
be reported as an adverse event. 
 
9.18 
Follow-up of Unresolved Adverse Events 
 
Adverse events will be tracked for 30 days following the last study treatment (Pembrolizumab 
dose, Temozolomide dose, or wearing Optune, whichever comes last). Events continuing at that 
time will be notes as such.  
 
9.19 
Adverse Event Reporting 
 
All serious and unexpected adverse drug reactions must be reported to Merck Global Safety (if 
attributable to pembrolizumab) and FDA (as applicable).  Serious adverse events will be reported 
to the IRB and DISC per local policy.  Serious, unexpected and related SAEs will be tracked for 
90 days after last following last study treatment (Pembrolizumab dose, Temozolomide dose, or 
wearing Optune, whichever comes last). 
 
10. STATISTICAL CONSIDERATIONS:   
 
10.1 
Primary Endpoint 
 
Our primary endpoint is progression-free survival time from enrollment to progression or death or 
censoring, whichever occurs first, with the goal of determining whether the triple combination 
treatment increases PFS in newly diagnosed GBM patients when compared to TTFields+TMZ 
historical control patients from the EF-14 study. We will use  one-sample log-rank test to compare 
PFS between  the triple combination arm relative to the historical control arm. 
 
10.2 
Secondary endpoints     
 
We are proposing 3 secondary endpoints: 
 
1. Toxicity and tolerability of the triple combination treatment in newly diagnosed GBM 
patients. 
 
2. Overall survival time from enrollment to death or censoring, whichever occurs first() and 
radiographic response (RR) at 6, 12, 18 and 24 months of the triple combination in newly 

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diagnosed GBM, as compared to the historical control arm. 
 
3. Augmentation of TTFields-initiated glioma-specific immune reaction by pembrolizumab. 
 
We will estimate proportions and 95% confidence intervals for patients in the triple combination 
arm who experience toxicities and other types of AEs and SAEs. We will use the log-rank test to 
compare OS between the triple combination arm relative to the historical control arm. We will use 
one-sample proportion test to compare RR between the triple combination arm and historical 
control arm. We will use mixed effect regression to assess changes in response variables related 
to glioma-specific immune reaction before, during, and after treatment with pembrolizumab. 
 
10.3 
Sample Size Considerations 
 
To determine if the proposed sample size of 24 patients enrolled in the triple combination arm will 
allow us to detect a clinically relevant improvement in median PFS relative to the median PFS of 
6.7 months observed in the historical control arm, we assumed an accrual period of 12 months, an 
accrual rate of 2 patients per month, an additional 18 months of follow-up after the end of accrual, 
and proportional hazards. After confirming that the Weibull distribution could reasonably be used 
to characterize PFS times in the historical control arm, we estimated the Weibull shape parameter 
k from the historical control PFS curve. The shape parameter k determines if the hazard rate 
underlying a survival curve is accelerating over time (k>1), constant over time (k=1; identical to 
exponential survival), or decelerating over time (k<1). Based on a shape parameter estimate of 
k=0.88 with empirical 95% confidence interval (0.82,0.95) obtained via simulation of the historical 
control data, our proposed sample size of 24 patients in the triple combination arm should allow 
us to detect in improvement in PFS of 6 to 8 months with 80% power and a 1-sided significance 
level of 0.05 (detectable effect size methodology from Wu and Xiong, 2014 [69]). 
 
10.4 
Data Analysis Considerations (Protocol v10.1) 
 
Dr. David Tran, sub-Investigator at USC, will assist with secondary analysis of coded clinical data 
for primary and secondary endpoints.  A coded limited data set will be shared for purposes of data 
analysis and a data use agreement (DUA) will be included as part of the statement of work. Data 
will be stored in UF Box and Dr. Tran and his designee will be provided access via UF institutional 
procedures.  The LDS will be transferred to USC and will be stored on secure, duallyauthenticated 
USC servers with limited access only to Dr. Tran and his designees. Analyzed data files will also 
be password protected and stored on password protected computers. 
 
 
Additionally, Dr. Tran will perform correlative studies which include expression analysis of 
peripheral blood mononuclear cells (PBMCs) and tumor samples to determine if correlations in 
expression of key gene pathways with the clinical outcome of enrolled subjects with newly 
diagnosed GBM receiving the study treatment of adjuvant temozolomide + TTFields + 
pembrolizumab.  PBMCs and tumor samples will include the subject’s study ID, sample type and 
timepoint and date of collection.  A corresponding coded limited data set that includes subject ID, 
dates associated with the individual, clinical data/survival data, treatment history and detailed 
response data will be shared with Dr. Tran in order to accurately identify and characterize 
signatures of response. We will treat survival in the 2THETOP data as a continuous variable and 

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develop computational models that incorporate all key clinical and molecular characteristics to 
define response signatures that are also continuous with correlation with survival. We plan to apply 
novel computational bioinformatics to identify cytotoxic T lymphocyte (CTL) clones that are 
shared between the tumor microenvironment (TME) and the periphery prior to treatment and at 
the time of radiographic changes and between pathologically proven immune changes and true 
recurrence. The goal is to identify T cell clones that were expanded after treatment and capable of 
infiltrating the TME to induce productive anti-tumor immunity. This information will help 
determine if immune resistance is a function of changing of the “guards” or changing in the TME’s 
immunosuppressive functions. Each TCR clone will be paired with its expression profile to allow 
for the identification of the master regulatory subnetwork specific in these TME access-enabled 
tumor-specific CTL clones as compared to those that were expanded in the periphery but failed to 
reach the TME. Next, we plan to answer the following questions: 1) What defines the systemic 
signal created by study treatment? 2) What systemic signals distinguish objective responders from 
non-responders? and 3) What systemic signals may prevent non-responders from responding?  For 
example, in certain non-responders, is it because their immune system also activates an alternate 
immune checkpoint (e.g., LAG3, CTLA4, IDO1, TGIT etc.) in addition to PD-1/PD-L1? and if 
so, will using a combination of checkpoint inhibitors be more effective? The answers to these 
questions will help us develop a more robust signature that can predict response and guide 
subsequent TTFields-based combination therapy. Clinical data will be stored in UF Box and Dr. 
Tran and his designee will be provided access via UF institutional procedures.  Sequencing data 
will be raw RNAseq and DNA sequences in FASTQ format.  The raw sequencing data from all 
correlative studies for 2THETOP are stored in UF HiPerGator.  UF will initiate the transfer to USC 
using Globus (which is a highly secure and fast transfer system frequently used in high data content 
transfer). Sequencing and associated clinical data will be stored on secure dually-authenticated 
USC supercomputer and servers with limited access to only Dr. Tran and his designees. Analyzed 
data files will also be password protected and stored on password protected computers. 
 
 
 
 

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11. STUDY CALENDAR 
 
Screening 
Week 0 
(TMZ/ 
Optune 
Cycle 
1) 
Week 4 
(TMZ/ 
Optune 
Cycle 
2, 
Pembro 
Dose 1) 
Week 7 
(Pembro 
Dose 2) 
Week 8 & 
every 4 weeks 
on-treatment 
management 
(TMZ Cycles 3-
12) 
Week 10 & 
every 3 weeks 
on-treatment 
management 
(Pembro Dose 
3 and beyond)  
Post TMZ 
Treatment 
follow-up 
Post-
Pembro 
Treatment 
follow-up 
Post 
treatment 
termination 
Informed Consent 
  X1 
 
 
 
 
 
 
 
 
Medical History  
   X12 
 
 
 
 
 
 
 
 
Pregnancy Test 
   X17 
 
 
 
 
 
 
 
 
PBMC & Urine 
Specimen 
   X18 
 
 
X18 
 
 
 
  X19    
 
 
 
 
 
 
 
 
 
 
 
Physical Exam, KPS 
X8 
 
X8 
X8 
 
X8 
X8 
X8 
 
Tumor Tissue 
   X21 
 
 
 
 
 
 
X22 
 
PT/PTT, INR 
 
X23 
X23 
 
X23 
 
X23 
 
 
CBC with Differential 
X 
X9 
 X9 
 
X9 
 
X15 
X 
 
CMP 
X 
X10 
 X10 
X10 
X10 
X10 
X15 
     X 
 
TSH/Free T4 
X 
 
 X11 
X11 
 
X11 
X15 
     X 
 
MRI 
 X2 
 
 
 
 X13 
 
X13, 20 
 
 
 
 
 
 
 
 
 
 
 
 
Temozolomide Cycle  
 
 X3 
    X4 
 
   X4 
 
 
 
 
Pembrolizumab 
 
 
    X5 
X5 
 
X5 
X5 
 
 
Optune 
 
 X6 
    X6 
 
   X6 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Optune Compliance  
 
 
    X6 
 
 
 
 
    X 
 
AE Assessment 
 X7 
   X16 
 X16 
 
X16 
 
 
    X 
 
Concomitant 
Medications 
X 
X 
   X 
  X 
  X 
X 
 
    X 
 
Survival Contact 
 
 
 
 
 
 
 
 
X14 

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1. No study-specific procedures are to be performed prior to obtaining informed consent.  However, assessments performed according 
to SOC prior to consent may be used to fulfill the screening requirement.  Study treatment should start no later than 6 weeks from 
last dose of concomitant Temozolomide or radiation therapy (the latter of the two). 
2. Patients will undergo SOC brain MRI scans with RANO disease/response evaluation at screening, 4 weeks (+7/-14 days) after end 
of chemoradiation.   
3. Patients will begin treatment with temozolomide at 4 weeks (+14 days) from end of radiotherapy, week 0.  Cycle 1 will be dosed at 
150mg/m2 daily for 5 consecutive days of a 28-day cycle. 
4. Patients will begin treatment with temozolomide Cycle 2 and subsequent cycles every 4 weeks (+7 days) at 200mg/m2 PO daily for 
5 consecutive days, unless toxicity occurs.  See 6.3.1 for dose escalation parameters. 
5. Pembrolizumab will be given every 3 weeks (+/- 4 days) beginning no sooner than 3 weeks from the start of Optune. For subjects 
who receive pembrolizumab alone after the completion of TMZ or due to TMZ intolerance, pembrolizumab infusions may be 
administered per the treatment plan if absolute neutrophil count (ANC) is ≥ 1.0 x 109/L, and the platelet count is ≥ 50 x 109/L, and if 
it is determined by the treating physician that the cytopenia was unlikely to be related to pembrolizumab treatment. 
6. Optune treatment will begin at Week 0 (+7 days) and will be continuous throughout study.  Compliance documentation will be 
obtained every 4 weeks (+/- 7 days). 
7. The adverse event-reporting period will begin immediately following initiation of treatment with the adjuvant treatment with TMZ 
and the Optune device. 
8. Physical exam and KPS will be performed prior to the first and second dose of pembrolizumab, and every 3 weeks (+/- 4 days) to 
coincide with each subsequent pembrolizumab dose while on TMZ adjuvant therapy, then every three pembrolizumab dose 
thereafter. Neurological status will be included as part of the assessment. 
9. CBC with Differential will be performed within 3 days prior to starting each cycle of temozolomide.  
10. CMP will be performed prior to each cycle of pembrolizumab and prior to starting each cycle of temozolomide (+/- 7 days). When 
temozolomide and pembrolizumab are given within 3 days of each other, only one set of CMP will be done for both drugs. 
11. TSH/Free T4 will be performed prior to the first infusion of pembrolizumab and then prior to every other pembrolizumab infusion 
thereafter. 
12. Medical history may be performed at any time prior to registration. 
13. Patients will undergo SOC brain MRI scans with iRANO response evaluation every 2 months (+/- 7 days) until second progression. 
14. All patients will have their survival status documented every 3 months (+/- 1 month) for up to 5 years or death, whichever occurs 
first. Survival information can be obtained via telephone or from clinic notes. 

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15. If study treatment is ended due to disease progression or toxicity prior to the 24 months study term, a final research blood draw will 
be obtained within 30 (+/- 7) days of progression and no further research blood draws will be performed. 
16. The AE reporting period will be continuous throughout the study, ending at least 30-days following last study treatment 
(Pembrolizumab dose, Temozolomide dose, or wearing Optune, whichever comes last).    
17. Either serum or urine testing accepted. 
18. Research blood draws and urine samples will be obtained prior to start of study intervention, prior to first and second dose of 
pembrolizumab (-14 days), 2-, 4-, 6-, 12-, and 24-months after the first dose of pembrolizumab (-7 days each dose). See section 
7.1.1. 
19. A final peripheral blood mono-nuclear cells will be drawn and urine specimen will be collected after end of study treatment see 
Section 7.1.1  
20. In the case of clinical progression, an MRI will be obtained within 7 days of the treating physician becoming aware. 
21. Verification of tissue availability and location needs to be determined during screening so that it can be retrieved at a later time. 
22. Collection of recurrent tissue and research blood if the patient has a resection or biopsy. 
23. For patients receiving relevant anti-coagulants only 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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12. DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
following schedule:   
 
Table 7: Data Submission Schedule 
 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
Registration Form 
Eligibility Form 
On-Study Form 
 
Prior to starting treatment 
Treatment Summary Form for TTFields 
Every 4 weeks until completion of treatment 
Treatment Summary Form for Pembrolizumab Every 3 weeks while patient is on cycle 
Treatment Summary Form for Temozolomide 
Every 4 weeks while patient is on cycle 
MRI Form 
Baseline and every 2 months thereafter until 
completion of treatment 
KPS Form 
Physical Exam Form 
Lab result 
 
Per Study Calendar 
Adverse Events Form 
As per Section 9.0 
End of Treatment Form 
30 days after completion of treatment. 
Survival Information 
Every 3 months after completion of study 
therapy.  
 
13. RESPONSE EVALUATION 
 
For the purposes of this study, patients should be re-evaluated for response every 2 months +/- 7 
Days. In addition to a baseline scan, confirmatory scans should also be obtained 2 months +/- 7 
days following initial documentation of objective response.  If a patient develops symptoms that 
are potentially indicative of disease progression, scans may be done sooner than every 8 weeks as 
per standard practice discretion. 
 
Response and progression will be evaluated in this study using the updated response assessment 
criteria for high-grade gliomas: Response Assessment in Neuro-Oncology (RANO) [65] prior to 
pembrolizumab and Immunotherapy RANO (iRANO) working group guidelines once 
pembrolizumab has started [64] with minor modifications.   
 
The goal of treatment compliance for this study is wearing the system for an average of no less 
than 75% of the time over a 4-week period for as many months as possible. Compliance reports 
with Optune will be obtained by Novocure’s DSS per usual procedures. If a patient’s compliance 
is below 50% over the first and second 4-week periods consecutively from the start of treatment, 
the patient will be trained on the importance of compliance and any barriers to compliance will be 
addressed. If a patient’s compliance is still below 50% in the third 4-week period, the patient will 
be removed from study and that subject should be considered non-evaluable for survival analysis 

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and should be replaced.  This subject however should remain evaluable for the toxicity and 
tolerability endpoints as per end of treatment requirement detailed in section 6.6.  
 
13.1 
Criteria for Determining First Progression Depending on Time from Initial 
Chemoradiotherapy 
 
Table 8: RANO and iRANO Criteria for Determining First Progression 
 
First Progression 
Definition 
Progressive disease < 12 weeks 
after completion of 
chemoradiotherapy 
 
Progression can only be defined using diagnostic imaging if 
there is new enhancement outside of the radiation field 
(beyond the high-dose region or 80% isodose line) or if there 
is unequivocal evidence of viable tumor on histopathologic 
sampling (e.g., solid tumor areas [i.e., > 70% tumor cell 
nuclei in areas], high or progressive increase in MIB-1 
proliferation index compared with prior biopsy, or evidence 
for histologic progression or increased anaplasia in tumor). 
Note: Given the difficulty of differentiating true progression 
from pseudoprogression, clinical decline alone, in the 
absence of radiographic or histologic confirmation of 
progression, will not be sufficient for definition of 
progressive disease in the first 12 weeks after completion of 
concurrent chemoradiotherapy. 
Progressive disease ≥ 12 weeks 
after chemoradiotherapy 
completion  
 
1. New measurable contrast-enhancing lesion on decreasing, 
stable, or increasing doses of corticosteroids.  
2. Increase by ≥ 25% in the sum of the products of 
perpendicular diameters between the first postradiotherapy 
scan, or a subsequent scan with smaller tumor size, and the 
scan at 12 weeks or later on stable or increasing doses of 
corticosteroids.  
3. Clinical deterioration not attributable to concurrent 
medication or comorbid conditions is sufficient to declare 
progression on current treatment but not for entry onto a 
clinical trial for recurrence.  
4. For patients receiving antiangiogenic therapy, significant 
increase in T2/FLAIR nonenhancing lesion may also be 
considered progressive disease. The increased T2/FLAIR 
must have occurred with the patient on stable or increasing 
doses of corticosteroids compared with baseline scan or 
best response after initiation of therapy and not be a result 
of comorbid events (e.g., effects of radiation therapy, 
demyelination, ischemic injury, infection, seizures, 
postoperative changes, or other treatment effects). 

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Note: RANO guidelines will be applied prior to first pembrolizumab infusion. After 
pembrolizumab treatment has been initiated, iRANO will be applied as described in Sections 
13.4 and 13.5 
 
13.2 
Disease Parameters 
 
Measurable disease:  Bi-dimensionally measurable lesions with clearly defined margins 
by MRI scan of ≥ 10 mm.  All tumor measurements must be recorded in millimeters (or 
decimal fractions of centimeters).   
 
Non-measurable or evaluable disease:  Uni-dimensionally measurable lesions or lesions 
with margins not clearly defined such as areas of T2/FLAIR signal abnormality or poorly 
defined enhancing abnormality.  
 
Note: For cystic lesions, the only measurable part is any enhancement area around the cyst 
that is clearly defined and bi-dimensionally measurable. The cyst itself should not be 
considered measurable or non-measurable disease. 
 
Target lesions: All measurable lesions that are seen at baseline MRI. Target lesions should 
be selected on the basis of their size (lesions with the longest diameter), 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 itself to reproducible 
measurement in which circumstance the next largest lesion, which can be measured 
reproducibly should be selected.  When there are too many measurable lesions, choose the 
largest 3 lesions as target lesions to follow.  The other measurable lesions should be 
considered evaluable for the purpose of objective status determination. 
 
Non-target lesions:  All non-measurable lesions should be identified as non-target lesions 
and should also be recorded at baseline.  Measurements of these lesions are not required, 
but the presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow-up.  
 
13.3 
Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler.  All 
baseline MRI evaluations should be performed as closely as possible and prior to 
registration. An MRI should be collected and evaluated after any surgical procedure 
(surgical resection/debulking or biopsy).   
    
Clinical lesions:  Clinical lesions will only be considered measurable on brain MRI when 
they are ≥ 10 mm in bi-dimensional diameters as assessed using a ruler. 
 
Histology:  This technique can be used to differentiate between partial responses (PR) and 
complete responses (CR) in rare cases when biopsy or surgical resection of a measurable 
lesion is clinically indicated.  
 

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Perfusion/CBV: This advanced brain MRI technique can be used as an adjunct test to 
determine treatment response or disease status.  However, it should not be used as the 
primary or sole method to determine response or disease status.  
 
Brain FDG-PET or amino-acid PET coupled with head CT or brain MRI: This 
advanced metabolic imaging technique can be used as an adjunct test to determine response 
or disease status. However, it should be used as the primary or sole method of determining 
response or disease status. 
 
13.4 
Criteria for Immunotherapy Response Assessment in Neuro-Oncology Incorporating 
MRI and Clinical Factors (Adapted from [64]) with modifications 
 
The iRANO criteria integrated into the existing RANO criteria for malignant gliomas by providing 
recommendations for the interpretation of progressive imaging changes.  Specifically, iRANO 
recommends confirmation of disease progression on follow-up imaging 2-3 months after initial 
radiographic progression if there is no new or substantially worsened neurological deficits that are 
not due to comorbid events or concurrent medications, and it is 6 months or less from starting 
immunotherapy.  If follow-up imaging confirms disease progression, the date of actual progression 
should be backdated to the date of initial radiographic progression.  The appearance of new lesions 
6 months or less from the initiation of immunotherapy alone does not define progressive disease.  
In cases of equivocal findings, biopsy for definitive diagnosis per clinical judgment is allowed in 
this protocol.  
 
For progressive imaging changes that occur more than 6 months from starting immunotherapy and 
if there is no new or substantially worsened neurological deficits that are not due to comorbid 
events or concurrent medications, and adjunct imaging tests such as perfusion/CBV and/or brain 
FDG-PET and/or amino-acid PET suggest a predominant treatment-induced effect, study 
treatment may continue and confirmation of disease progression status should be performed on 
follow-up imaging 2-3 months after initial radiographic progression. If follow-up imaging 
confirms disease progression, the date of actual progression should be backdated to the date of 
initial radiographic progression.    
 
In the event of surgical intervention for clinical reasons of a radiographically suspicious lesionand 
then subsequent surgical pathology demonstrates treatment related changes with no obvious 
progression of tumor, the subject will be deemed not progressed and allowed to resume study 
treatment as assigned prior to the surgery at a time deemed safe by the treating physician, but no 
later than 8 weeks from the surgery. 
 
13.4.1 Complete Response 
 
Disappearance of all enhancing disease for ≥ 4 weeks; no new lesions; stable or improved 
T2/FLAIR; no more than physiological steroids; clinically stable or improved. 
 
13.4.2 Partial Response 
 
Decrease of ≥50% compared with baseline in the sum of products of perpendicular diameters 
of all target lesions that are sustained for at least 4 weeks; no new measurable lesions; stable 
or improved T2/FLAIR; stable or decreased steroid dose; clinically stable or improved. 

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13.4.3 Stable Disease 
 
Does not quality for complete response, partial response, or progressive disease; no new 
lesions; stable or improved T2/FLAIR; stable or decreased steroid dose; clinically stable or 
improved. 
 
13.4.4 Progressive Disease 
 
At least a 25% increase in the sum of products of perpendicular diameters of at least 1 target 
lesion, taking as reference the smallest sum of products of perpendicular diameters on study 
(this includes the baseline sum if that is the smallest on study). The absolute increase in any 
dimension must be at least 5mm when calculating the products of perpendicular diameters.; or 
new measurable lesions; or substantial worsened T2/FLAIR; or substantial clinical decline that 
is a direct cause of the tumor and cannot be attributable to a non-tumor cause. 
 
13.5 
Modified iRANO Criteria 
 
Table 9: Key Considerations for modified iRANO 
 
a. A repeat scan is needed to confirm radiographic progressive disease for patients without 
significant decline if ≤ 6 months after the start of immunotherapy. 
b. The minimum time interval for confirmation of disease progression for patients without 
significant decline is ≥ 2-3 months per iRANO. 
c. Further immunotherapy treatment is allowed ≤ 6 months after start of immune therapy after initial 
radiographic progressive disease (if clinically stable) pending disease progression confirmation. 
d. A new measurable lesion defines progressive disease if occurring > 6 months after the start of 
immunotherapy, unless adjunct imaging is consistent with predominant treatment effects and 
there are no worsened neurological deficits that are not due to comorbid events or concurrent 
medications. 
 
13.6 
Response Evaluation after a Complete Resection 
 
A complete resection will be defined as contiguous contrast enhancement < 1cm in 2 perpendicular 
measurements in each of 2 perpendicular planes (i.e., axial and coronal).  Because neither the 
RECIST [70] nor MacDonald [71] criteria are completely appropriate for patients with minimal 
residual disease, a modified version of these criteria will be used as outlined below. 
 
13.6.1 Complete Response 
 
Complete disappearance of enhancing tumor on consecutive CT or MRI images at least 1 
month apart, and neurologically stable or improved and at the same or a lower steroid dose.  
To be assigned a status of “Complete Response” as a best overall response, changes in tumor 
measurements must be confirmed by repeat assessments that should be performed no less than 
4 weeks after the criteria for response is first met. 
 

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13.6.2 Partial Response 
 
Partial response is not assessable in patients without sufficient measurable disease. 
 
13.6.3 Stable Disease 
 
Insufficient change to qualify for Complete Response or Progressive disease. 
 
13.6.4 Progressive Disease 
 
At least a 25% increase in the longest diameter on an axial image of any enhancing tumor on 
consecutive CT or MRI images with a minimum of ≥ 5mm of contiguous contrast enhancement 
in 2 perpendicular measurements in each of 2 perpendicular planes (i.e., axial and coronal). 
 
13.6.5 Not Assessable 
 
Progression has not been documented and one or more sites have not been assessed.  
 
14. QUALITY CONTROL AND QUALITY ASSURANCE 
 
14.1 
Data and Safety Monitoring Plan 
 
14.1.1 Data Monitoring Plan 
 
Adverse events meeting the definition of an SAE and any grade 2 or greater AEs where there 
is a possible, probable or definite relationship between the AE and investigational drug must 
be reported to the Investigator within 24 hours of discovery.  These will be assessed and 
reported to the IRB, DISC and FDA as required by policy and/or regulation. 
 
The UFHCC SRMC conducts initial review of IITs and determines the level of risk which 
corresponds with DISC review requirements.  The UFHCC DISC will conduct monitoring and 
audit activities as outlined in the DISC Charter.   The results of such activities will be provided 
to the PI and IRB. 
 
The UF study team will conduct annual QA self-assessments that include review of regulatory 
documentation (e.g., IRB documentation, FDA IND records, IND Sponsor-Investigator 
responsibilities), recruitment procedures, informed consent process/form documentation, 
subject selection, AE and SAE reporting, CRF and source documents. 
 
14.1.2 Data Safety Monitoring Board 
 
Oversight and monitoring of study related activities such as the safety of research participants, 
appropriateness of the study, and integrity of the data, will be provided by the University of 
Florida Health Cancer Center DSMB, now called the Data Integrity and Safety Committee 
(UFHCC DISC).  DSMB reports will be submitted to the IRB per local policy. 
  

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14.2 
Audits 
 
An IRB or other local oversight group may conduct audits to evaluate compliance with the protocol 
and the principles of GCP. The PI will provide the auditor(s) with direct access to all relevant 
documents and to allocate his/her time and the time of the study team to the auditor(s) in order to 
discuss findings and any relevant issues. 
 
Audits are designed to protect the rights and well-being of human research subjects. Audits may 
be routine or directed (for cause). Routine audits are selected based upon risk metrics generally 
geared towards high subject enrollment, studies with limited oversight or monitoring, Investigator 
initiated Investigational Drugs or Devices, federally-funded studies, high degree of risk (based 
upon adverse events, type of study, or vulnerable populations), Phase I studies, or studies that 
involve Medicare populations.  Directed audits occur at the directive of the IRB or an authorized 
Institutional Official. 
 
Audits examine research studies/clinical trials methodology, processes and systems to assess 
whether the research is conducted according to the protocol approved by the IRB. The primary 
purpose of the audit/review is to verify that the standards for safety of human subjects in clinical 
trials and the quality of data produced by the clinical trial research are met. The audit/review will 
serve as a quality assurance measure, internal to the institution. Additional goals of such audits are 
to detect both random and systemic errors occurring during the conduct of clinical research and to 
emphasize “best practices” in the research/clinical trials environment. 
 
14.3 
Data Management and Processing 
 
14.3.1 Study Documentation 
 
Study documentation includes but is not limited to source documents, case report forms, 
monitoring logs, appointment schedules, study team correspondence with sponsors or 
regulatory bodies/committees, and regulatory documents that can be found in the “Regulatory 
Binder,” which includes but is not limited to signed protocol and amendments, approved and 
signed informed consent forms, FDA Form 1572, CAP and CLIA laboratory certifications, and 
clinical supplies receipts and distribution records. 
 
Source documents are original records that contain source data, which is all information in 
original records of clinical findings, observations, or other activities in a clinical trial necessary 
for the reconstruction and evaluation of the trial. Source documents include but are not limited 
to hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries 
or evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, copies or transcriptions certified after verification as being accurate copies, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject files, and 
records kept at the pharmacy, at the laboratories and at medico-technical departments involved 
in the clinical trial. When possible, the original record should be retained as the source 
document. However, a photocopy is acceptable provided that it is a clear, legible, and an exact 
duplication of the original document. 
 

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14.3.2 Case Report Forms 
 
Only the PI and key study personnel are permitted to make entries, changes, or corrections in 
the case report forms. 
 
14.3.3 Data Management and Procedures and Data Verifications 
 
Users of the electronic CRF will have access based on their delegated specific roles on the 
study.  
 
Completeness of entered data will be checked and cross-referenced to verify accuracy. Missing 
or implausible data will be highlighted for the PI requiring appropriate responses (i.e. 
confirmation of data, correction of data, completion or confirmation that data is not available, 
etc.). 
 
The database will be reviewed and discussed prior to database closure, and will be closed only 
after resolution of all remaining queries. An audit trail will be kept of all subsequent changes 
to the data. 
 
 

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16. APPENDIX A: Karnofsky Performance Scale 
 
 
 
 
 
 
 
 
 
 
 
 
Able to carry on normal 
activity and to work; no 
special care needed. 
 
100 
 
Normal no complaints; no evidence of disease. 
 
90 
 
Able to carry on normal activity; minor signs or 
symptoms of disease. 
 
80 
 
Normal Activity with effort; some signs or 
symptoms of disease. 
Unable to work; able to live 
at home and care for most 
personal needs; varying 
amount of assistance 
needed. 
 
70 
 
Cares for self; unable to carry on normal activity or 
to do active work. 
 
60 
 
Requires occasional assistance, but is able to care 
for most of his personal needs. 
 
50 
 
Requires considerable assistance and frequent 
medical care. 
Unable to care for self; 
requires equivalent of 
institutional or hospital care; 
disease may be progressing 
rapidly 
 
40 
 
Disabled; requires special care and assistance. 
 
30 
 
Severely disabled; hospital admission is indicated 
although death not imminent. 
 
20 
 
Very sick; hospital admission necessary; active 
supportive treatment necessary. 
 
10 
 
Moribund; fatal processes progressing rapidly. 
 
0 
 
Dead 

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17. APPENDIX B:  RANO/iRANO Measurement Form 
 
RANO DISEASE ASSESSMENT FORM  
 
 Study ID: 
2-The-Top 
Name: 
 
DOB: 
Subject ID: 
Baseline Scan Date: 
TARGET 
Lesion(s)* 
Lesion 
Location/
Identifier 
Series 
No. 
Image 
No. 
Measurement 
1 (cm) 
Measurement 
2 (cm) 
Product (cm2) 
T1 
 
 
 
 
 
0.00 
T2 
 
 
 
 
 
0.00 
T3 
 
 
 
 
 
0.00 
T4 
 
 
 
 
 
0.00 
T5 
 
 
 
 
 
0.00 
Sum of Products of Diameters (SPD) 
0.
0
0 
*Measurable lesions must be contrast enhancing, have 2 perpendicular 
diameters >10mm & no cavity or cyst in measurement. Select a minimum of 2 
& a maximum of 5 lesions. Largest lesions that are suitable for reproducible 
measurements are preferred. 
 
NON-
TARGET 
Lesion(s) 
Lesion 
Location/
Identifier 
Series 
No. 
Image 
No. 
Measurement 
1 (cm) 
Measurement 
2 (cm) 
Enhancing or 
Non-enhancing? 
NT1 
 
 
 
 
 
 
NT2 
 
 
 
 
 
 
NT3 
 
 
 
 
 
 
NT4 
 
 
 
 
 
 
NT5 
 
 
 
 
 
 
^Non-measurable lesions include lesions that are too small (<10 x 10mm), lesions that do not 
enhance, and lesions with a poorly defined margin. Non-target lesions can also include 
measurable lesions not included in the 5 target lesions. 
Dexamethasone 
Dose: 
________ 
mg 
Frequency: 
BID_____________ 
Indication:  
Clinical status: 
 
Intracranial Edema  
Physiologic Replacement  
Other (Specify) _____________________ 
Clear deterioration due to tumor  
Clear deterioration due to non-tumor causes 
Others (Specify) ______________________ 
Stable Clinically  
Improved Clinically 

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RANO DISEASE ASSESSMENT FORM cont. 
 
Study ID: 
2-The-Top 
 
Name: 
 
DOB: 
Subject ID: 
 
Subsequent Scan Date: 
 
TARGE
TLesion(
s)* 
Lesion 
Location/
Identifier 
Series No. Image 
No. 
Measure
ment 
1 
(cm) 
Measure
ment 
2 
(cm) 
Product(c
m2) 
SPD 
from 
Baseli
ne or 
Best 
Respo
nse 
 
% 
Chan
ge of 
SPD 
T1 
 
 
 
 
 
0.00 
T2 
 
 
 
 
 
0.00 
T3 
 
 
 
 
 
0.00 
T4 
 
 
 
 
 
0.00 
T5 
 
 
 
 
 
0.00 
                                                                                                              Sum 
of Products of Diameters (SPD) 
0.00 
 
#DIV
/0 
*Measurable lesions must be contrast enhancing, have 2 perpendicular 
diameters >10mm & no cavity or cyst in measurement. Select a minimum 
of 2 & a maximum of 5 lesions. Largets lesions that are suitable for 
reproducible measurements are preferred. 
 
 
NON-
TARGE
TLesion(
s)^ 
Lesion 
Location/
Identifier 
Series No. Image 
No. 
Measure
ment 
1 
(cm) 
Measure
ment 
2 
(cm) 
Enhancin
g or Non-
enhancin
g? 
 
NT1 
 
 
 
 
 
 
NT3 
 
 
 
 
 
 
NT4 
 
 
 
 
 
 
NT5 
 
 
 
 
 
 
^Non-measurable lesions include lesions that are too small (<10 x 10mm), lesions that 
do not enhance, and lesions with a poorly defined margin. Non-target lesions can also 
include measurable lesions not included in the 5 target lesions. 
Dexamethaso
ne Dose: 
________ 
mg 
Frequency: 
BID_________
____ 
Indication:  
Clinical status 
Intracranial EdemaPhysiologic ReplacementOther (Specify) _____________________Clear 
deterioration due to tumorClear deterioration due to non-tumor causesOthers (specify) 
______________________Stable ClinicallyImproved Clinically 
 
 
 

2-THE-TOP 
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67 
Confidential 
18. APPENDIX C: GUIDANCE ON CONTRACEPTION 
 
For the purposes of the proposed study, “highly effective” contraceptive methods are defined as 
those, alone or in combination, that result in a low failure rate (i.e., less than 1 percent per year) 
when used consistently and correctly, and include the following: 
 
• Surgical sterilization at least 6 months before Study Drug administration 
• Implants 
• Levonorgestrel (LNG) and Copper T IUDs 
• Sexual abstinence 
 
Subjects who prefer methods which evidence a higher (6-9%) failure rate with typical use will be 
required to employ at least two methods of contraception concurrently.  These methods include 
the following: 
 
• Injectable hormone depos 
• Oral contraceptive pill 
• Hormone patch 
• Vaginal ring 
 
Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and 
withdrawal are NOT acceptable methods of contraception. 
 
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.p
df for a list of contraceptive methods and effectiveness.