Phase I/II Dose Escalation and Cohort Expansion of Safety and Tolerability Study of Intratumoral CD40 Agonistic Monoclonal Antibody APX005M in Combination With Systemic Pembrolizumab in Patients With Metastatic Melanoma
Phase: PHASE1
Conditions: Melanoma
Sponsor: M.D. Anderson Cancer Center

CONFIDENTIAL 
This is a University of Texas MD Anderson Cancer Center document that contains confidential 
information.  It is intended solely for the recipient clinical investigator(s) and must not be 
disclosed to any other party.  This material may be used only for evaluating or conducting 
clinical investigations; any other proposed use requires written consent from University of 
Texas MD Anderson Cancer Center. 
APX005M in Combination with Systemic Pembrolizumab in Patients with Metastatic Melanoma 
2015-0654, Version 8 
PROTOCOL 
TITLE: Phase I/II Dose Escalation and Cohort Expansion 
of Safety and Tolerability Study of Intratumoral 
CD40 Agonistic Monoclonal Antibody APX005M 
in Combination with Systemic Pembrolizumab in 
Patients with Metastatic Melanoma 
STUDY NUMBER: MDACC: 2015-0654 
VERSION NUMBER: 8 
PROTOCOL DATE: 01 February 2024 
AMENDMENT: Amendment 7 
TEST PRODUCTS: APX005M 
INVESTIGATOR: Adi Diab, MD 
Assistant Professor 
Melanoma Medical Oncology 
1515 Holcombe Boulevard 
Houston, Texas 77030 
Telephone: (713) 792-6111 
Fax:  (713) 745-1046 
E-mail:  ADiab@mdanderson.org
SUPPORT PROVIDED BY: Pyxis Oncology 
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APX005M in Combination with Systemic Pembrolizumab in Patients with Metastatic Melanoma 
2015-0654, Version 7 
2 
 
Protocol Amendments 
Protocol Version and Date 
Amendment Number 
Approval Date 
Version 1 – 1 Dec 2015 
Initial 
3 February 2016 
Version 2 – 20 May 2016 
Amendment 1 
14 July  2016 
Version 3 – 4 Aug 2016 
Amendment 2 
29 September 2016 
Version 4 – 17 Aug 2017 
Amendment 3 
18 September 2017 
Version 5 – 25 January 2018 
Amendment 4 
14 March 2018 
Version 6 – 01 November 2018  
Amendment 5 
8 April 2019 
Version 7 – 08 May 2019 
Amendment 6 
26 May 2020 
Version 8 – 01 February 2024 
Amendment 7 
 
 
 
 
 
 
 
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APX005M in Combination with Systemic Pembrolizumab in Patients with Metastatic Melanoma 
2015-0654, Version 7 
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Table of Contents 
Abstract ............................................................................................................................................ 6 
1 
Background & Rationale .......................................................................................................... 6 
1.1 
Melanoma ......................................................................................................................... 6 
1.2 
Rationale for Combination of Selective Local Innate Immune Activation with Systemic 
Checkpoint Blockade Immunotherapy Objectives ....................................................................... 7 
1.3 
CD40 Activation Has a Crucial Role in Licensing DCs to Prime CD8+ T-cell Responses
 
8 
1.4 
CD8+ T-cells Drive Responses to TIL in Melanoma Patients ........................................ 10 
1.5 
Clinical Data of CD40 Agonists ...................................................................................... 10 
1.6 
APX005M ....................................................................................................................... 11 
1.6.1 
Preclinical Pharmacokinetics ................................................................................. 13 
1.6.2 
Animal Toxicology .................................................................................................. 13 
1.6.3 
Clinical Experience ................................................................................................. 14 
1.6.4 
Rationale for the Starting Dose .............................................................................. 18 
1.6.5 
Packaging and Labeling ......................................................................................... 19 
1.6.6 
Storage and Dispensing ......................................................................................... 19 
1.6.7 
Expired or Used APX005M .................................................................................... 19 
1.7 
Pembrolizumab .............................................................................................................. 19 
2 
Objectives .............................................................................................................................. 20 
2.1 
Primary Objectives ......................................................................................................... 20 
2.2 
Secondary Objectives .................................................................................................... 20 
2.3 
Exploratory Objectives ................................................................................................... 20 
3 
Materials and Methods ........................................................................................................... 20 
3.1 
Eligibility Criteria ............................................................................................................. 20 
3.1.1 
Inclusion Criteria .................................................................................................... 20 
3.1.2 
Exclusion Criteria ................................................................................................... 21 
3.2 
Treatment Plan ............................................................................................................... 23 
3.2.1 
Trial Design ............................................................................................................ 23 
3.2.2 
Phase 1 Dose Escalation ....................................................................................... 25 
3.2.3 
Phase 2 Expansion ................................................................................................ 26 
3.3 
Concomitant Treatment .................................................................................................. 27 
3.3.1 
Premedication Prior to APX005M Administration and Guidance for Management of 
Cytokine Release Syndrome ................................................................................................. 27 
3.3.2 
Guidance for Management of Injection Site Reactions .......................................... 28 
3.3.3 
Optional and Allowed Concomitant Medications .................................................... 29 
3.3.4 
Prohibited and/or Restricted Therapies ................................................................. 30 
3.4 
Clinical Procedures and Evaluation ............................................................................... 31 
3.4.1 
Pretreatment Evaluation ......................................................................................... 31 
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3.4.2 
Main Study ............................................................................................................. 32 
3.4.3 
Follow-Up ............................................................................................................... 36 
3.4.4 
Post Treatment Follow-Up ..................................................................................... 37 
3.4.5 
Correlative Studies ................................................................................................. 37 
4 
Evaluation of Toxicity ............................................................................................................. 38 
4.1 
Dose Limiting Toxicity .................................................................................................... 38 
4.2 
Criteria for Treatment Continuation ................................................................................ 39 
4.3 
Dose Modifications ......................................................................................................... 39 
4.3.1 
Dose Modifications for Hematologic Toxicity ......................................................... 40 
4.3.2 
Dose Modifications for Non-hematologic Toxicities ............................................... 40 
4.4 
Duration of Treatment .................................................................................................... 41 
4.5 
Criteria for Removal from Treatment ............................................................................. 42 
5 
Criteria for Response ............................................................................................................. 43 
6 
Adverse Events ...................................................................................................................... 43 
6.1 
Suspected Adverse Reaction ......................................................................................... 43 
6.2 
Adverse Reaction ........................................................................................................... 43 
6.3 
Life-Threatening ............................................................................................................. 43 
6.4 
Serious Adverse Event (SAE) ........................................................................................ 44 
6.5 
Unexpected Adverse Event ............................................................................................ 44 
6.6 
Adverse Event Classification .......................................................................................... 44 
6.6.1 
Relationship to Study Drugs ................................................................................... 44 
6.6.2 
Severity .................................................................................................................. 45 
6.7 
Collection and Reporting ................................................................................................ 46 
7 
Statistical Considerations ....................................................................................................... 46 
7.1 
Dose Escalation ............................................................................................................. 46 
7.2 
Expansion Phase ........................................................................................................... 47 
7.2.1 
Sample Size/Power for the Primary Efficacy Objective ......................................... 47 
7.3 
Endpoints ....................................................................................................................... 48 
7.3.1 
Primary Endpoints .................................................................................................. 48 
7.3.2 
Secondary Endpoints ............................................................................................. 48 
7.3.3 
Exploratory Endpoints ............................................................................................ 48 
7.3.4 
Exploratory Studies ................................................................................................ 48 
7.3.5 
Toxicity Summary Review ...................................................................................... 48 
8 
Data Entry and Protocol Management ................................................................................... 49 
9 
Administrative Procedures ..................................................................................................... 49 
9.1 
Changes to the Protocol ................................................................................................. 49 
9.2 
Ethics and Good Clinical Practice .................................................................................. 49 
10 
References ............................................................................................................................. 50 
11 
Appendices ............................................................................................................................ 53 
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Table of Figures 
Figure 1: CD40 is at the interface between Innate and adaptive Immunity ..................................... 8 
Figure 2: rAd.CD40L induces upregulation of PD-1 on tumor infilatrating CD8 T cells. (A&B) 
B.16F10 TILs were stained after 6 days of treatment for the presence of CD45 + CD8 + PD-1 ..... 8 
Figure 3: Intratumoral rAd.CD40L+α-PD-L1 suppress local and distant melanoma growth ........... 9 
Figure 4: Therapeutic activity of rAd.CD40L + αCTLA-4 induces strong tumor suppression and 
complete, long-lasting tumor regression. ....................................................................................... 10 
Figure 5: Role of CD8+ T cells as predictive biomarkers in TIL ACT ............................................ 10 
Figure 6: APX005M is a Potent CD40 Agonistic Antibody ............................................................. 12 
Figure 7: Induction of Apoptosis and ADCP Effector Functions by APX005M on CD40+ Human 
Tumor Cells .................................................................................................................................... 12 
Figure 8: In Vitro Effect of APX on Human DCs ............................................................................ 13 
Figure 9: Scheme of the Trial Design ............................................................................................ 23 
Figure 10: Main Study .................................................................................................................... 24 
 
 
List of Tables 
Table 1: Study APX005M-001 Enrollment by Dose Level, Sex, Race, Type of Cancer ................ 15 
Table 2: Study APX005M-001 Serious Adverse Events Regardless of Causality......................... 16 
Table 3: Study APX005M-001 Number of Adverse Events by Grade and Number of Subjects by 
Maximum Grade of Adverse Event Experienced ........................................................................... 17 
Table 4: Study APX005M-001 Adverse Events in > 2 Subjects .................................................... 17 
Table 5: Number (%) of Subjects in APX005M-001 with Adverse Events Considered Related to 
APX005M by System Organ Class and Grade .............................................................................. 18 
Table 6: Dose Levels (DL) and Number of Injection Sites ............................................................. 26 
Table 7: Modified DLs for APX005M Following Qualifying AEs..................................................... 40 
Table 8: APX005M Dose Modifications for Hematologic Toxicity .................................................. 40 
Table 9: Dose Modifications for Non-hematologic Toxicity ............................................................ 41 
Table 10: Imaging and Treatment after 1st Radiologic Evidence of PD ........................................ 42 
Table 11: Toxicity Grading for AEs Not Covered in NCI-CTCAE (Version 4.03) ........................... 45 
Table 12: Stopping Boundaries ...................................................................................................... 47 
Table 13: Operating Characteristics .............................................................................................. 47 
 
Appendices 
Appendix 1: Priority of Assays and Quantitative Parameters for Analysis .................................... 53 
Appendix 2: Study Schedule of Events .......................................................................................... 54 
Appendix 3: Injection Site Patient Diary ......................................................................................... 56 
 
 
 
 
 
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ABSTRACT 
Novel immunotherapies have transformed the treatment of metastatic melanoma. Checkpoint 
blockade modalities like ipilimumab (anti-CTLA-4 antibody) and PD-1 blocking agents have 
significantly enhanced overall survival. However, long-term survival and durable remission rates 
remain low and new treatment options are needed to improve clinical outcome. Checkpoint 
blockade therapies enhance the anti-tumor immune response through inhibition of negative 
signaling in already existing and spontaneously induced tumor-specific T-cells. However, many 
tumors may not be immunogenic enough to induce such specific T-cells, which is consistent with 
the relatively low response rate of these modalities, in particular ipilimumab. 
In situ vaccination or utilizing the patient’s own tumor as a “vaccine site” through direct intra-tumoral 
(IT) immune modulation will lead to activation of dendritic cells (DCs) and subsequent T-cell 
stimulation, which can generate a specific anti-tumoral immunity. Combining this strategy with 
systemic immune stimulation such checkpoint blockade could lead to specific and long lasting anti-
tumor immune response that may be translated into higher clinical response and durable remission 
rates. 
There is growing body of evidence supporting the crucial role of CD40 activation for full maturation 
and activation of DCs that can promote antigen/tumor specific T-cell responses and generate 
potent anti-tumor response. Indeed, our preclinical data demonstrated that IT treatment with 
recombinant adenovirus encoding the dendritic cell-activating CD40L induced systemic anti-tumor 
effects, mediated by CD8+ T-cells. Furthermore, these tumor specific T-cell responses were further 
enhanced when the IT CD40L treatment was combined with systemic injection of anti CTLA-4 or 
anti PD-1, which led to distant tumors eradication. 
APX005M is a CD40 agonistic monoclonal antibody (mAb). In vitro, upon binding to CD40, 
APX005M activates the CD40 signaling pathway, leading to activation of DCs. In vivo, APX005M 
demonstrated potent anti-tumor activity in multiple human tumor xenograft models. 
We hypothesize that local innate immune activation through IT administration of a CD40 agonistic 
mAb can lead to enhanced induction of tumor-specific CD8+ T-cells and synergize with systemic 
therapies based on PD-1 blockade, resulting in superior anti-melanoma activity. This phase I/II trial 
evaluates the safety and immunological impact of IT administration of CD40 mAb APX005M in 
combination with intravenous (IV) administration of pembrolizumab in patients with metastatic 
melanoma. The immune response in both injected and non-injected tumors is evaluated. This trial 
may help in the generation of principles that can be applied to the treatment of other common 
cancers. 
1 
BACKGROUND & RATIONALE 
1.1 
MELANOMA 
Metastatic melanoma (MM) is a challenging disease with very poor prognosis. It is estimated that 
there will be around 76,000 new cases of melanoma with 9700 deaths in 2014 [1]. The incidence 
of invasive melanoma in the United States continues to increase approximately 4-6% annually 
despite efforts to improve primary prevention. Additionally, melanoma survivors are 9 times as high 
as the general population to develop additional melanomas due to genetic risk factors and/or 
overexposure to ultraviolet radiation [2]. However, the landscape of therapy of metastatic 
melanoma is rapidly progressing. Recently, new drugs have been approved by FDA. Ipilimumab, 
a monoclonal antibody targeting cytotoxic T-lymphocyte–associated antigen (CTLA-4), has been 
shown to improve median survival of MM patients in randomized trials[3]; however, response rates 
are still under 11%[3]. By contrast, oncogene-targeted therapy with the small molecule BRAF 
inhibitors vemurafenib, debrafenib and trametinib has shown high response rates in metastatic 
melanoma patients harboring BRAF mutations. However, these responses are transient owing to 
the frequent development of resistance to these drugs.  
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Additionally, only around 50% of patients carry the BRAFV600E mutation sensitive to these 
targeted agents. Immunotherapeutic agents against PD-1 have been approved with higher 
response rates than ipilimumab[4-7]. Yet durable response remains in small fraction of patient. In 
summary, metastatic melanoma remains largely fatal disease, and the 5-year survival rates for 
distant stage diseases are 15% [8]. 
1.2 
RATIONALE FOR COMBINATION OF SELECTIVE LOCAL INNATE IMMUNE 
ACTIVATION 
WITH 
SYSTEMIC 
CHECKPOINT 
BLOCKADE 
IMMUNOTHERAPY OBJECTIVES 
Melanoma is one of the most responsive cancers to immune-based therapies; particularly those 
mediated by cytotoxic T-lymphocytes (CTL), and melanoma represents a good model system that 
may lead to immune-based therapies for other common cancers. Checkpoint blockade (CTLA-4 or 
PD-1/L1 blockade) has become a major modality in the treatment of metastatic melanoma, and 
significantly prolongs survival of melanoma patients through inhibition of negative signaling in 
tumor-specific T-cells [3-7]. However, long-term survival and durable remission rates remain low, 
and new treatment options are needed to overcome low clinical response rate. 
One promising avenue in animal models has been to add vaccination to anti-CTLA-4 therapy [9]. 
However, the addition of a gp100/IFA peptide vaccine did not enhance but instead slightly reduced 
the efficacy of anti-CTLA-4 monotherapy [3]. We recently reported that vaccine-intrinsic features of 
IFA-based peptide vaccines induce the sequestration, dysfunction and death of activated, tumor-
specific T-cells at the inflamed vaccination site. Our recent preclinical data indicate that anti-CTLA-
4-induced, melanoma-specific T-cells are also subject to this effect, resulting in lack of synergy and 
suggesting different, non-IFA-based vaccine approaches may be better candidates for combination 
with anti-CTLA-4 therapy [10]. 
Manipulating the tumor itself may be the best “vaccine” 
Most vaccine studies have utilized non-mutated, differentiation antigens, such as gp100 [11], which 
have had real but modest clinical benefit. For example, we and others have shown that gp100 
vaccination in combination with high dose IL-2 resulted in longer PFS in MM patients compared to 
those who received IL-2 alone [11]. However, recent evidence suggests that the most potent 
antigens may be mutated antigens, regarded as “foreign” by the immune system [12]. Anti-PD-1 
therapy, for example, was effective in patients with MM and in patients with smoking-induced lung 
cancer, associated with large numbers of missense mutations due to UV rays and cigarettes, 
respectively. Robert Schreiber’s group showed that mutated antigens were the most potent at 
eliciting murine tumor rejection [13, 14]. Finally, tumor-infiltrating lymphocytes (TIL) that upon 
adoptive transfer mediated MM rejection in patients also recognized mutated antigens [15]. 
Activation of potent tumor-specific T-cells has been shown to require ligation of the CD40 receptor 
on antigen presenting cells (APCs) [16]. Therefore, we hypothesize that using the tumor itself as a 
“vaccine site” by intratumoral injection of a CD40 agonistic molecule such as APX005M, will 
activate innate immunity and lead towards “immunizing” patients against their own unique mutated 
antigens.  In preclinical models, we have tested the IT administration of the recombinant adenovirus 
encoding the dendritic cell-activating CD40L in mice and found CD8+ T-cell-mediated systemic 
activity against B16 melanoma. Importantly, IT administration of CD40L also augmented the activity 
of anti-CTLA-4 monotherapy. In this study we are testing the clinical efficacy, tolerability and 
immunological impact of IT administration of the CD40 agonistic mAb APX005M, in combination 
with anti-PD-1 mAb pembrolizumab in patients with MM. 
We are utilizing the tumor itself as a “vaccine site” by activating innate immunity via IT 
administration of the CD40 agonistic mAb APX005M. Although others have attempted to enhance 
immunity at the tumor site, this study will be the first clinical trial of a CD40 agonistic monoclonal 
antibody in combination with pembrolizumab. Preclinical models suggest that combining a CD40 
agonistic mAb with an anti-PD-1/PD-L1 mAb holds significant promise for inducing systemic anti-
tumor immunity and tumor regression in patients with MM and other cancers [17, 18] 
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1.3 
CD40 ACTIVATION HAS A CRUCIAL ROLE IN LICENSING DCS TO PRIME 
CD8+ T-CELL RESPONSES 
CD40 is expressed on all APC such as DCs, macrophages and other cells. CD40 interaction with 
its ligand (CD40L) on DCs will result in their activation and maturation with subsequent upregulation 
of co-stimulatory molecules (including CD80, CD86 and CD70) [19] as well as of other TNF 
superfamily members, such as 4-1BBL, OX40L and GITR ligand. CD40 also induces the 
expression of pro-inflammatory cytokines, such as IL-1β, IL-6 and IL-12, by DCs [19] (Figure 1). 
Expression of CD40 on DCs is crucial for cytotoxic T lymphocyte (CTL) function and for CD8+ T-
cell memory.  CD40 activation on macrophages will lead to upregulation of TLR9 and an increase 
in tumoricidal activity, NO and TNF production.  
Furthermore, CD40 may be expressed on tumor cells, and its 
ligation with its ligand induces re –expression of MHC I, 
rendering the cancer cell more immunogenic. In addition, CD40 
activation may induce apoptosis of the cancer cells [20]. 
APX005M is a humanized IgG1 mAb. In vitro, APX005M binds 
to both human and cynomolgus monkey CD40 with high-affinity, 
triggering activation of B-cells, monocytes, and dendritic cells 
and stimulating cytokine release from both human and monkey 
lymphocytes and monocytes. APX005M does not bind to rodent 
CD40. In comparison with CP-870,893 and SGN-40, APX005M 
has both more potent CD40 agonistic effects and ADCP effector 
function. In vitro, APX005M exerts its anti-tumor activity via 
ADCP and induction of apoptosis in CD40+ tumor cells (e.g. 
CD40+ lymphoma xenograft models). 
 
 
Preclinical data suggests synergy between 
Intratumoral 
CD40 
therapy 
and 
PD‐1 
blockade. 
Our preclinical studies show that IT injection of 
rAd.CD40L, 
a 
recombinant 
adenovirus 
expressing a stabilized version of the cognate 
CD40 ligand in mice harboring B16 tumors 
resulted in strong expansion of  tumor infiltrating 
CD8 T-cells , in particular those with up-regulated 
PD-1+ 
as 
compared 
to 
empty 
vector, 
demonstrating the requirement for CD40L 
(Figure 2). 
 
 
 
 
 
We evaluated the effects of IT rAd.CD40L injections on non-injected, distant lesions. Importantly, 
Tumor-bearing mice receiving IT rAdCD40L in 1 tumor were able to suppress non-injected tumors 
on the opposite flank (Figure 3A), demonstrating the ability of rAd.CD40L to turn a locally injected 
tumor into a “vaccine site” capable of activating responses in distal lesions, and establishing a 
rationale to explore this approach in combination with systemic checkpoint blockades. In further 
experiments, we tested whether anti-PD-L1 would enhance the anti-melanoma activity of 
Figure 1: CD40 is at the interface between 
Innate and adaptive Immunity 
MFI
PD-1
CD8 T cells
PD-1
Gated on CD8 T cells
27%
96%
rAd.empty
rAd.CD40L
rAd.empty
rAd.CD40L
A
B
Figure 2: rAd.CD40L induces upregulation of
PD-1 on tumor infilatrating CD8 T cells. (A&B) 
B.16F10 TILs were stained after 6 days of
treatment for the presence of CD45 + CD8 + 
PD-1 
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Figure 3: Intratumoral rAd.CD40L+α-PD-L1 suppress local and distant
melanoma growth  
(A) B16.F10 tumors were treated with rAd.CD40L or rAd empty. Overall 
mice survival is shown.  
(B&C) Mice bearing subcutaneous B16.F10 tumors in left (B; 7-day tumor) 
and right (C; 3-day tumor) flanks were treated only in the left tumor on day
0, 4, and 11 with rAd.CD40L and received α-PD-L1 or IgG twice weekly
tumor growth is plotted as individual mouse, n=5 or 20 mice in each
group. 
rAd.CD40L.  We found that rAd.CD40L strongly increased the therapeutic activity of anti-PD-L1 on 
rapidly progressing B16 melanoma tumors each agent dramatically reduced tumor growth and 
increased T-cell responses when combined with IT injection of rAd.CD40L (Figure 3B). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
As expected, this anti-tumor activity of combination IT rAd.CD40L and anti-PD-L1 was dependent 
on CD8+ T-cells (data not shown). Thus, IT therapy with rAd.CD40L can enhance the systemic 
activity of checkpoint blockade therapy against distant, non-injected wild-type B16F10 melanomas. 
These results lay the groundwork to inform the design of our clinical studies testing a combination 
of PD-1 checkpoint blockade with IT and rAd.CD40L for MM. 
IT CD40 activation plus systemic anti-CTLA-4 exert potent anti-melanoma effects. 
Our studies in defined peptide vaccine systems [9] and those of other groups show that the T-cell-
inducing activity of TLR 7/8 agonists is greatly enhanced by concomitant provision of CD40 
agonists. This combination potently activates antigen presenting cells to provide optimal priming of 
antigen-specific CD8+ T-cells [21]. 
We found robust activity of the combination of IT rAd.CD40L + systemic anti-CTLA-4 was very 
potent curing 3/20 mice of this very aggressive melanoma (Figure 4). The anti-tumor activity of 
combination IT rAd.CD40L and anti-CTLA-4 was dependent on CD8+ T-cells (data not shown). 
Together, these results provide a strong rationale to test the combination of IT CD40 activation 
eventually with anti-CTLA-4 or anti-PD-1(checkpoint blockade) in patients with MM. 
 
days after treatm ent
P e rc e n t s u rv iv a l
0
10
20
30
40
50
0
50
100
rA d .C D 4 0 L
rA d .e m p ty
p = .0 0 0 3
Non-injected 
distant tumors
B
Injected 
tumors
D a y s  P o s t T re a tm e n t
T u m o r s iz e (m m 2 )
0
1 0
2 0
3 0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
D a y s  p o s t tre a tm e n t
T u m o r s iz e (m m
2)
0
1 0
2 0
3 0
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
rAd.CD40L+IgG
rAd.CD40L+α-PD-L1
D a ys post tre atm ent
T u m o r s iz e (m m
2)
0
1 0
2 0
3 0
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
PBS+α-PD-L1
D a y s  p o s t tre a tm e n t
T u m o r s iz e (m m 2 )
0
5
1 0
1 5
2 0
2 5
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
D a y s  P o s t T re a tm e n t
T u m o r s iz e (m m 2 )
0
5
1 0
1 5
2 0
2 5
0
50
100
150
200
250
D a y s  P o s t T re a tm e n t
T u m o r s iz e (m m 2 )
0
5
10
15
20
25
0
20
40
60
80
100
1 mouse cured
C
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Figure 5: Role of CD8+ T cells as predictive biomarkers in TIL ACT 
 
 
 
 
 
 
1.4 
CD8+ 
T-CELLS 
DRIVE 
RESPONSES TO TIL IN MELANOMA PATIENTS 
Our adoptive T-cell transfer (ACT) study at MD Anderson Cancer Center [22] has demonstrated a 
strong positive correlation between the number of infused CD8+ TILs and clinical response in MM 
patients. In fact, a direct relationship was observed between the percentage of CD8+ T-cells found 
initially in the tumor biopsy and the ability to expand TIL to clinically significant numbers for infusion 
(data not shown) as  well as the number of CD8+ TIL in the infusion product (Figure 5A,B). Patients 
with higher numbers of CD8+ T-cells in the initial tumor biopsy also had increased overall survival 
from the time of tumor harvest (Figure 5C), which is consistent with an earlier report [23]. 
 
 
1.5 
CLINICAL DATA OF CD40 AGONISTS 
A few CD40 agonistic antibodies have been evaluated in human clinical trials. The majority of the 
clinical studies in cancer subjects with solid tumors have been conducted with the fully human IgG2 
CD40 antibody CP-870,893. In a phase I clinical trial, CP-870,893 was well tolerated; the maximum 
tolerated dose (MTD) was found to be 0.2 mg/kg. The main toxicity of CP-870,893 was cytokine 
release syndrome (CRS) of mild to moderate severity. Anti-tumor activity was observed in several 
melanoma subjects treated with CP-870,893 [24]. 
Figure 
4: 
Therapeutic 
activity 
of
rAd.CD40L + αCTLA-4 induces strong
tumor suppression and complete, long-
lasting tumor regression. 
C57BL/6 mice bearing 7-day s.c. wild-type
B16F10 melanomas received i.t. therapy
with 1x1010 pfu rAd.CD40L or rAd5 control
on day 0 and 7, and aCTLA-4 twice weekly.
Tumor growth is plotted. Experiment still 
in 
progress; 
3/20 
mice 
cured 
in
combination group. 
 (A) Percentage of CD8+ T cells within the infused TIL correlates with clinical response (N=31). (B) The frequency of CD8+ 
T cells in the tumor used to grow TIL is predictive of the frequency of CD8+ T cells in the expanded TIL product and (C) The 
frequency of CD8+ T cells in tumor is significantly associated with overall survival from the time of tumor harvest in TIL treated 
patients. (N=42 patients) 
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A recent study indicated that CP-870,893 can also mediate an anti-tumor effect when combined 
with chemotherapy in subjects with metastatic pancreatic cancer [25]. Other CD40 agonistic 
antibodies that have been studied in human clinical trials are SGN-40 and ChiLob 7/4. SGN-40 is 
an IgG1 humanized anti-CD40 antibody, which has been tested predominantly in hematological 
malignancies as monotherapy or in combination with rituximab and chemotherapy [26, 27]. The 
major adverse effects of SGN-40 were anemia, pleural effusion, and thrombocytopenia [26].  
ChiLob 7/4 is an IgG1 chimeric CD40 agonistic antibody that has been tested in a phase I clinical 
trial in subjects with solid tumors. The MTD of ChiLob 7/4 is 200 mg/weekly x4 and the major dose-
limiting toxicity (DLT) was reversible liver enzyme elevation [28]. Although CP-870,893 has potent 
CD40 agonistic activities, it is an IgG2 antibody, and thus lacks antibody effector functions that 
constitute an important mechanism of action for CD40 antibody-mediated anti-tumor activities. 
SGN-40 is an IgG1 antibody, but it is a weak CD40 agonist. Due to its chimeric structure, ChiLob 
7/4 might be immunogenic especially considering that the immune response is boosted by its CD40 
agonistic effects. 
1.6 
APX005M 
APX005M is a humanized IgG1 mAb. In vitro, APX005M binds to both human and cynomolgus 
monkey CD40 with high-affinity, triggering activation of B-cells, monocytes, and dendritic cells and 
stimulating cytokine release from both human and monkey lymphocytes and monocytes. 
APX005M is an IgG1 humanized CD40 agonistic mAb with the S267E mutation at the Fc region. 
APX005M binds with high-affinity to human CD40 (Kd = 1.2 ×10-10 M) and monkey CD40 (Kd = 
3.5×10−10 M), but does not cross-react with mouse or rat CD40. APX005M blocks the binding of 
CD40 to CD40L. In contrast, CP-870,893 and SGN-40 failed to block CD40 binding to CD40L 
suggesting that APX005M binds to an epitope that is different from the CP-870,893 and SGN-40 
binding site(s). 
Upon binding to CD40, APX005M activates the CD40 signaling pathway, leading to activation of 
APC, as seen in increased expression of CD80, CD83, CD86 and release of cytokines from human 
lymphocytes and monocytes. To benchmark APX005M with other CD40 agonistic antibodies, CP-
870,893 and SGN-40 analogues were generated by Pyxis Oncology based on their published 
antibody sequences. In comparison with CP-870,893 and SGN-40 analogs, APX005M is the most 
potent CD40 agonist (Figure 6). 
Upon binding to CD40+ tumor cells, APX005M is capable of inducing potent antibody effector 
functions such as ADCP (Figure 7A) and inducing tumor cell apoptosis (Figure 7B). APX005M does 
not appear to have a significant ADCP effect on DC (Figure 8). 
 
 
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Figure 7: Induction of Apoptosis and ADCP Effector Functions by APX005M on CD40+
Human Tumor Cells 
Figure 6: APX005M is a Potent CD40 Agonistic Antibody 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Human B cells were cultured with APX005M, CP-870,893 analog or SGN-40 analog for 48 hrs. B cell activation was 
quantified by measuring the expression of activation marker CD86 and % of CD86+ activated B cells. 
A) Expression of B-Cell Activation Marker CD86
(B) % of Activated B-cells
Human lymphoma Ramos cells were co-cultured with human peripheral blood mononuclear cells (PBMCs) in the presence of 
APX005M, CP-870,893 analog or SGN-40 analog for 96 hrs and cell viability was measured using CellTiter-Glo (A). Ramos 
cells were cultured with antibodies for 72 hrs and cell viability was measured using CellTiter-Glo (B). 
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Figure 8: In Vitro Effect of APX on Human DCs 
 
 
 
 
 
1.6.1 
Preclinical Pharmacokinetics 
Preclinical pharmacokinetics of APX005M was determined in the good laboratory practice (GLP) 
toxicology study using cynomolgus monkeys. Weekly intravenous administration of 5 doses of 
APX005M was well tolerated at 0.3, 3 and 30 mg/kg/dose. The PK properties of APX005M are 
typical of other mAbs and comprise low clearance (average range of 0.401-7.27 mL/h/kg), small 
volume of distribution (average range of 57-80.1 mL/kg) and long terminal half-life (average greater 
than 66 hours at 3 mg/kg and 30 mg/kg). Positive ADA titers were observed in all animals in the 
low dose group (0.3 mg/kg) but not in the high dose group (30 mg/kg). Based on these results, the 
no observed adverse effect level (NOAEL) was considered 30 mg/kg/dose. 
1.6.2 
Animal Toxicology 
The toxicology of APX005M was evaluated in 2 non-human primate (cynomolgus monkey) studies: 
a pilot single-dose non GLP study and a multi-dose GLP study. 
The toxicology profile of APX005M appears distinct from that of the IgG2 CD40 agonist antibody 
CP-870,893, as no evidence of hepatotoxicity was evident in monkeys.  The predominant effect 
seen with APX005M was a reduction in B-lymphocytes at doses > 3 mg/kg/dose consistent with 
that observed with CP-870,893 in prior studies and the pilot comparator toxicology study conducted 
with APX005M (23). These effects were prolonged and did not resolve over the course of the 28-
day treatment-free recovery period. No evidence of any other clinical pathology effects was 
observed and APX005M was not associated with any anatomical pathology findings.  Differences 
seen on selected flow cytometry and cytokine parameters in the pilot and definitive studies may be 
attributable to the larger number of animals evaluated in the definitive study or the timing of sample 
collection. With regard to the latter, samples were collected 24 hours postdose for flow cytometry 
and 10 minutes, 1, 2, 4, 8, and 24 hours for cytokine analyses in the single-dose pilot study. In the 
definitive study, sample collection for flow cytometry was conducted 48 hours post-administration 
(Days 1 and 15) and 24 and 48 hours post-administration on Day 29 (as well as during the recovery 
period) and cytokine sample collection performed 1, 4 and 24 hours following each dose. Positive 
Human PBMC were cultured under conditions similar to those used in the ADCP assay with APX005M, CP-870,893 or SGN-40 
for 4 hrs. Myeloid dendritic cells (MDCs) or plasmacytoid DCs (PDCs) were quantified using Miltenyi Biotech’s Blood Dendritic 
Cell Enumeration Kit. 
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ADA titers were observed predominantly in low-dose (0.3 mg/kg/dose) animals. Exposure 
increased over the course of the GLP study in animals dosed > 3 mg/kg/dose. 
The local tolerance was evaluated in the context of the repeat-dose GLP study in which gross and 
microscopic evaluation of the injection sites was conducted.  No evidence of local irritation was 
observed in this study.     
An in vitro hemolytic potential study was performed and consistent with the in vivo data in 
cynomolgus monkeys, no evidence of hemolytic activity was seen with the APX005M formulation. 
In the tissue cross reactivity study, multiple cells/tissues exhibited specific binding to APX005M. In 
many cases the binding observed was cytoplasmic and thus, is of questionable clinical relevance. 
Selected human tissues exhibited specific binding (that was not cytoplasmic) that was not seen in 
monkeys.  For these tissues it is possible that data derived from the monkey may not predict 
toxicity/effects in human. Based upon the monkey study results and those obtained with other 
similarly acting antibodies, hematological toxicities and/or cytokine-release related effects might 
occur at appropriate doses/exposures. These parameters will be monitored closely in the proposed 
clinical trial.  
In this trial, unlike the monkey studies, APX005M, will be injected directly into the tumor lesions 
and not administered intravenously, which further minimize any potential toxicity, yet it is expected 
to be immunologically active dose. 
1.6.3 
Clinical Experience 
Study APX005M-001 (NCT02482168) is an ongoing Phase 1, dose-escalation study of IV 
APX005M utilizing a modified 3+3 dose escalation design (the first 2 dose levels were single subject 
cohorts). As of 01 March 2016, 17 subjects have been enrolled in the Study APX005M-001 into 7 
dose levels. Sixteen out of the 17 subjects enrolled have been withdrawn from study treatment, the 
majority of them due to progressive disease (by RECIST 1.1, or clinical progression). A summary 
of demographics and reasons for withdrawal of study treatment is provided in Table 1. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Table 1: Study APX005M-001 Enrollment by Dose Level, Sex, Race, Type of Cancer 
  
    
Study APX005M-001:   
Dose Levels and Dose (mg/kg) 
  
    
 
 
 
DL1 
 
DL2    DL3    DL4    DL5    DL6    DL7  All DLs 
 
 
 (0.000
1) 
 (0.00
1) 
 (0.0
1) 
 (0.0
3) 
 (0.1)  (0.3)  (1.0)  
N (%) 
 
 
 N = 1 
 N =1  N =3  N = 
3 
 N = 
3 
 N = 
3 
 N = 
3 
 
N = 17 
Sex  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
Male   
0 
 
0 
 
1 
 
2 
 
1 
 
0 
 
1 
 
5 (29.
4) 
 
Female   
1 
 
1 
 
2 
 
1 
 
2 
 
3 
 
2 
 
1
2 
(70.
6) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Rac
e 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
Asian   
 
 
 
 
 
 
 
 
1 
 
 
 
 
 
1 (5.9) 
 
Black   
 
 
 
 
 
 
 
 
 
 
1 
 
 
 
1 (5.9) 
 
White   
1 
 
1 
 
3 
 
3 
 
2 
 
2 
 
3 
 
1
5 
(88.
2) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Type of Cancer 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
Anal  
1 
1 (5.9) 
 
Colorectal 
2 
1 
1 
1 
1 
6 
(35.
3) 
 
Endometrial 
1 
1 
2 
(11.
8) 
 
Hepatocellular 
1 
1 (5.9) 
 
Melanoma 
1 
1 (5.9) 
 
Pancreatic 
1 
2 
3 
(17.
6) 
 
SCC penis  
1 
1 (5.9) 
 
Small Intestine 
  
1 
1 (5.9) 
 
Unknown Primary   
  
  
  
  
  
  
  
  
  
  
1 
  
  
  
1 (5.9) 
Reason 
For 
Withdrawal 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
Disease 
progression  
1 
 
1 
 
3 
 
3 
 
3 
 
1 
 
1 
 
1
3 
(76.
5) 
 
Transfer to 
hospice  
- 
 
- 
 
- 
 
- 
 
- 
 
1 
 
- 
 
1 (5.9) 
 
Adverse Event  
- 
 
- 
 
- 
 
- 
 
- 
 
1 
 
1 
 
2 
(11.
8) 
 Data Cut-off 01 March 2016 
 
 
 
 
 
 
 
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Table 2: Study APX005M-001 Serious Adverse Events Regardless of Causality 
Subj No. 
System Organ Class 
Even
t 
Study Drug 
SAE 
Preferred Term  
Grad
e 
Action Taken 
Criteria 
3000-
0001 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
Pyrexia 
3 
Dose Not 
Changed 
Hospitalized 
3000-
0004 
GASTROINTESTINAL DISORDERS 
Intestinal obstruction* 
3 
Dose Not 
Changed 
Hospitalized 
3000-
0004 
INFECTIONS AND INFESTATIONS 
Salmonellosis** 
3 
Dose Not 
Changed 
Hospitalized 
3000-
0013 
RENAL AND URINARY DISORDERS 
   Acute kidney injury 
3 
Dose Not 
Changed 
Hospitalized 
3000-
0013 
METABOLISM AND NUTRITION DISORDERS 
   Hyperuricaemia 
4 
Dose Not 
Changed 
Hospitalized 
9152-
0012 
GASTROINTESTINAL DISORDERS 
   Faecaloma 
3 
Dose Not 
Changed 
Hospitalized 
9152-
0012 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
   Pleural effusion 
3 
Dose Not 
Changed 
Hospitalized 
9182-
0014 
NERVOUS SYSTEM DISORDERS 
   Seizure 
4 
Drug Withdrawn 
Hospitalized 
9182-
0016 
IMMUNE SYSTEM DISORDERS 
   Cytokine release syndrome 
4 
Drug Withdrawn 
Hospitalized 
Drug Safety (Argus) Database extract 01 March 2016, reconciliation not complete with the clinical database 
[*] Event Intestinal Obstruction is reported as “Abdominal Pain in the clinical database 
[**] Event Salmonellosis is reported as “Salmonella bacteremia and enteritis:  in the clinical database 
 
 
 
 
 
 
 
 
The majority of adverse events reported were mild to moderate in severity (Table 3). 
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Table 3: Study APX005M-001 Number of Adverse Events by Grade and Number of Subjects 
by Maximum Grade of Adverse Event Experienced 
NCI CTCAE Grade 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5  
Not 
Graded 
All AES 
  87 (71.3)  18 (14.8)  10 (8.2)  1 (0.8)  
0 
 
 
6 
(4.9) 
Number of Subjects*   4 (23.5)  7 (41.2)  4 (23.5)  1 (5.9)  
0 
 
 
 
 
[*] 16/17 (94.%); one subject has no AEs reported  
 
 
Most frequent AEs (reported in more than 2 subjects) independent of causality are presented in 
Table 4 and AEs considered related to APX005M are presented in Table 5. 
 
Table 4: Study APX005M-001 Adverse Events in > 2 Subjects 
Adverse Event  
    System Organ Class (OC) 
       Preferred Term  
All Grades  
  
GASTROINTESTINAL DISORDERS 
  
  
Abdominal distension 
2 (11.8) 
Abdominal pain 
3 (17.6) 
Abdominal pain upper 
2 (11.8) 
Constipation 
2 (11.8) 
Diarrhea 
5 (29.4) 
Gastroesophageal reflux disease 
2 (11.8) 
Nausea 
4 (23.5) 
Vomiting 
4 (23.5) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
  
Asthenia 
2 (11.8) 
Chills 
3 (17.6) 
Edema peripheral 
2 (11.8) 
Fatigue 
6 (35.3) 
Pyrexia 
4 (23.5) 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS 
  
  
Infusion related reaction 
2 (11.8) 
Weight decreased 
2 (11.8) 
METABOLISM AND NUTRITION DISORDERS 
  
  
Decreased appetite 
5 (29.4) 
Dehydration 
2 (11.8) 
Hyponatremia 
3 (17.6) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
    
Back pain 
2 (11.8) 
Muscle spasms 
2 (11.8) 
NERVOUS SYSTEM DISORDERS 
  
  
Dyspepsia 
2 (11.8) 
Headache 
2 (11.8) 
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RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
  
Cough 
2 (11.8) 
Dyspnea 
4 (23.5) 
Hypoxia 
3 (17.6) 
Pleural effusion 
2 (11.8) 
VASCULAR DISORDERS 
  
  
Hypertension 
2 (11.8) 
 
 
Table 5: Number (%) of Subjects in APX005M-001 with Adverse Events Considered Related 
to APX005M by System Organ Class and Grade 
Grade 
1 
  
Grade 
2 
  
Grade 
3 
  
Grade 
4 
  
Grade 
5 
  
Any 
Grade  
GASTROINTESTINAL DISORDERS 
  
  
Diarrhea 
1 
5.9% 
1 
5.9
% 
  
  
  
  
  
  
2 
11.8
% 
Dry mouth 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
Vomiting 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
  
Chest discomfort 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
Chills 
2 
11.8
% 
  
  
  
  
  
  
  
  
2 
11.8
% 
Fatigue 
3 
17.6
% 
  
  
  
  
  
  
  
  
3 
17.6
% 
Malaise 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
Pyrexia 
3 
17.6
% 
  
  
  
  
  
  
  
  
3 
17.6
% 
IMMUNE SYSTEM DISORDERS 
  
  
Cytokine release syndr
ome 
  
  
  
  
  
  
1 
5.9
% 
  
  
1 
5.9% 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS 
  
  
Infusion related reactio
n 
  
  
1 
5.9
% 
  
  
  
  
  
  
1 
5.9% 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
  
Myalgia 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
NERVOUS SYSTEM DISORDERS 
  
  
Dysgeusia 
2 
11.8
% 
  
  
  
  
  
  
  
  
2 
11.8
% 
Headache 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
  
Hiccups 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
VASCULAR DISORDERS 
  
  
Flushing 
1 
5.9% 
  
  
  
  
  
  
  
  
1 
5.9% 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Overall, IV administration of APX005M appears to be well tolerated at doses tested to date. AEs 
were consistent with this patient population and with the mechanism of action of a CD40 agonistic 
antibody. Preliminary pharmacodynamics data shows a dose dependent activation of antigen 
presenting cells in peripheral blood 24 hours after administration of APX005M. 
1.6.4 
Rationale for the Starting Dose 
The proposed starting dose for APX005M of 0.1 mg (about 0.0014 mg/kg for a 70 kg person) was 
chosen based on the safety and biological activity observed in the ongoing APX005M single agent 
IV dose escalation Phase 1 study (APX005M-001). APX005M dosed up to 0.03 mg/kg was very 
well tolerated, with no ≥ Grade 2 drug related AEs or laboratory abnormalities. 
The safety of APX005M is currently explored at the 1 mg/kg dose level, which is >700 times higher 
than the proposed starting dose for the intra-tumoral administration. The only severe (Grade 4) 
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toxicity observed to date with APX005M is CRS (at 1mg/kg dose level) which is non-overlapping 
with pembrolizumab toxicities. 
In the IV study, the dose of 0.001 mg/kg of APX005M showed minimal biological effect as measured 
by expression of activation markers on antigen presenting cells in peripheral blood. The systemic 
exposure and biological activity is expected to be similar after IV and IT administration therefore 
the proposed stating dose of 0.1 mg is expected to be safe and provide minimal biological activity. 
1.6.5 
Packaging and Labeling 
APX005M investigational product is supplied in 20 mL Type 1 clear glass vials labeled for 
intravenous injection.  Each depyrogenated vial contains 16.9 ml (10 mg/mL) APX005M. APX005M 
is a sterile, clear to slightly opalescent, colorless to slightly yellow, preservative-free solution (pH 
5.5) containing 25 mM sodium acetate, 248 mM trehalose, and 0.02% polysorbate 20 in water for 
injection (WFI) with a target fill volume of 16.9 mL per vial.  Glass vials are plugged with Teflon 
coated rubber stoppers and sealed with aluminum seals. The 20 mL vials (16.9 mL/vial) are 
intended for single-use.  
Additional APX005M details including labeling, storage, and preparation information for 
intratumoral administration are provided in the Pharmacy Manual. It should be noted that the 
Pharmacy Manual may be updated/revised as additional information becomes available. 
1.6.6 
Storage and Dispensing 
The APX005M investigational product should be stored in a secure location with limited access 
under controlled temperature conditions of 2-8◦C and in accordance with local regulations. Vials 
should be stored in their original folding carton to protect from light. If concerns regarding the quality 
or appearance of the investigational product arise, do not dispense the investigational product and 
contact the sponsor immediately. 
The investigational product must be dispensed only from official study sites by authorized personnel 
according to local regulations. It is the responsibility of the investigator to ensure that investigational 
product is only dispensed to study subjects. APX005M must be administered to study subjects by 
qualified personnel. 
Safety Precautions: When preparing investigational product wear laboratory coats and disposable 
protective gloves. Avoid contact with eyes, skin, and clothing. Protect from light and contamination. 
1.6.7 
Expired or Used APX005M 
All expired or unused study drug will be reconciled and destroyed/disposed in accordance with the 
MDACC institutional policy for investigational drugs.  
1.7 
PEMBROLIZUMAB 
Pembrolizumab (Keytruda™) is a highly-selective humanized mAb of IgG4/kappa isotype, 
designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2. It was 
approved for the treatment of patients with unresectable or metastatic melanoma and disease 
progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor since 
pembrolizumab has shown 26% clinical response in patients with ipilimumab refractory advanced 
melanoma [25]. Pembrolizumab will be purchased by M.D. Anderson Pharmacy from commercial 
sources and administered in accordance with manufacturer’s guidance. 
 
 
 
 
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2 
OBJECTIVES 
2.1 
PRIMARY OBJECTIVES 
• 
To assess safety and tolerability of intratumoral APX005M given with systemic 
pembrolizumab and identify of the maximum tolerated dose/recommended phase 2 dose 
(MTD/RP2D) of the combination therapy in patients with metastatic melanoma (dose 
escalation phase) 
• 
To assess overall response rate (ORR) at 12 weeks after intratumoral injection of 
APX005M in combination with systemic pembrolizumab (dose expansion phase) 
2.2 
SECONDARY OBJECTIVES 
• 
To evaluate the immunological impact of IT APX005M given with systemic pembrolizumab 
by quantifying  the tumor infiltrated CD8+T-cells (pre/post-therapy) both in injected and 
non-injected tumors 
• 
To assess the overall safety and tolerability of IT APX005M given with systemic 
pembrolizumab in patients with metastatic melanoma (expansion phase) 
• 
To evaluate anti-tumor immune responses and clinical efficacy of intratumoral injection of 
IT APX005M with systemic Pembrolizumab (dose escalation phase). 
2.3 
EXPLORATORY OBJECTIVES 
• 
To explore potential associations between biomarker measures and anti-tumor activity 
• 
To assess overall survival at 1 year and 2 years following the start of therapy. 
3 
MATERIALS AND METHODS 
3.1 
ELIGIBILITY CRITERIA 
3.1.1 
Inclusion Criteria 
1. Be willing and able to provide written informed consent/assent for the trial. 
2. Histologically or cytologically confirmed malignant melanoma arising from skin, or 
mucosal melanoma  (i.e., ocular melanoma subjects are not eligible) 
3. Measurable, unresectable stage III (in transit lesions) or stage IVA, IVB or IVC 
disease 
4. At least 2 injectable lesions (amenable for direct injection or through the use of 
image guidance such ultrasound [US], CT or MRI) defined as any injectable 
cutaneous, subcutaneous, nodal, or visceral melanoma lesion ≥ 10 mm in longest 
diameter.  
5. Age ≥ 18 year 
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6. ECOG performance status of 0 or 1 
7. Total bilirubin less than or equal to 2.0 mg/dl, except in patients with Gilbert’s 
Syndrome who must have a total bilirubin less than 3.0 mg/dl 
8. Platelet count greater than or equal to 100,000/mm3 
9. WBC > 3000/mm3 
10. ANC > 1500/mm3 
11. Hemoglobin >9 g/dL 
12. Serum ALT and AST <3 the upper limit of normal (ULN); <5 ULN if there is liver 
involvement secondary to the tumor 
13. Serum creatinine < 2.0 mg/dl 
14. Seronegative for HIV antibody 
15. Patients with a negative pregnancy test (urine or serum) must be documented 
within 14 days of screening for women of childbearing potential (WOCBP).  A 
WOCBP has not undergone a hysterectomy or who has not been naturally 
postmenopausal for at least 12 consecutive months (i.e. who has not had menses 
at any time in the preceding 12 consecutive months).Unless surgically sterile by 
bilateral tubal ligation or vasectomy of partner(s), the patient agrees to continue to 
use a barrier method of contraception throughout the study and for 4 months after 
the last dose of APX005M or pembrolizumab such as: condom, diaphragm, 
hormonal, IUD, or sponge plus spermicide.  Abstinence is an acceptable form of 
birth control. 
3.1.2 
Exclusion Criteria 
1. Patients who have previously received pembrolizumab or PD-/L1 blockade 
therapy. Adjuvant IFN-α, is allowed if last dose was received at least 6 months of 
starting study treatment 
2. Active autoimmune disease requiring disease-modifying therapy 
3. Concurrent systemic steroid therapy higher than physiologic dose (>7.5 mg/day of 
prednisone or equivalent) 
4. Any form of active primary or secondary immunodeficiency 
5. History of hematologic malignancy 
6. Active coagulopathy 
7. History of New York Heart Association class 3-4 congestive heart failure or history 
myocardial infarction within 6 months of starting study treatment 
8. History of arterial thrombosis within 3 months of starting study treatment 
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9. Patients with known symptomatic brain metastases requiring systematic 
corticosteroids. Patients with previous diagnosed brain metastases are eligible if 
they have completed their treatment and have recovered from acute effects of 
radiation therapy or surgery prior to the start of study medication, have 
discontinued corticosteroid treatment for their metastases for at least 2 weeks and 
are neurologically stable. Mild neurological deficits are allowed, if they do not 
interfere with the ability to judge the safety profile of APX005M. 
10. Prior malignancy except the following: adequately treated basal cell or squamous 
cell skin cancer, in-situ cervical cancer, thyroid cancer (except anaplastic) or any 
cancer from which the patient has been disease-free for at least 2 years 
11. Subjects who have received prior immune checkpoint inhibitors (e.g., anti-PD-1, 
anti-PD-L1), anti-CD40 
12. Subjects that have received experimental vaccines or other immune therapies 
should be discussed with the Principal Investigator to confirm eligibility 
13. Active known clinically serious infections (> Grade 2 NCI- CTCAE version 4.03) 
14. Prior systemic therapy, radiation therapy, or surgery within the 28 days of starting 
study treatment. Palliative radiotherapy to a limited field or palliative cryoablation 
is allowed after consultation with the Principal Investigator, at any time during the 
study participation including screening 
15. Women of child-bearing potential (WOCBP), women who are pregnant, or women 
who are nursing. 
16. Known or underlying medical condition that, in the opinion of the investigator or 
sponsor, could make the administration of study drug hazardous to the subjects, 
or could adversely affect the ability of the subject to comply with or tolerate study 
procedures and/or study therapy, or confound the ability to interpret the tolerability 
of combined administration of APX005M and Pembrolizumab in treated subjects. 
17. Has received a live vaccine within 30 days prior to the first dose of study drug.  
Examples of live vaccines include, but are not limited to, the following:  measles, 
mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus 
Calmette–Guérin (BCG), and typhoid vaccine.  Seasonal influenza vaccines for 
injection are generally killed virus vaccines and are allowed; however, intranasal 
influenza vaccines (eg, FluMist®) are live attenuated vaccines and are not 
allowed. 
18. Has received a TB skin test within 14 days before the first dose of study drug. 
19. Other severe, acute or chronic medical or psychiatric condition or laboratory 
abnormality that may increase the risk associated with study participation or study 
treatment administration or that may interfere with the interpretation of study 
results and, in the judgment of the Investigator, would make the patient an 
inappropriate candidate for the study.  
 
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3.2 
TREATMENT PLAN 
3.2.1 
Trial Design 
This is a phase I/II, single-institution, clinical study which comprises a phase I dose escalation and 
a phase II expansion (Figure 9). 
 
 
Figure 9: Scheme of the Trial Design 
 
All subjects will receive standard-of-care pembrolizumab, every 3 weeks until progressive disease 
(PD), unacceptable toxicity or up to 2 years from study entry. 
A cycle is defined as the 21 days (3 weeks) period starting with the administration of APX005M and 
pembrolizumab or pembrolizumab alone.  
Both phases of the study will comprise of 3 periods: 
• 
Main Study: is the 4 cycles (approximately 12 weeks) period during which subjects will 
receive up to 4 IT injections of APX005M along with IV pembrolizumab every 3 weeks 
(Figure 7) as long as they do not experience PD or unacceptable toxicity 
• 
Follow-up: Subjects that did not experience PD or unacceptable toxicity may continue to 
receive IV pembrolizumab until PD, unacceptable toxicity or up to 2 years from study entry. 
Note that in the escalation phase of the study, patients receive 2 mg/Kg (max of 200 mg) 
of IV Pembrolizumab, and in the expansion phase of the study, there will be a flat dose of 
200 mg given to patients.   
• 
Post Treatment Survival Follow-up: All subjects that discontinue treatment for any 
reason will be followed-up for 2 years from study entry or until death, whichever occurs first 
Intratumoral injection of APX005M: Injectable lesions (amenable for direct injection or through 
the use of image guidance such US, CT) may be defined as any injectable cutaneous, 
subcutaneous, nodal, or visceral melanoma lesion ≥ 10 mm in longest diameter. 
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(Measured by perpendicular diameter) Eligible subjects must have tumors with diameter 
perpendicular to longest diameter greater than 1cm to accommodate the anticipated injection 
volume: 
• 
Up to 1 ml will be injected into tumors 1cm to 1.5 cm 
• 
Up to 2 ml into tumors 1.5 to 2.5 cm 
• 
Up to 4 ml into tumors >2.5 cm 
Pharmacokinetic models of monoclonal antibodies such as APX005M suggest an increase in 
maximum exposure with rapid/bolus administration of the drug therefore there is a risk for unknown 
or more severe side effects. To limit accidental systemic exposure to rapid administration of 
APX005M, splitting the total dose/volume into two injections, separated by an interval time of 
approximately 15 minutes (± 5 minutes), will be performed at each APX005M treatment timepoint, 
applicable to cohort 5 and the expansion phase.    
Selection of injectable lesions should also take into accountability to obtain biopsies, accessibility, 
safety of the injection procedure (no encasing or in close proximity to crucial structure-carotid 
artery, jugular vein, trachea, etc.). The investigator together with the interventional radiologist will 
eventually determine if a tumor lesion is amenable for injection. 
Due to tumor heterogeneity, and building on our experience from prior intratumoral therapeutic and 
ablative studies, soft tissue lesions are preferred as injectable and non-injectable target lesions. 
Also, based on our experience from prior studies, we anticipate that the large majority of all 
injections/biopsies will be image guided (US or CT), therefore they will be performed in the 
interventional radiology (IR) suite. 
 
 
Figure 10: Main Study 
 
The same tumor site will be injected for each of the 4 IT injections of APX005M. 
APX005M  
Pembrolizumab  
Tumor 
Blood Draw  
: FNA to be done ~ 24 hrs. post injection 
: Pembrolizumab administration continues q 3wks  
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All subjects will be monitored per institutional guidelines after each injection of APX005M and as 
clinically indicated thereafter. All subjects will be discharged from clinic after clinical evaluation. 
Subjects should have stable vital signs including: lack of orthostatic hypotension (systolic blood 
pressure >100 mmHg, or no lower than 10 mm from baseline) without IV hydration (no hydration 
for at least 2 hours prior to discharge), lack of hypoxia (oxygen saturation >90% without oxygen), 
temperature <38◦C, heart rate <110 beats/min.  
After discharge, all subjects should be monitored by a caregiver for 24 hours after the first 2 
injections of APX005M and as clinically indicated thereafter.  
Tumor biopsies and blood samples will be collected at time points indicated in Figure 10 from all 
subject enrolled in this study. Samples will be analyzed for T-cell specificity and phenotype, 
cytokine expression and antigen spreading using the assays as described in Appendix 1. 
 
 
3.2.2 
Phase 1 Dose Escalation 
In the phase 1 dose escalation increasing dose levels (DL) of APX005M (Table 6) are combined 
with the approved dose and regimen of pembrolizumab. 
The 21-day cycle starting with the first administration of IT APX005M and IV pembrolizumab 
represents the tolerability observation period. 
A subject who meets all the study eligibility criteria, receives the entire planned dose of APX005M 
and pembrolizumab, and is assessed for the tolerability observation period (i.e., subject does not 
come off study for reasons other than toxicity) is considered evaluable. All subjects who do not 
meet these criteria will be replaced for the purpose of establishing the MTD. 
Dose escalation of APX005M will be determined based on an accelerated 3+3 design using the 
following decision rules: 
1) The 1st subject will enroll at DL1. 
a) If this subject does not experience a Grade ≥ 2 adverse event that cannot be clearly 
attributable to extraneous causes (drug related adverse event [DRAE]), the dose will 
escalate to DL2. 
b) If this subject experiences DRAE, 2 additional subjects will be enrolled at this dose level. 
If 0 of the 3 subjects experience a dose limiting toxicity (DLT), the dose will escalate to 
DL2.  If any of the subjects experiences DLT the dose escalation will stop and no MTD will 
be established. 
2) The 2nd or 4th subject will enroll at DL2. 
a) If this subject does not experience DRAE, the dose will escalate to DL3. 
b) If this subject experiences DRAE, 2 additional subjects will be enrolled at this dose level 
then follow rules in step 3. 
3) If escalated, then enroll 3 subjects at the escalated dose. 
a) If 0 of the 3 subjects experiences DLT, escalate to next dose level. 
b) If 1 of the 3 subjects experiences DLT, then 3 additional subjects will be enrolled at the 
current dose level. If 0 of the additional 3 subjects experiences DLT, then escalate to next 
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dose level.  If ≥ 1 of the additional 3 subjects experiences DLT, then de-escalate to previous 
dose level. 
Repeat step 3 until all 5 dose levels have been explored.  MTD will be defined as the highest dose 
level where ≤ 1 of 6 subjects experiences DLT. 
In any of the multi-subject cohorts, the first 2 subjects must receive first dose of APX005M at least 
72 hours apart. 
In dose level 5 the total amount of APX005M could be administered to one tumor lesion with the 
dose being split equally between 2 syringes.   
 
 
Table 6: Dose Levels (DL) and Number of Injection Sites 
Dose Level 
(DL) 
Injected tumor 
lesions 
APX005M 
dose 
Pembrolizumab 
Minimum number of 
subjects 
DL1 
(Starting 
Dose) 
1 
0.1 mg 
2 mg/kg 
1 
DL2 
1 
0.5 mg 
2 mg/kg (max 
200 mg) 
1 
DL3 
1 
1 mg 
2 mg/kg (max 
200 mg) 
3 
DL4 
1 
3 mg 
2 mg/kg (max 
200 mg) 
3 
DL5 
 (2 syringes) 
10 mg 
2 mg/kg (max 
200 mg) 
3 + 3 
Expansion 
Cohort 
1 (2 syringes) 
10  mg 
200 
mg 
(flat 
dose) 
20 
 
There will be no intra-patient APX005M dose escalation above the assigned dose level at 
study entry. 
All patients will receive standard-of-care pembrolizumab at 2 mg/kg every 3 weeks until PD, 
unacceptable toxicity or up to 2 years from study entry. 
The recommended phase 2 dose (RP2D) of APX005M in combination with 200 mg IV 
pembrolizumab will be based on MTD and the overall safety and tolerability of IT APX005M in 
combination with IV pembrolizumab. 
3.2.3 
Phase 2 Expansion 
In the Phase 2 Expansion portion of this study, 20 subjects will be enrolled to receive the RP2D of 
APX005M in combination with 200 mg flat dose of pembrolizumab. 
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The Expansion Phase dose of APX005M will be 10 mg.   
 
3.3 
CONCOMITANT TREATMENT 
3.3.1 
Premedication Prior to APX005M Administration and Guidance for 
Management of Cytokine Release Syndrome 
Symptoms associated with CRS, including but not limited to chills, fever, rash, tachycardia, 
hypotension, rigor, and myalgias after IT administration of APX005M, are possible. In the ongoing 
Phase 1 dose escalation study APX005M-001 symptoms responded rapidly to supportive care in 
the outpatient setting. 
If 2 or more Grade ≥ 2 CRS events are observed in two different subjects during the dose 
escalation, all subjects should be pre-medicated approximately 30 minutes before any 
administration of APX005M with a regimen containing (applicable to Cohort 5 and Expansion 
Phase): 
• 
Oral H1 antagonist (e.g., loratadine 10 mg) 
• 
Optional oral H2 antagonist (e.g., ranitidine 150−300 mg, cimetidine 300−800 mg, 
nizatidine 150−300 mg, and famotidine 20−40 mg) 
• 
Oral non-steroidal anti-inflammatory drug (may comprise ibuprofen 400 mg or equivalent) 
• 
Acetaminophen 650 mg 
When the time between premedication and scheduled APX005M administration exceeds 4 hours, 
subjects may receive an additional course of premedication prior to APX005M administration. 
CRS precautions should be observed during the administration of APX005M. Emergency agency 
agents including oxygen, oral and endotracheal airways, intubation equipment epinephrine, 
antihistamines, and corticosteroids should be available and used if required at the Investigator’s 
discretion. 
Subjects should be instructed that symptoms associated with CRS can occur at any time following 
the administration of the APX005M, and if such symptoms develop while they are at home, they 
should contact the Investigator and/or seek emergency medical care if appropriate. 
If the subject experiences adverse events suggestive of infusion reaction/cytokine release 
syndrome, treat symptoms using the following guidance: 
Suspected CRS-Related Toxicity 
Recommended Treatment 
Mild toxicity requiring symptomatic treatment only 
(e.g., fever, nausea, fatigue, headache, myalgia, 
malaise) 
• 
Vigilant supportive care 
• 
Maintain adequate hydration 
• 
Antipyretics, non-steroidal anti-
inflammatory drugs, antihistaminics,  
antiemetics, analgesics as needed 
• 
In case of mild symptoms persisting 
for > 24 hours assess for infections; 
empiric treatment of concurrent 
bacterial infections 
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Symptoms or clinical findings 
requiring and responding to 
moderate intervention, such 
as: 
• 
O2 requirement  < 40% 
• 
Hypotension 
responsive 
to fluids ± low dose of one 
vasopressor (e.g., < 50 
mg/min  phenylephrine) 
• 
CTCAE Grade 2 organ 
toxicity 
• 
No extensive 
co-morbidities 
• 
All of the above 
• 
Monitor cardiac and other organ 
functions closely 
• 
Extensive     
co-morbidities 
• 
Age ≥ 70 years 
• 
All of the above 
• 
Corticosteroids 
• 
Consider tocilizumab 
Symptoms or clinical findings requiring  aggressive 
intervention, such as: 
• 
O2 requirement  ≥  40% 
• 
Hypotension requiring high dose or multiple 
vasopressors 
• 
Ventilator support required 
• 
CTCAE Grade ≥3 organ toxicity 
• 
All of the above 
• 
Corticosteroids 
• 
Consider tocilizumab 
• 
Discontinue APX005M 
Steroids should not be used routinely to prevent or treat CRS as steroidal therapy may significantly 
impair the therapeutic benefit, however, these suggestions do not contraindicate the use of any 
medicine 
clinically 
needed 
under 
emergency 
circumstances 
including 
epinephrine, 
diphenhydramine, methylprednisolone or other steroids, nebulized albuterol, or any other medicine 
needed including additional narcotics to manage treatment-related symptoms as clinically 
indicated. 
Ensure that subjects are well-hydrated prior to discharge.  
• 
Consider administration of IV fluids  
Instruct the subject to drink volume-increasing fluids (e.g. gatorade, broth) for the remainder of the 
infusion day and maintain an adequate oral fluid intake for the first 24 - 48 hours after APX005M 
administration  
Consider prophylactic fever management for the first 24 hours (e.g. ibuprofen 400-600 mg every 8 
hours, alternating with acetaminophen 1000 mg every 6 hours)  
Consider withholding anti-hypertensive medications on the day of APX005M administration if in the 
opinion of the Investigator such action poses no risk to the subject. 
 
3.3.2 
Guidance for Management of Injection Site Reactions 
Local injection site reactions are possible following IT injection of APX005M. 
Only patients with cutaneous or subcutaneous lesions will be provided with a diary to collect 
information on the injection site(s) for 7 days after the IT injection (Appendix 3) 
 
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CTCAE Criteria for Injection Site Reactions 
 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Tenderness with or without 
associated symptoms 
(e.g., warmth, erythema, 
itching) 
Pain; 
lipodystrophy; 
edema; 
phlebitis 
Ulceration or necrosis; 
severe tissue damage; 
operative intervention 
indicated 
Life-threatening 
consequences; 
urgent intervention 
indicated 
Death 
Note: Based on NCI CTCAE v.4.03. Definition of Injection Site Reaction: A disorder characterized by an intense adverse reaction 
(usually immunologic) developing at the site of an  
 
Symptomatic treatment of injection site reactions should be consistent with the severity of the 
reactions as well as the institutional standards, and may include treatment with ice, acetaminophen, 
NSAIDS, antihistamines and narcotics. Due to their potentially immunosuppressive effects, the use 
of steroids should be avoided if clinically feasible. For severe reactions (Grade 3 or higher) inpatient 
admission with surgical consultation, and IV antibiotics will be required. 
For treatment-related AEs </= Grade 2 that remain unresolved at the time of scheduled injection, 
no changes in dose or schedule are recommended. Grade 2 injection site reactions (despite optimal 
medical management) that remain unresolved at the time of scheduled reinjection should be 
managed as follows: 
In the setting of Grade 2 local injection site reactions, an alternate easily accessible lesion, if 
available, should be considered for the injection of APX005M. If an alternate lesion cannot be 
identified, then injection of APX005M should be delayed until the event resolves to baseline or </= 
Grade 1. If the injection is delayed for more than one week, then the injection should be omitted 
and subsequent injections continued per original schedule. If 2 sequential scheduled injections are 
missed, the subject should be considered for withdrawal from the trial. 
In the setting of second occurrence of persistent injection site reaction despite optimal medical 
management, APX005M should be permanently discontinued. 
For treatment-related AEs=Grade 3, injection should be held until the toxicity resolves to Grade 1 
or baseline. If resolution occurs within 14 days, then the investigator can consider continued dosing 
of APX005M at the next lowest dose level as long as the AE of concern was not considered life 
threatening, e.g. anaphylaxis, cytokine release syndrome, etc. If the toxicity does not resolve to 
</=Grade 1 or baseline within 14 days, then permanently discontinue APX005M. 
For treatment related AEs >/= Grade 4, permanently discontinue APX005M. 
 
3.3.3 
Optional and Allowed Concomitant Medications 
The following medications are optional and are allowed during the study: 
• 
Anti-nausea and antiemetics (e.g., ondansetron, aprepitant, lorazepam) might be used for 
the prophylaxis or treatment of nausea and vomiting. National Comprehensive Cancer 
Network or institutional guidelines for treatment and prevention of nausea and vomiting 
should be followed 
• 
Anti-diarrheals: For subjects developing Grade 1–2 diarrhea, loperamide (2 mg every 2 
hours) is strongly recommended at the first onset of symptoms. For subjects with persistent 
diarrhea despite the use of loperamide, the use of octreotide is recommended. Other 
antidiarrheal agents may be used if necessary; a work-up for other etiologies is suggested 
for subjects who progress to Grade 3 or 4 diarrhea while taking loperamide 
• 
Myeloid growth factors (e.g., granulocyte-colony stimulating factor) may be used if 
neutropenia occurs, in accordance with American Society of Clinical Oncology Guidelines, 
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but are not to be given prophylactically and should not be substituted for a required dose 
reduction 
• 
Red blood cell transfusions, erythropoietic-stimulating agents, or platelet transfusions, if 
clinically indicated in accordance with institutional guidelines 
• 
Bisphosphonates for bone metastases 
• 
Treatment with non-conventional therapies (e.g., acupuncture), and vitamin/mineral 
supplements is acceptable provided that they do not interfere with treatment and the study 
endpoints 
• 
Subjects may receive standard of care for any underlying illness or treatment emergent 
AEs 
• 
Palliative radiotherapy during the study will be allowed for local pain control provided that: 
o 
In the opinion of the Investigator, the subject does not have progressive disease 
o 
The radiation field does not encompass the only target lesion (as defined by 
RECIST 1.1) 
o 
No more than 10% of the subject’s bone marrow is irradiated 
o 
Note: Investigational product may be continued during palliative radiotherapy at 
the discretion of the Principal Investigator. 
3.3.4 
Prohibited and/or Restricted Therapies 
Concurrent therapy with a marketed or investigational anti-cancer therapeutic, for either a palliative 
or therapeutic intent, is not allowed. Additionally, no alternative anti-cancer therapy (other than that 
administered in the study) or other investigational agents are allowed prior to treatment 
discontinuation. Herbal medicine for anticancer treatment should be stopped 1 week prior to 1st 
dose of investigational product. 
Subjects taking narrow therapeutic index medications (such as warfarin, phenytoin, quinidine, 
carbamazepine, phenobarbital, cyclosporine, and digoxin) should be monitored proactively.  
Concomitant treatment with systemic corticosteroids or other systemic immunosuppressive drugs 
is prohibited (excluding management of acute AEs). Please note that aromatase inhibitors, 
estrogen modulators, and adjuvant therapy is allowed (i.e. Arimidex).   
TB (tuberculosis) Skin testing is prohibited 14 days prior to initial study treatment through 14 days 
post-treatment of APX005M. 
Live vaccines within 30 days prior to the first dose of study treatment, while participating in the 
study, and 30 days post APX005M are prohibited.  Examples of live vaccines include, but are not 
limited to, the following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and 
typhoid vaccine. Seasonal influenza vaccines for injection are generally killed virus vaccines and 
are allowed; however, intranasal influenza vaccines (eg, FluMist®) are live attenuated vaccines 
and are not allowed. 
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3.4 
CLINICAL PROCEDURES AND EVALUATION 
3.4.1 
Pretreatment Evaluation 
At the screening visit, potential subjects will be assessed for study eligibility. All subjects must sign 
an informed consent form before enrollment and being registered in CORe/Prometheus.  Consent 
will be obtained within 28 days of starting study treatment. 
The following baseline assessments and procedures must be completed within 28 days of starting 
study treatment: 
• 
Complete history, demographics, concurrent medication usage and physical examination 
including ECOG Performance Score, vital signs, height, weight, noting in detail the exact 
size and location of any lesions that exist will be performed 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium 
• 
CBC with differential and platelet count 
• 
Coagulation: PT/PTT (prothrombin time/partial thromboplastin time) 
• 
β-HCG pregnancy test (urine or serum) on all women of childbearing potential 
• 
ECG 
• 
HIV serology 
• 
Thyroid function testing (TSH, Free-T4) 
• 
Baseline radiological studies to evaluate the status of disease (CT scans of chest, 
abdomen, pelvis; MRI/CT of brain) to evaluate the status of disease. Ultrasound or CT of 
area of in transit lesions is required. 
The following pre-treatment assessments and procedures must be completed within 7 days of 
treatment initiation: 
• 
β-HCG pregnancy test (urine or serum) on all women of childbearing potential 
• 
Medical photography and measurements only obtained when Lesion A or Lesions A and B 
are in-transit lesions and/or cutaneous lesions.  However, this will be case by case basis 
• 
Baseline AE recording, physical exam and concurrent medication usage will be 
documented 
• 
Baseline tumor biopsy (pretreatment) of the selected injection site (Injectable Non-Target 
or Lesion A) and non-injected site (Target or Lesion B) 
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
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3.4.2 
Main Study 
During the Main Study Period subjects will receive up to 4 IT injections of APX005M along with IV 
pembrolizumab every 3 weeks and will be treated and evaluated as outlined below. 
Cycle 1 (+2 Days) 
Day 1: 
• 
Physical Exam 
• 
ECOG performance status 
• 
Vital signs (includes height, weight, temperature, pulse, respiratory rate, systolic and 
diastolic blood pressure measurements)    Please note that height is only taken at 
Screening.   
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
PT/PTT 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium 
• 
β-HCG pregnancy test (urine or serum) on all women of childbearing potential 
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
• 
Medical photography and measurements only obtained when Lesion A or Lesions A and B  
are in-transit lesions and/or cutaneous lesions 
• 
Tumor biopsy (harvest) of treated tumor (Lesion A) and non-treated tumor (Lesion B) 
• 
First IT injection of APX005M  
Day 2: 
• 
Vital signs 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
One tumor biopsy of the APX005M injection site (Lesion A) to be collected at 24 hours (±7 
hours) after first APX005M injection. This will occur prior to Pembrolizumab administration 
• 
First dose of Pembrolizumab  
 
 
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Day 3 
• 
Vital signs 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
 
Days 8 and 15 (± 1 day): 
• 
Vital signs 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression (Day 8 ONLY) 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium 
 
Cycle 2 (± 3 days) 
Day 1: 
• 
Verify criteria for treatment continuation (See Section 4.2) 
• 
Physical Exam 
• 
ECOG performance status 
• 
Vital signs and weight 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
PT/PTT 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium 
• 
β-HCG pregnancy test (urine or serum) on all women of childbearing potential 
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• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
• 
IT injection of APX005M 
Day 2: 
• 
Vital signs  
• 
IV pembrolizumab  
Days 8 and 15 (± 1 day): 
• 
Vital signs and weight 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium 
Cycle 3 (± 3 days) 
Day 1: 
• 
Verify criteria for treatment continuation (See Section 4.2) 
• 
Physical Exam 
• 
ECOG performance status 
• 
Vital signs and weight 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
PT/PTT 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, and  fractionated bilirubin, 
and magnesium 
• 
Thyroid Function Test (TSH and Free T4) 
• 
β-HCG pregnancy test (urine or serum) on all women of childbearing potential 
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
• 
Tumor biopsy (harvest) of treated tumor (Lesion A) and non-treated tumor (Lesion B) 
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• 
IT injection of APX005M 
• 
Medical photography and measurements only obtained when Lesion A or Lesions A and B  
are in-transit lesions and/or cutaneous lesions, only case by case basis 
 
Day 2: 
• 
Vital signs and weight 
• 
IV pembrolizumab  
 
Cycle 4: (± 3 days) 
Day 1: 
• 
Verify criteria for treatment continuation (See Section 4.2) 
• 
Physical Exam 
• 
ECOG performance status 
• 
Vital signs and Weight 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
PT/PTT 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium 
• 
β-HCG pregnancy test (urine or serum) on all women of childbearing potential 
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
• 
IT injection of APX005M 
 
 Day 2: 
• 
Vital Signs and Weight 
• 
IV pembrolizumab 
 
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3.4.3 
Follow-Up 
 
Day 1 of Cycles 5-8 (± 3 days): 
• 
Verify criteria for treatment continuation. See Section 4.2.  
• 
Physical Exam 
• 
ECOG performance status 
• 
Vital signs and Weight 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium  
• 
β-HCG pregnancy test (urine or serum) on all women of childbearing potential 
• 
IV pembrolizumab  
 
Day 1 of Cycle 5 and Cycle 8 (± 3 days): 
• 
Radiological studies to evaluate the status of disease (CT scans of chest, abdomen, pelvis; 
(MRI/CT of the brain) to evaluate the status of disease. Ultrasound or CT of area of in 
transit lesions is required.  
NOTE: Radiological studies will be performed every 12 weeks after Cycle 8 until 2 
years from patient’s protocol entry date. 
• 
Medical photography and measurements only obtained when Lesion A or Lesions A and B  
are in-transit lesions and/or cutaneous lesions, only case by case basis 
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
• 
Thyroid function testing (TSH and Free T4) and every 12 weeks after cycle 8 until 2 years 
from patient’s protocol entry date.   
• 
PT/PTT (Cycle 5 only) 
• 
Mandatory tumor biopsy (harvest) of treated tumor (Lesion A) and if possible non-treated 
tumor (Lesion B) prior to Pembrolizumab infusion (Cycle 5 only).  Biopsy is optional at 
progression of disease 
 
 
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Off treatment: is at time of documented progression as per RECIST 1.1, clinical progression, 
unacceptable toxicity, withdrawal of consent or significant noncompliance with the protocol. Off 
treatment procedures will include: 
• 
Physical Exam 
• 
ECOG performance status 
• 
Vital signs and weight 
• 
Record AEs and concomitant medication 
• 
CBC with differential and platelet count 
• 
Clinical Chemistry to include serum electrolytes, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus, fractionated bilirubin, and 
magnesium  
• 
Blood sample draw (70 mL) for assays including but not limited to T-cell specificity and 
phenotype, cytokine expression 
3.4.4 
Post Treatment Follow-Up 
Subjects that have completed the Main Study and the Follow-up (pembrolizumab treatment per 
standard of care), will be followed every 12 weeks per the discretion of the treating physician until 
progression or for up to 2 years. If the patients wish to seek care at an outside institution after the 
completion of the Main study, they will be contacted every 12 weeks for up to 2 years from study 
entry to assess status of disease. Please note that these patients will be scanned at MDACC if 
possible.   
3.4.5 
Correlative Studies 
3.4.5.1 
Immunological Evaluations 
Immunologic evaluations will be processed through M.D. Anderson’s Immunotherapy Platform, 
which is a core processing facility within the Institution designed to help clinical researchers obtain 
immunologic expertise, guidance and immune monitoring analysis on patient blood and tumor 
samples. The Immunotherapy Platform provides the following services: (1) Isolation and 
cryopreservation of serum and peripheral blood mononuclear cells from sample (2) Data entry into 
Visual Specimen Manager (3) Sample transfer to liquid nitrogen for long-term storage (4) multiple 
cytokine analysis using serum (ELISA, Luminex) to measure antigen-specific cytokine production 
(5) Immunophenotyping with flow cytometry (6)The assessment of TCR Vß CDR3 clonal diversity 
will be done using ImmunoSeq™ (Adaptive Biotechnologies, Seattle, WA). Please see details in 
Appendix 1. 
To evaluate the baseline tumor microenvironment, we will obtain biopsies from 2 tumors (A-Injected 
and B-not injected) before treatment if patients have ≥2 lesions. Then tumor A will be injected with 
APX005M, while tumor B will be left uninjected. After 6 weeks of treatment, tumors A and B will be 
biopsied again for analysis, TIL generation, and tumor cell line generation. One injected tumor will 
be harvested 24 hours after the 3rd dosing of APX005M + pembrolizumab, and when feasible one 
non-injected tumor will be harvested at the same time for TIL expansion. An optional biopsy will be 
obtained in week 12 to assess late changes to the immune microenvironment. One quarter of each 
biopsy will be evaluated using IHC, one quarter will be used for TIL growth, and DNA and RNA will 
be isolated from the remaining half. Since infiltration of tumors by CD8+ T-cells is a primary 
endpoint of this trial, this will be quantified by IHC. DNA isolated from treated and untreated tumors 
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resected for TIL expansion will be used in a new method called “QuanTILfy” to quantify T-cells in 
the tumor. Briefly, this assay will analyze matched 20 micron tumor FFPE tissue sections from 
untreated and treated tumor harvests used to grow TILs. DNA samples isolated from at least two 
FFPE tumor sections will used to assess TCR Vß CDR3 clonal diversity using ImmunoSeq™ 
(Adaptive Biotechnologies, Seattle, WA). If patients have only one injectable lesion, we will obtain 
FNA instead of punch biopsy from the lesion. 
3.4.5.2 
Biopsies 
If possible, two areas will be biopsied during the course of the study including APX005M injected 
and non-injected sites. The first biopsy will be taken as a base line at any time after enrollment onto 
the trial, but prior to the first injection. Tumor biopsy of an injected site will be taken approximately 
24 hours after initial injection to allow for analysis early and transient changes occurs on different 
immune cells in particular DCs.  At week 9, before the 3rd injection, biopsy of both injected and non-
injected sites will be taken. Tumor biopsies may be taken using any biopsy method to optimize 
tumor yield using standard sterile techniques. We anticipate most biopsies, patients will undergo 
biopsy (excisional, punch, or 4-6 passes by imaging-guided of both tumors (A-injected and B-non 
injected) before treatment. At least 1 injected and 1 non-injected tumor/lesion must not be biopsied 
to allow for preservation of measureable disease. 
Blood and tissue specimens collected in the course of this research project may be banked and 
provided in the future to investigators with IRB approved research protocols. 
4 
EVALUATION OF TOXICITY 
This study will utilize the National Cancer Institute Common Terminology Criteria for Adverse 
Events (NCI-CTCAE) version 4.03 for toxicity reporting. All appropriate treatment areas should 
have access to a copy of the NCI-CTCAE version 4.03. 
4.1 
DOSE LIMITING TOXICITY 
DLT is defined as any of the following AEs attributed to APX005M (i.e., AEs that are not clearly 
attributable to extraneous causes), or AEs that are specific to pembrolizumab but are more severe 
that normally observed with pembrolizumab alone: 
• 
Grade 4 neutropenia (ANC <500 cells/mm3) for five or more consecutive days or Grade 3 
or 4 neutropenia of any duration with sepsis or a fever greater than 38.5°C (oral). Grade 4 
lymphopenia lasting less than 2 weeks will not be considered a DLT 
• 
Grade 4 anemia 
• 
Grade 4 thrombocytopenia (platelet count <25,000 cells/mm3) or Grade ≥3 
thrombocytopenia with signs or symptoms of bleeding or requiring platelet transfusion 
• 
Grade ≥3 disseminated intravascular coagulation 
• 
Grade ≥3 nausea, vomiting, or diarrhea despite the use of adequate/maximal medical 
intervention and/or prophylaxis (Grade 3 nausea, vomiting, or diarrhea that can be 
subsequently controlled in less than 72 hours [below Grade 3] with medical intervention or 
prophylaxis will not be considered a DLT) 
• 
Grade ≥3 CRS 
• 
Any other Grade ≥3 non-hematological and hematological toxicity except: 
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o 
Transient Grade 3 asymptomatic electrolyte abnormalities or transient Grade 3 
elevation in liver function tests in subjects with liver metastasis have to be longer 
than 48 hours to be considered a DLT 
o 
Grade 3 autoimmune thyroiditis that resolves to grade 1 or baseline within 28 days 
of onset 
o 
Grade 3 AST/ALT/total bilirubin <8 x ULN if improves to Grade 1 within 7 days in 
patients who receive intrahepatic APX005M injections 
• 
Delayed DLTs are drug-related adverse events that occur after Cycle 1. Delayed DLTs will 
not be used to determine the MTD for dose escalation. Delayed DLTs will be collected and 
evaluated by the Investigator on an ongoing basis. All AEs that meet criteria, as well as 
any >/= Grade 3 immune-related adverse events (regardless of attribution), must be 
reported to the IRB and Sponsor within 24 hours using the same rapid notification 
procedures that are used for serious AEs. Dosing of APX005M can be delayed for recovery 
from toxicity for up to 7 days. 
• 
Delayed recovery from toxicity related to treatment with investigational product which 
delays scheduled retreatment for >3 weeks, or >1 week for cytokine release related 
complications. 
4.2 
CRITERIA FOR TREATMENT CONTINUATION 
Subjects that do not experience PD may start a new cycle as scheduled if ANC >1,500/mm3, 
platelets >100,000/mm3, and disease or treatment-related non-hematologic toxicity has resolved to 
baseline or ≤ Grade 1. The following conditions are allowed to proceed:  
• 
Grade 2 alopecia and Grade 2 fatigue, for which resolution is not required 
• 
Grade 2 AST, ALT or total bilirubin for patients with liver metastasis who started treatment 
with Grade 2 AST/ALT/total bilirubin and the highest increases was <50% relative to 
baseline and lasted for less than 1 week 
If a subject fails to meet criteria for retreatment then the treatment cycle should be delayed and the 
subject should be re-evaluated weekly. Any subject who fails to recover from a disease or 
treatment-related toxicity to baseline or ≤ Grade 1 (except alopecia and Grade 2 fatigue) within 12 
weeks of scheduled retreatment should discontinue treatment. Failure to recover within 1 week of 
scheduled retreatment to baseline or ≤ Grade 1 of symptoms related to cytokine release should 
lead to APX005M discontinuation. 
 
4.3 
DOSE MODIFICATIONS 
Management of suspected adverse drug reactions may require temporary interruption of both drugs 
and/or dose reduction of APX005M only. If a subject experiences several toxicities, the 
recommended dose adjustment should be based on the highest grade toxicity. All dose reductions 
for APX005M, if required, will follow the DLs defined in Table 7. If the APX005M dose needs to be 
reduced below DL1, treatment with APX005M will be discontinued. If more than 2 dose reductions 
are required for APX005M, subject will enter the Follow-up period (single agent pembrolizumab). 
There will be no dose modifications for pembrolizumab. 
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Table 7: Modified DLs for APX005M Following Qualifying AEs 
DLs 
(mg) 
DL1 
(0.1) 
DL2 
(0.5) 
DL3 
(1) 
DL4 
(3) 
DL5 
(10) 
First Dose 
Reduction 
Discont. 
DL1 
DL2 
DL3 
DL4 
Second 
Dose 
Reduction 
NA 
Discont. 
DL1 
DL2 
DL3 
 
 
4.3.1 
Dose Modifications for Hematologic Toxicity 
Dose adjustments are based on nadir blood counts since the preceding administration of 
investigational product. APX005M dose adjustments for hematologic toxicity during treatment are 
described in Table 8. 
 
Table 8: APX005M Dose Modifications for Hematologic Toxicity 
Drug related toxicity 
Action taken with 
APX005M 
Action taken with 
Pemborlizumab 
Neutrophils (ANC) <500/mm3 
lasting ≥5 days 
Dose reduction/Discontinue 
Hold 
Neutropenic fever (body 
temperature ≥38.5ºC (oral) and 
ANC <1000/mm3) 
Dose reduction/Hold 
Hold 
Platelets <25,000/mm3 
Dose reduction/Discontinue 
Hold 
Platelets <50,000/mm3 with 
significant bleeding or requiring 
blood transfusion 
Dose reduction/Discontinue 
Hold 
Grade ≥3 disseminated 
intravascular coagulation 
Discontinue 
Discontinue 
 
4.3.2 
Dose Modifications for Non-hematologic Toxicities 
APX005M dose adjustments for non-hematologic toxicity during treatment are described in Table 
9. All dose modifications should be made based on the worst preceding toxicity. For all toxicity 
≤Grade 2, the current DL should be maintained. 
 
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Table 9: Dose Modifications for Non-hematologic Toxicity 
Drug-related toxicity 
Action taken with 
APX005M 
Action taken with 
pembrolizumab 
Grade 2 pneumonitis 
Hold 
Hold 
Grade ≥2 colitis 
Hold 
Hold 
Symptomatic hypophysitis 
Hold 
Hold 
Grade 2 nephritis 
Hold 
Hold 
Grade 3 hyperthyroidism 
Hold 
Hold 
Nausea/vomiting ≥Grade 3 despite 
optimal medical treatment 
Dose 
reduction/Discontinue 
Hold 
Diarrhea ≥Grade 3 despite optimal 
medical treatment 
Dose 
reduction/Discontinue 
Hold 
CRS Grade 3 ≤7 days 
Dose reduction 
Hold 
CRS Grade 3 >7 days 
Discontinue 
Hold 
Grade ≥3 pneumonitis or nephritis 
Discontinue 
Discontinue 
Other ≥3 Grade toxicities (except 
alopecia) 
Hold, then adjust dose as 
medically indicated after 
discussion with Principal 
Investigator 
Hold 
Other Grade 4 event 
Discontinue 
Discontinue 
  Abbreviations: CRS = cytokine release syndrome. 
 
4.4 
DURATION OF TREATMENT 
All subjects will receive up to 4 cycles of IV pembrolizumab in combination with IT APX005M 
followed by pembrolizumab single agent until documented disease progression, unacceptable 
toxicity, or up to 2 years from study entry. 
If radiologic imaging shows PD, tumor assessment should be repeated  ≥4 weeks later in 
order to confirm PD with the option of continuing treatment per below while awaiting radiologic 
confirmation of progression.  If repeat imaging shows a reduction in the tumor burden compared 
to the initial scan demonstrating PD, treatment may be continued as per treatment calendar. If 
repeat imaging confirms progressive disease, subjects will be discontinued from study therapy.    
In determining whether or not the tumor burden has increased or decreased, Investigators should 
consider all target lesions as well as non-target lesions. 
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When feasible, subjects should not be discontinued until progression is confirmed; however, the 
decision to continue study treatment after the 1st evidence of disease progression is at the 
Investigator’s discretion based on the clinical status of the subject as described in Table 10 
below.  Subjects  that  are  deemed  clinically  unstable  or  who  have  biopsy  proven  new 
metastatic lesions are not required to have repeat imaging for confirmation of progressive 
disease. 
Note: Treatment may be continued despite modified RECIST 1.1 defined progression if the 
subject  is  clinically  stable  and  is  considered  to  be  deriving  clinical  benefit  by  the 
Investigator. 
Clinical Stability is defined as: 
• 
Absence of signs and symptoms (including worsening of laboratory values) indicating 
disease progression 
• 
No decline in ECOG performance status 
• 
Absence of rapid progression of disease 
• 
Absence of progressive tumor at critical anatomical sites (e.g., cord compression) 
requiring urgent alternative medical intervention 
 
Table 10: Imaging and Treatment after 1st Radiologic Evidence of PD 
Clinically Stable 
Clinically Unstable 
Imaging 
Treatment 
Imaging 
Treatment 
1st radiologic 
evidence of PD 
Repeat imaging at >4 
weeks to confirm PD 
May continue study 
Treatment at the 
Investigator’s 
discretion while 
awaiting confirmatory 
scan 
Repeat imaging at > 
4 weeks to confirm 
PD if possible 
Discontinue 
treatment 
Repeat scan 
confirms PD 
No additional imaging 
required 
Discontinue treatment 
 
No additional 
imaging required 
N/A 
Repeat scan   
shows SD, PR 
or CR 
Continue regularly 
Scheduled imaging 
assessments every  
6 
weeks 
Continue 
study 
treatment 
at 
the 
Investigator’s 
discretion 
Continue regularly 
scheduled imaging 
assessments every 6 
weeks 
May restart study 
treatment if condition 
has 
improved and/or 
clinically stable per 
Investigator’s 
discretion 
First scan is on Cycle 5.  Second scan is on Cycle 8.  Subsequent, Radiological Imaging will be performed every 
12 weeks (+/- 7 days) thereafter. 
  
 
4.5 
CRITERIA FOR REMOVAL FROM TREATMENT 
Subjects will be taken off treatment for any of the following reasons: 
• 
Decision to withdrawal of the consent for any reason 
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• 
Significant noncompliance (e.g.; failure to appear to more than 2 protocol specified 
procedures) 
• 
Progression of disease 
• 
Any toxicity requiring treatment discontinuation as outlined in the dose modification section 
of this protocol 
5 
CRITERIA FOR RESPONSE 
Subjects will be evaluated for tumor response according to the RECIST 1.1 guidelines and also 
irRC (immune-related Response Criteria). Tumor measurements will be performed during the 
pretreatment evaluation, approximately every 6 weeks while subject remains in the main study and 
approximately every 9-12 weeks during follow-up up to 2 years from study entry. 
For visible cutaneous or palpable subcutaneous tumors, target sites will be assessed by 
measurements of tumor size on clinical exam and photographically documented and placed in the 
patient’s electronic chart. 
For visceral or other subcutaneous or soft tissue metastases, radiologic evaluations in the form of 
CT scans of chest, abdomen, pelvis; MRI/CT of brain; ultrasound or CT of area of in transit lesions 
will be performed. 
6 
ADVERSE EVENTS 
Adverse event means any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related. 
Adverse event recording will occur up to 90 days after the last injection of APX005M. 
6.1 
SUSPECTED ADVERSE REACTION 
Suspected adverse reaction (SAR) means any AE for which there is a reasonable possibility that 
the drug caused the AE. For IND safety reporting, "reasonable possibility" means there is evidence 
to suggest a causal relationship between the drug and the AE. SAR implies a lesser degree of 
certainty about causality than adverse reaction (AR), which means any AE caused by a drug. 
SARs are the subset of all AEs for which there is a reasonable possibility that the drug caused the 
event. 
6.2 
ADVERSE REACTION 
An AR means any AE caused by a drug. ARs are a subset of all SARs where there is reason to 
conclude that the drug caused the event. 
6.3 
LIFE-THREATENING 
An AE or SAR is considered "life-threatening" if, in the view of either the Investigator or sponsor, 
its occurrence places the subject at immediate risk of death. It does not include an AE or SAR that, 
had it occurred in a more severe form, might have caused death. 
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6.4 
SERIOUS ADVERSE EVENT (SAE) 
An AE or SAR is considered “serious” if, in the view of the investigator, it results in any of the 
following outcomes: 
• 
Death 
• 
A life-threatening adverse drug experience – any adverse experience that places the 
patient, in the view of the initial reporter, at immediate risk of death from the adverse 
experience as it occurred. It does not include an adverse experience that, had it occurred 
in a more severe form, might have caused death 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly/birth defect 
• 
Important medical events that may not result in death, but be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
Examples of such medical events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home, blood dyscrasias or convulsions that do not 
result in inpatient hospitalization, or the development of drug dependency or drug abuse 
(21 CFR 312.32). 
• 
Important medical events as defined above may also be considered serious adverse 
events. Any important medical event can and should be reported as an SAE if deemed 
appropriate by the Principal Investigator or IND Office. 
6.5 
UNEXPECTED ADVERSE EVENT 
An AE or SAR is considered "unexpected" if it is not listed in the APX005M Investigator’s Brochure 
or is not listed at the specificity or severity that has been observed. "Unexpected," as used in this 
definition, also refers to AEs or SARs that are mentioned in the Investigator’s Brochure as occurring 
with a class of drugs or as anticipated from the pharmacological properties of the drug, but are not 
specifically mentioned as occurring with the particular drug under investigation. Any condition, 
laboratory abnormality, or physical finding with an onset date prior to the subject signing the 
informed consent is considered to be pre-existing in nature and part of the subject’s medical history. 
6.6 
ADVERSE EVENT CLASSIFICATION 
All AEs that are observed, elicited by the Investigator or appropriately qualified designee, or 
reported by the subject will be evaluated by the Investigator and recorded in the appropriate section 
of the case report form. The NCI-CTCAE v 4.03 should be used to describe the event. 
6.6.1 
Relationship to Study Drugs 
The Investigator will assign attribution of the possible association of the event with use of the 
investigational drug, and this information will be entered into the case report form using the 
classification system listed below: 
Related to Investigational Product 
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The event is suspected to be related if: 
• 
There is a clinically plausible time sequence between the AE onset and administration of 
investigational product 
• 
There is a biologically plausible mechanism for the investigational product to cause or 
contribute to the AE 
• 
The event improves or diminishes upon temporary interruption of the investigational 
product without the initiation of any specific treatment for the event (dose delay) and/or 
recurs or worsens when resuming treatment after criteria for retreatment are met 
• 
The AE cannot be reasonably attributed to concurrent or underlying illness, other drugs, or 
procedures 
Unrelated to Investigational Product 
• 
The event is not suspected to be related if: 
• 
The AE is more likely to be explained by the subject’s underlying disease, clinical state, 
concomitant medical, or study or non-study procedure 
• 
The time occurrence of the AE is not reasonably related to administration of investigational 
product 
• 
The event is not related to the investigational product. 
6.6.2 
Severity 
The NCI-CTCAE v 4.03 should be used to assess the severity of AEs. For AEs not adequately 
addressed in the NCI-CTCAE version 4.03, Table 10 should be used. 
 
Table 11: Toxicity Grading for AEs Not Covered in NCI-CTCAE (Version 4.03) 
Severity 
Description 
GRADE 1 – Mild 
Asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated 
GRADE 2 – Moderate 
Minimal, local or noninvasive intervention indicated; 
limiting age-appropriate instrumental activities of ADL  
GRADE 3 – Severe 
Medically significant but not immediately life 
threatening; hospitalization or prolongation of 
hospitalization indicated; disabling; limiting self-care 
ADL 
GRADE 4 – Life-threatening 
Life-threatening consequences; urgent intervention 
indicated 
GRADE 5 – Fatal 
Death 
Abbreviations: ADL = activities of daily living. 
 
Abnormal laboratory findings should be reported as AEs only if they are clinically relevant. 
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6.7 
COLLECTION AND REPORTING 
All events occurring during the conduct of a protocol and meeting the definition of a SAE must be 
reported to the IRB in accordance with the timeframes and procedures outlined in “The University 
of Texas M.D. Anderson Cancer Center Institutional Review Board Policy for Investigators on 
Reporting Unanticipated Adverse Events for Drugs and Devices. Unless stated otherwise in the 
protocol, all SAEs, expected or unexpected, must be reported to the IND Office, regardless of 
attribution (within 5 working days of knowledge of the event). 
All events occurring during the conduct of a protocol and meeting the definition of a SAE must be 
reported to Pyxis Oncology (ds.apexigen@pyxisoncology.com), regardless of attribution (within 24 
hours of knowledge of the event). 
All life-threatening or fatal events, that are unexpected, and related to the study drug, must have a 
written report submitted within 24 hours (next working day) of knowledge of the event to the Safety 
Project Manager in the IND Office and Pyxis Oncology. 
Unless otherwise noted, the electronic SAE application (eSAE) will be utilized for safety reporting 
to the IND Office and MDACC IRB. 
Serious adverse events of any causality will be captured from the time of informed consent, until 
90 days after the last dose of APX005M, unless the participant withdraws consent. Serious adverse 
events must be followed until clinical recovery is complete and laboratory tests have returned to 
baseline, progression of the event has stabilized, or there has been acceptable resolution of the 
event. 
Additionally, any serious adverse events that occur after the 90 day time period that are related to 
the APX005M and pembrolizumab combination must be reported to the IND Office and Pyxis 
Oncology (ds.apexigen@pyxisoncology.com). This may include the development of a secondary 
malignancy. 
Reporting to FDA: Serious adverse events will be forwarded to FDA by the IND Sponsor (Safety 
Project Manager IND Office) according to 21 CFR 312.32. 
It is the responsibility of the Principal Investigator and the research teams to ensure serious adverse 
events are reported according to the Code of Federal Regulations, Good Clinical Practices, the 
protocol guidelines, the sponsor’s guidelines and Institutional Review Board policy. 
The Principal Investigator will monitor the data and toxicities to identify trends. The principal 
investigator will be responsible for revising the protocol as needed to maintain safety. The M.D. 
Anderson IRB will review serious adverse events as they are submitted.  Serious adverse events 
will be submitted to the FDA by the IND Safety Project Manager in the IND Office. The principal 
investigator will also review serious adverse events and evaluate trends. Whenever a trend is 
identified, the principal investigator will determine an appropriate follow up plan. The Principal 
Investigator or physician designee is responsible for verifying and providing source documentation 
for all adverse events and assigning the attribution for each event for all subjects enrolled on the 
trial. 
 
7 
STATISTICAL CONSIDERATIONS 
7.1 
DOSE ESCALATION 
A minimum of 6 subjects and maximum of 30 subjects will be enrolled in the dose escalation phase 
of the study.  The study design, dose levels, and decision rules for this phase are described in 
Section 3.2.2. 
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7.2 
EXPANSION PHASE 
An additional 20 patients will be enrolled at the MTD/RP2D dose level established in the dose 
escalation phase of the study.  The objectives of the expansion phase are to assess ORR as well 
as to continue to evaluate safety of the treatment combination.  Continuous monitoring of DLT will 
be assessed for all patients in the expansion phase, beginning with the first five patients.  Assuming 
a prior beta distribution of (0.6, 1.4) which has a mean of 0.30 corresponding to a 30% targeted 
DLT rate, the expansion phase will terminate if the Pr (δt > 0.30 | data) > 0.80, where δt is the DLT 
rate attributable to the treatment combination.  The decision rule for terminating for safety is 
presented in Table 13 and the operating characteristics (OCs) for this rule are presented in Table 
14. The method used to produce the decision rule/stopping boundaries and OCs was designed by 
Thall, Simon, and Estey [29] and was implemented using the Multc Lean Desktop application 
(version 2.1) in the Biostatistics department. The monitoring rules will be assessed by the study 
team with assistance as necessary from the Department of Biostatistics at MD Anderson Cancer 
Center. 
 
Table 12: Stopping Boundaries 
Total number of patients 
Stop if this many patients have toxicity: 
1-4 
Never stop with this many patients 
5-6 
3-6 
7-8 
4-8 
9-11 
5-11 
12-14 
6-14 
15-17 
7-17 
18-19 
8-19 
20 
Always stop at 20 patients 
 
 
Table 13: Operating Characteristics 
If the true DLT rate is… 
Early Stopping Probability 
Average Number of patients treated 
0.1 
0.018 
19.7 
0.2 
0.137 
18.3 
0.3 
0.399 
15.2 
0.4 
0.704 
11.4 
0.5 
0.908 
8.3 
 
7.2.1 
Sample Size/Power for the Primary Efficacy Objective 
The primary efficacy objective for this study is to assess ORR at 12 weeks of APX005M and 
pembrolizumab combined treatment.  A sample size of 26 patients (6 from escalation phase + 20 
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from expansion phase) will have 75% power to detect an improvement from a null ORR of 33% to 
55%, using a one group chi-square test and assuming a one-sided α–level of 5% (software: nQuery 
Advisor v7.0). 
7.3 
ENDPOINTS 
7.3.1 
Primary Endpoints 
Safety and tolerability will be assessed by the rate of DLTs, incidence and severity of AEs and 
specific laboratory abnormalities graded according to NCI-CTCAE, v4.03 and by changes from 
baseline of vital signs and clinical laboratory results during and following study drug administration. 
Categorical measures will be summarized using frequencies and percentages while continuous 
variables will be summarized using means, standard deviations, medians, minimums, and 
maximums. The primary efficacy endpoint (ORR) is defined as best overall response of complete 
response and partial response and will be estimated with 95% confidence intervals. The patients 
treated at the MTD/RP2D in the Phase I trial and those in the expansion cohort will be included in 
data analysis. 
7.3.2 
Secondary Endpoints 
The correlation between change in CD8+ T-cell density of injected lesion and tumor shrinkage of 
non-injected lesion will be conducted based on Pearson’s correlation coefficient and Spearman’s 
rank correlation coefficient.  Progression-free survival (PFS) will be defined from start of treatment 
to disease progression, death, or last evaluation assessment visit. Any patient who does not die or 
experience progression of disease by their last evaluation assessment visit will be censored. PFS 
will be estimated using the Kaplan-Meier method [31]. Cox proportional hazards regression models 
will be employed to assess the association between PFS and treatment and other 
clinical/demographic factors of interest. Duration of response (DOR) is defined as the time from the 
first evidence of confirmed PR or better to disease progression or death due to any cause. 
7.3.3 
Exploratory Endpoints 
Associations between biomarker measures and anti-tumor activity will be assessed using 
Pearson’s correlation coefficient and Spearman’s rank correlation coefficient. Multiple testing 
adjustments using FDR will be considered. Overall survival (OS) will be defined from start of 
treatment to death or last evaluation assessment visit.  Any patient who does not die by their last 
evaluation assessment visit will be censored.  OS will be analyzed similar to PFS as described 
above. 
7.3.4 
Exploratory Studies 
Associations between biomarker measures and anti-tumor activity will be assessed using 
Pearson’s correlation coefficient and Spearman’s rank correlation coefficient. Multiple testing 
adjustments using FDR will be considered. Overall survival (OS) will be defined from start of 
treatment to death or last evaluation assessment visit.  Any patient who does not die by their last 
evaluation assessment visit will be censored.  OS will be analyzed similar to PFS as described 
above. 
7.3.5 
Toxicity Summary Review 
a. Phase I – Dose Escalation 
A toxicity summary will be submitted to the IND Office Medical Monitor after the first evaluable 
patient completes 1 cycle of study therapy, and every evaluable patient thereafter. Accrual must 
be halted until summary is reviewed and study continuation is approved.  
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b. Phase II – Dose Expansion 
An efficacy/toxicity summary will be submitted to the IND Office Medical Monitor when the first 5 
evaluable patients complete 12 weeks of study therapy, and every 3 evaluable patients thereafter.  
If there is no Grade 3 AE occurred with the first 5 evaluable patients of Dose Expansion, an 
efficacy/toxicity summary can be submitted every 5 evaluable patients thereafter. 
8 
DATA ENTRY AND PROTOCOL MANAGEMENT 
For the purposes of this study at M. D. Anderson Cancer Center, the electronic data capture, 
Prometheus will be employed.  All patients will be registered in CORe utilizing a two-turnstile 
registration before any study specific tests are performed. Concomitant medications will be 
captured in the medical record. 
The principal investigator agrees to keep all information and results concerning the study 
confidential. The confidentiality obligation applies to all personnel involved with this clinical 
trial.  The Investigator must ensure that each participant’s anonymity will be maintained in 
accordance with applicable laws.  The principal investigator should keep a separate log of ID 
numbers, names and addresses.  Documents that contain the names associated with these ID 
numbers (e.g., written consent/assent forms), should be maintained by the Investigator in strict 
confidence except to the extent necessary to allow auditing by regulatory authorities, auditing or 
monitoring by the IRB. 
The Principal Investigator shall obtain all such permissions and authorizations as may be necessary 
or desirable to allow the collection and use of information protected under Federal privacy laws and 
State privacy laws, including permission/authorization for monitoring and analysis (including re-
analysis in combination with results of other studies), for regulatory submission purposes and for 
applicable reporting (if any). 
9 
ADMINISTRATIVE PROCEDURES 
9.1 
CHANGES TO THE PROTOCOL 
Any change or addition to this protocol requires a written protocol amendment that must be 
approved by the IND Office and the IRB. A copy of the written approval of the IRB must be received 
by the IND Office and the principal investigator before implementation of any changes.  The IRB 
must review and approve all amendments to the protocol. This study will be monitored for 
compliance by the IND office. 
9.2 
ETHICS AND GOOD CLINICAL PRACTICE 
This study must be carried out in compliance with the protocol and Good Clinical Practice, as 
described in: 
• 
ICH Harmonized Tripartite Guidelines for Good Clinical Practice 1996. 
• 
US 21 Code of Federal Regulations dealing with clinical studies (including parts 50 and 56 
concerning informed consent and IRB regulations). 
• 
Declaration of Helsinki, concerning medical research in humans (Recommendations 
Guiding Physicians in Biomedical Research Involving Human Subjects, Helsinki 1964, 
amended Tokyo 1975, Venice 1983, Hong Kong 1989, Somerset West 1996). 
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• 
The investigator agrees, when signing the protocol, to adhere to the instructions and 
procedures described in it and thereby to adhere to the principles of Good Clinical Practice 
10 
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Vonderheide RH, Flaherty KT, Khalil M, Stumacher MS, Bajor DL, Hutnick NA, Sullivan P, 
Mahany JJ, Gallagher M, Kramer A et al: Clinical activity and immune modulation in cancer patients 
treated with CP-870,893, a novel CD40 agonist monoclonal antibody. Journal of clinical oncology 
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25. 
Beatty GL, Chiorean EG, Fishman MP, Saboury B, Teitelbaum UR, Sun W, Huhn RD, 
Song W, Li D, Sharp LL et al: CD40 agonists alter tumor stroma and show efficacy against 
pancreatic carcinoma in mice and humans. Science 2011, 331(6024):1612-1616. 
26. 
Lewis TS, McCormick RS, Stone IJ, Emmerton K, Mbow B, Miyamoto J, Drachman JG, 
Grewal IS, Law CL: Proapoptotic signaling activity of the anti-CD40 monoclonal antibody 
dacetuzumab circumvents multiple oncogenic transformation events and chemosensitizes NHL 
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27. 
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Drachman JG, Lobuglio AF, Moskowitz CH: Pilot study of dacetuzumab in combination with 
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11 
APPENDICES 
Appendix 1: Priority of Assays and Quantitative Parameters for Analysis 
Tissue 
End Point 
Type 
Parameter 
Modality 
Assay 
Quantitative 
Measurement 
Priority 
Tumor 
Primary 
CD8+ 
infiltration into 
tumor (% 
CD8 T cells). 
Flow Cytometry 
Specific 
antibodies for 
CD3/4/8 and 
use of a dump 
channel 
Percentage/number of 
CD8 T cells normalized 
per infiltrating 
Lymphocytes (CD45+) 
and/or tumor weight 
1 
IHC 
Specific 
Antibodies 
Number of CD8 T cells 
normalized per field 
Secondary 
T-cell 
specificity for 
de novo 
antigens* 
Mutanome 
Exome 
Sequencing 
and in silico 
identification of 
candidate 
peptiedes 
Identification of tumor-
specific mutations 
2 
Secondary 
T-cell 
specificity 
(both de novo 
mutated 
antigens and 
Melanoma 
Differentiation 
Antigens – 
MDAs) 
1) Flow 
Cytometry 
using UV-
Induced 
p*MHC 
peptide 
exchange 
technology1 
or 
Dextramers) 
P*MHC peptide 
Exchange with 
mutanome/MDA 
identified 
peptides (or 
MDA 
Dextramers) 
Percentage of antigen 
specific CD8+ T-cells 
which are positive for 
mutated peptide/MDA 
loaded-
pMHC/Dextramers or 
induce IFN-γ production 
(ELISPOT) 
3 
2) ELISPOT 
ELISPOT with 
identified 
mutant/MDA 
peptides 
Secondary 
T-cell 
Infiltration 
PCR 
Quan TILfy 
Enumeration of tumor-
infiltrating T-cell numbers 
4 
Secondary 
Immune cell 
function 
qRT-PCR 
qRT-PCR for 
cytokine gene 
expression 
Relative expression of 
cytokine genes compared 
to control (treated pt to 
untreated pt; treated 
tumor to untreated tumor) 
5 
Secondary 
T-cell clonal 
diversity 
PCR 
High-throughput 
Bβ CDR3 region 
sequencing 
technology 
T-cell clone Tracking 
through Vβ CDR3 region 
sequencing 
6 
Secondary 
Immune cell 
phenotype 
Flow Cytometry 
Antibodies 
specific for NK 
cells, pDC/mDC 
and to 
characterize T 
cells: effector-
memory panel 
and Treg 
(FoxP3) 
Percentage of cells 
expressing markers 
7 
 
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Appendix 2: Study Schedule of Events 
 
Screening 
Treatment Period 
Follow-Up q 
Early 
Discontinuation 
or EOT 
Cycle a 
(≤28 Days) 
1 
2 
3 
4 
 
5+ 
Day 
-28 to 0 -7 to 0 1 (+2 
days 
2 
3 
8 
(±1 day) 
15 
(±1 day) 
1 
(±3 days) 
8 
(±1 day) 
15 
(±1 day) 
1 
(±3 days) 
1 
(±3 days) 
1 
(±3 days) 
Study Assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographic data 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History b 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam 
x 
x 
x 
 
 
 
 
x 
 
 
x 
x 
x 
x 
ECOG Performance Status 
x 
 
x 
 
 
 
 
x 
 
 
x 
x 
x 
x 
Vital Signs, Height(for screening only) 
Weight c 
x 
 
x 
x 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
Medications d 
x 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Adverse Events 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Clinical Chemistry e 
x 
 
x 
 
 
X 
X 
x 
x 
x 
x 
x 
x 
x 
CBC with differential and platelet count 
x 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Coagulation (PT/PTT) (up to Cycle 5) 
X 
 
X 
 
 
 
 
X 
 
 
X 
X 
X 
 
β-HCG Pregnancy Test f 
x 
X 
 
 
 
 
 
X 
 
 
x 
X 
X 
X 
ECG 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
HIV Serology 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thyroid Function Testing g 
x 
 
 
 
 
 
 
 
 
 
x 
 
x 
 
Blood Sample – for Assays h 
 
 
x 
 
x 
x 
 
x 
 
 
x 
x 
x 
x 
Blood Sample – Cytokines Measurement  
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
Radiological Studies i 
X 
 
 
 
 
 
 
 
 
 
 
 
x 
 
Medical Photography and Measurements j 
X 
 
 
 
 
 
 
 
 
 
 
 
x 
 
Tumor Biopsy (Pretreatment)(k 
 
 
X 
 
 
 
 
 
 
 
X 
 
x 
X 
Tumor Biopsy (Post APX005M) l 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
APX005M IT Injectionr 
 
 
x 
 
 
 
 
x 
 
 
X 
x 
 
 
Pembrolizumab IV n 
 
 
 
x 
 
 
 
x 
 
 
x 
x 
x 
 
Treatment Continuation Verification p 
 
 
x 
 
 
 
 
x 
 
 
X 
X 
X 
 
 
a Each cycle is 21 days 
b A complete medical history must be completed. Additionally at the Screening Visit, in detail, the exact size and location of any lesions that exist must be noted. 
c Vital signs include temperature, pulse, respiratory rate, systolic and diastolic blood pressure measurements. Height and weight are collected at the Screening Visit. 
d Concurrent medications will be collected within 28 days of beginning treatment. Concomitant medication will be collected at the start of treatment through the end of study participation. 
e  Clinical Chemistry consists of: Serum electrolytes, BUN, creatinine, glucose, albumin, alkaline phosphatase, ALT, AST, LDH, calcium, phosphorus,fractionated bilirubin, and Magnesium.   

 
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Screening 
Treatment Period 
Follow-Up q 
Early 
Discontinuation 
or EOT 
Cycle a 
(≤28 Days) 
1 
2 
3 
4 
 
5+ 
Day 
-28 to 0 -7 to 0 1 (+2 
days 
2 
3 
8 
(±1 day) 
15 
(±1 day) 
1 
(±3 days) 
8 
(±1 day) 
15 
(±1 day) 
1 
(±3 days) 
1 
(±3 days) 
1 
(±3 days) 
Study Assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
f β-HCG Pregnancy test (urine or serum) will be conducted on all women of child-bearing potential before dosing of each cycle.. A negative pregnancy test must be confirmed at Screening and again with 7 days of the start 
of treatment. 
g Thyroid Functioning Tests for this protocol include: TSH and Free-T4 only. Thyroid function test will be done at Screening, C3, C5, C8 and then every 4 cycles 
h 70mL blood sample draw for assays including, but not limited to T-cell specificity and phenotype, cytokine expression, will be collected C1D1, C1D3, C1D8, C2D1, C3D1, C4D1, C5D1, and C8D1 
i Radiological studies to evaluate the status of disease (CT scans of the chest, abdomen, pelvis with/without contrast; MRI/CT of brain, Ultrasound or CT of area of in-transit lesions) is required at baseline and before C5 and 
C8 (+/- 7 days) and every 12 weeks (+/- 7 days) thereafter.  
j Medical photography and measurements only obtained when Lesion A or Lesions A and B are in-transit lesions and/or cutaneous lesions. Please note that intransit lesions will be captured by scans. Medical photography 
and measurements will be taken on a case by case basis. 
 k Pretreatment biopsy must be done on the selected injection site (Lesion A) and the non-injection site (Lesion B),C1D1 and C3D1 prior to APX005M injection.  
l   Post injection Biopsy must be performed on Lesion A (the injection site) 24 hours (±7 hours) after the first APX005M injection.  
m Mandatory tumor biopsies on Lesion A and, if possible, Lesion B. If Lesion A or Lesions A and B are able to be obtained, the tissue collection must be completed prior to Pembrolizumab administration cycle 5. Optional 
biopsy can be done at EOT, or if they progress with therapy.   
n Pembrolizumab will be administered on Day 2 of Cycle 1, Cycle 2, Cycle 3, and Cycle 4. Pembrolizumab will be administered on Day 1 of Cycle 5 and thereafter. 
o Only to be completed at Cycle 5 and Cycle 8. 
p  Starting Cycle 2 Day 1 See Section 4.2 for criteria details. 
q Follow-Up assessments apply to Cycles 5-8 (Pembrolizumab at MDACC). Follow-Up assessments after Cycle 8 (receive Pembrolizumab outside MDACC) will occur every 3 months (every 12 weeks thereafter as applicable) 
and will include only Radiological Studies (at MDACC). See Section 3.4.4 
r The APX005M initial injection can occur up to 2 days post the C1D1 physical exam, but prior to the first study dose of Pembrolizumab. 

 
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Appendix 3: Injection Site Patient Diary 
Subject Name: 
 
 
 
Lesion Location: 
 
 
 
Date of Injection: 
 
 
 
 
 
 
 
 
Please provide a score of  0 to 10  for each of the following for 
each day following your injection 
0 = None, and 10 = Very bad  
 
Date 
Pain 
Swelling 
Redness 
Itching 
Warmth 
Other 
Day 
1 
____/______/____ 
 
 
 
 
 
 
Day 
2 
____/______/____ 
 
 
 
 
 
 
Day 
3 
____/______/____ 
 
 
 
 
 
 
Day 
4 
____/______/____ 
 
 
 
 
 
 
Day 
5 
____/______/____ 
 
 
 
 
 
 
Day 
6 
____/______/____ 
 
 
 
 
 
 
Day 
7 
____/______/____ 
 
 
 
 
 
 
 
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