Focused Ultrasound Therapy to Augment Antigen Presentation and Immune-Specificity of Checkpoint Inhibitor Therapy With Pembrolizumab in Metastatic Breast Cancer
Phase: PHASE1
Conditions: Breast Cancer
Sponsor: Patrick Dillon, MD

Product:   Pembrolizumab 
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SPONSOR: Patrick Dillon 
 
TITLE: Focused Ultrasound Therapy to Augment Antigen Presentation and Immune-Specificity of 
Checkpoint Inhibitor Therapy with Pembrolizumab in Metastatic Breast Cancer 
 
IND NUMBER:  124939 
 
 

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SIGNATURE PAGE 
 
 
 
INVESTIGATOR’S AGREEMENT 
I confirm that I have read this protocol and I agree to conduct the study as outlined herein.  I agree to 
conduct the study in accordance with the ethical principles that have their origin in the Declaration of 
Helsinki and that are consistent with Good Clinical Practices, as outlined in ICH E6, and the applicable 
laws and regulations.  
 
 
Sponsor-Investigator 
 
______________________ 
 
_______________________ 
 
_________ 
Name  
 
 
 
Signature 
 
 
 
Date 

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TABLE OF CONTENTS 
1.0 
TRIAL SUMMARY ................................................................................................................ 6 
2.0 
TRIAL DESIGN ...................................................................................................................... 6 
2.1 
Trial Design ......................................................................................................................... 6 
2.2 
Trial Diagram ...................................................................................................................... 7 
3.0 
OBJECTIVES & HYPOTHESES ......................................................................................... 7 
3.1 
Primary Objectives & Hypotheses .................................................................................... 7 
3.2 
Secondary Objectives & Hypotheses ................................................................................. 7 
3.3 
Exploratory Objectives ....................................................................................................... 8 
4.0 
BACKGROUND & RATIONALE ........................................................................................ 8 
4.1 
Background ......................................................................................................................... 8 
 
Pharmaceutical and Therapeutic Background .................................................................. 8 
 
Preclinical and Clinical Trial Data .................................................................................... 9 
4.2 
Rationale .............................................................................................................................. 9 
 
Breast Cancer .................................................................................................................... 9 
 
Rationale for the Trial and Selected Subject Population ................................................ 10 
 
High Intensity Focused Ultrasound (HIFU) ................................................................... 11 
 
HIFU in Head and Neck Malignancies ........................................................................... 11 
 
HIFU in Breast Fibroadenoma ........................................................................................ 12 
 
Rationale for Combination .............................................................................................. 12 
4.3 
Rationale for Dose Selection for Pembrolizumab .......................................................... 14 
4.4 
Rationale for Endpoints ................................................................................................... 14 
 
Biomarker Research ........................................................................................................ 14 
5.0 
METHODOLOGY ................................................................................................................ 16 
5.1 
Entry Criteria .................................................................................................................... 16 
 
Diagnosis/Condition for Entry into the Trial .................................................................. 16 
 
Subject Inclusion Criteria ............................................................................................... 16 
 
Subject Exclusion Criteria .............................................................................................. 18 
5.2 
Trial Treatments ............................................................................................................... 20 
 
Dose Selection/Modification & Focused Ultrasound Administration ............................ 20 
 
Dose Modification .......................................................................................................... 21 
 
Timing of Dose Administration ...................................................................................... 24 
 
Trial Blinding/Masking................................................................................................... 25 
5.3 
Randomization or Treatment Allocation ........................................................................ 25 
5.4 
Stratification ...................................................................................................................... 25 
5.5 
Concomitant Medications/Vaccinations (allowed & prohibited) ................................. 25 
 
Acceptable Concomitant Medications ............................................................................ 25 
 
Prohibited Concomitant Medications ............................................................................. 25 
5.6 
Rescue Medications & Supportive Care ......................................................................... 26 
 
Supportive Care Guidelines ............................................................................................ 26 
5.7 
Diet/Activity/Other Considerations ................................................................................. 29 
 
Diet ................................................................................................................................. 29 
 
Contraception .................................................................................................................. 29 
 
Use in Pregnancy ............................................................................................................ 30 
 
Use in Nursing Women................................................................................................... 31 
5.8 
Subject Withdrawal/Discontinuation Criteria ............................................................... 31 
 
Treatment after Initial Radiologic Progression ............................................................... 32 
 
Discontinuation of Study Therapy after CR after Cycle 4 .............................................. 32 
 
Treatment with pembrolizumab after SD or PR ............................................................. 32 

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5.9 
Subject Replacement Strategy ......................................................................................... 33 
 
Replacement of Study Participants ................................................................................. 33 
5.10 
Clinical Criteria for Early Trial Termination ................................................................ 33 
6.0 
TRIAL FLOW CHART ........................................................................................................ 34 
6.1 
Study Flow Chart .............................................................................................................. 34 
7.0 
TRIAL PROCEDURES ........................................................................................................ 42 
7.1 
Trial Procedures ................................................................................................................ 42 
 
Administrative Procedures .............................................................................................. 42 
 
Clinical Procedures/Assessments ................................................................................... 44 
 
HIFU Device Performance Parameters ........................................................................... 45 
 
Laboratory Procedures/Assessments .............................................................................. 46 
 
Other Procedures ............................................................................................................ 48 
 
Visit Requirements ......................................................................................................... 48 
7.2 
Assessing and Recording Adverse Events ....................................................................... 50 
 
Time Span for Recording Adverse Events...................................................................... 50 
 
Definitions ...................................................................................................................... 50 
 
Attribution Assessment ................................................................................................... 52 
 
Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Sponsor and to Merck ..................................................................................................... 53 
 
Reporting of Pregnancy and Lactation to the Sponsor and to Merck ............................. 54 
 
Immediate Reporting of Adverse Events to the Sponsor and to Merck .......................... 54 
 
Evaluating Adverse Events ............................................................................................. 56 
 
Adverse Event Classifications ........................................................................................ 60 
 
Agent-Specific Expected Adverse Events List ............................................................... 60 
 Dose Limiting Toxicities ................................................................................................ 61 
 Recording and Reporting Adverse Events ...................................................................... 61 
 Sponsor Responsibility for Reporting Adverse Events .................................................. 64 
8.0 
STATISTICAL ANALYSIS PLAN ..................................................................................... 64 
8.1 
Statistical Analysis Plan Summary .................................................................................. 64 
8.2 
Statistical Analysis Plan ................................................................................................... 65 
9.0 
LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL 
SUPPLIES .............................................................................................................................. 66 
9.1 
Investigational Product and Device ................................................................................. 66 
9.2 
Packaging and Labeling Information ............................................................................. 66 
9.3 
Clinical Supplies Disclosure ............................................................................................. 66 
9.4 
Storage and Handling Requirements .............................................................................. 66 
9.5 
Returns and Reconciliation .............................................................................................. 66 
10.0 
ADMINISTRATIVE AND REGULATORY DETAILS ................................................... 67 
10.1 
Study Conduct and Ethical Considerations .................................................................... 67 
10.2 
UVA Institutional Review Board for Health Sciences Research .................................. 67 
10.3 
Consent Forms and the Consenting Process ................................................................... 67 
10.4 
Maintenance of Study Documents ................................................................................... 67 
10.5 
Compliance with Trial Registration and Results Posting Requirements ..................... 67 
10.6 
Data Collection .................................................................................................................. 68 
 Endpoint Data ................................................................................................................. 68 
10.7 
Data Safety Monitoring Plan ........................................................................................... 68 
10.8 
DSMC Monitoring Schedule ............................................................................................ 68 
11.0 
APPENDICES ....................................................................................................................... 69 
11.1 
ECOG Performance Status .............................................................................................. 69 
11.2 
Common Terminology Criteria for Adverse Events V4.0 (CTCAE) ........................... 69 

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11.3 
Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 Criteria for 
Evaluating Response in Solid Tumors ............................................................................ 69 
11.4 
Summary of Changes ........................................................................................................ 70 
 
 
 
 

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1.0 TRIAL SUMMARY 
Abbreviated Title 
Focused Ultrasound combined with Pembrolizumab in Metastatic Breast 
Cancer 
Trial Phase 
Pilot 
Clinical Indication 
Metastatic Breast Cancer 
Trial Type 
Investigator Initiated 
Type of control 
N/A 
Route of administration 
IV 
Trial Blinding 
N/A 
Treatment Groups  
Arm A: Pembrolizumab after High-Intensity Focused Ultrasound (HIFU) 
Arm B: Pembrolizumab before High-Intensity Focused Ultrasound (HIFU) 
Number of trial subjects 
Up to 15 
Estimated enrollment period 2 years 
Estimated duration of trial 
3 years 
Duration of Participation 
90 days to 2 years 
Estimated average length of 
treatment per patient 
90 days 
 
 
 
2.0 TRIAL DESIGN 
2.1 
Trial Design 
This is a two-arm pilot study of High-Intensity Focused Ultrasound (HIFU) and immunotherapy. The 
goals of the study are to obtain preliminary data on the safety of HIFU with immunotherapy, delivered 
concurrently, and to obtain preliminary estimates of change in T-cell frequency and activation for HIFU 
alone (day 15-21 of ARM A) and pembrolizumab and HIFU given in combination (day 15-21 of arm 
B).  The central hypothesis is that focused energy induced immunogenic cell death will overcome 
limitations in antigen availability, and effective T-cell responses, and thereby enhance immune-therapy 
of advanced breast cancer. Our secondary hypothesis is that concomitant immune-activation will 
further augment CD8+ T-cell responses to tumor antigen released by HIFU.  We will obtain preliminary 
data on whether HIFU promotes the presence of CD8+ T-cells in ablated primary tumors, blood and 
non-ablated distant metastases.  Additional correlative science endpoints will be tested as exploratory 
endpoints. 
Eligible subjects will be randomized 1:1 to the investigational treatments (Arm A) or (Arm B). Subjects 
on both arms will undergo HIFU treatment on day 15.   Subjects randomized to Arm A will receive 
pembrolizumab administered IV every 3 weeks on days 22, 43, and 64. Subjects randomized to Arm B 
will receive pembrolizumab administered IV every 3 weeks on days 1, 22, 43 and 64.  In all subjects, 
restaging breast cancer-dedicated chest, abdomen and pelvic CT scan will be performed at baseline and 
cycle 4. Biopsies of tumors treated with HIFU will be completed on all patients at days 1 and 22 with 
optional distant tumor site biopsies and additional biopsies of the HIFU treated breast lesion to be 
completed at day 64.  The tissue removed at the biopsies will be evaluated as part of the immunologic 
correlative studies.  
 

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2.2 
Trial Diagram 
 
3.0 OBJECTIVES & HYPOTHESES 
3.1 
Primary Objectives & Hypotheses 
Objective: To determine whether the addition of pembrolizumab to HIFU increases the 
proportion of CD8+ tumor infiltrating lymphocytes (ratio CD8+/CD4+) in the primary ablation 
zone of advanced or metastatic breast cancer.   
Hypothesis:  Focused energy induced immunogenic cell death is hypothesized to improve 
antigen availability, dendritic cell activity, effective T-cell responses. In combination with 
pembrolizumab, it is hypothesized that CD8+/CD4+ ratio in the ablation zone will increase by 
25%.   
3.2 
Secondary Objectives & Hypotheses 
Objective: To assess the adverse event profile of pembrolizumab and HIFU  
Hypothesis:  The combination of pembrolizumab and HIFU will result in adverse event profiles 
similar to previously reported profiles for each modality given alone. 

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3.3 
Exploratory Objectives 
(1) Objective:  To compare CD8+ T-cell responses at peri-ablation zones when pembrolizumab 
is given before or after HIFU.  (CD8+/CD4+ ratios compared between arms) 
 
(2) Objective:  To evaluate clinical responses at local and distant metastatic sites by CT scan as 
measured by RECIST 1.1. 
 
(3) Objective: To estimate the progression free survival (PFS) of breast cancer subjects treated 
with HIFU in combination with pembrolizumab. 
 
(4) Objective:  To estimate the overall survival (OS) of subjects with breast cancer treated with 
HIFU in combination with pembrolizumab.  
 
(5) Objective:  To evaluate immune responses to HIFU plus pembrolizumab by flow cytometric, 
immunohistochemical, cytokine, or other methods.    
 
4.0 BACKGROUND & RATIONALE 
4.1 
Background 
Refer to the Investigator’s Brochure (IB)/approved labeling for detailed background information on 
MK-3475. 
 
Pharmaceutical and Therapeutic Background 
The importance of intact immune surveillance in controlling outgrowth of neoplastic transformation 
has been known for decades.  Accumulating evidence shows a correlation between tumor-infiltrating 
lymphocytes (TILs) in cancer tissue and favorable prognosis in various malignancies.  In particular, the 
presence of CD8+ T-cells and the ratio of CD8+ effector T-cells / FoxP3+ regulatory T-cells seems to 
correlate with improved prognosis and long-term survival in many solid tumors. 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune 
control.  The normal function of PD-1, expressed on the cell surface of activated T-cells under healthy 
conditions, is to down-modulate unwanted or excessive immune responses, including autoimmune 
reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig superfamily member related to CD28 and CTLA-
4 which has been shown to negatively regulate antigen receptor signaling upon engagement of its 
ligands (PD-L1 and/or PD-L2).  The structure of murine PD-1 has been resolved.  PD-1 and family 
members are type I transmembrane glycoproteins containing an Ig Variable-type (V-type) domain 
responsible for ligand binding and a cytoplasmic tail which is responsible for the binding of signaling 
molecules.  The cytoplasmic tail of PD-1 contains 2 tyrosine-based signaling motifs, an 
immunoreceptor tyrosine-based inhibition motif (ITIM) and an immunoreceptor tyrosine-based switch 
motif (ITSM).  Following T-cell stimulation, PD-1 recruits the tyrosine phosphatases SHP-1 and SHP-
2 to the ITSM motif within its cytoplasmic tail, leading to the dephosphorylation of effector molecules 
such as CD3ζ, PKCθ and ZAP70 which are involved in the CD3 T-cell signaling cascade.  The 
mechanism by which PD-1 down modulates T-cell responses is similar to, but distinct from that of 
CTLA-4 as both molecules regulate an overlapping set of signaling proteins.  PD-1 was shown to be 
expressed on activated lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, T regs and 
Natural Killer cells.  Expression has also been shown during thymic development on CD4-CD8- 

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(double negative) T-cells as well as subsets of macrophages and dendritic cells.  The ligands for PD-1 
(PD-L1 and PD-L2) are constitutively expressed or can be induced in a variety of cell types, including 
non-hematopoietic tissues as well as in various tumors.  Both ligands are type I transmembrane 
receptors containing both IgV- and IgC-like domains in the extracellular region and contain short 
cytoplasmic regions with no known signaling motifs.  Binding of either PD-1 ligand to PD-1 inhibits 
T-cell activation triggered through the T-cell receptor.  PD-L1 is expressed at low levels on various 
non-hematopoietic tissues, most notably on vascular endothelium, whereas PD-L2 protein is only 
detectably expressed on antigen-presenting cells found in lymphoid tissue or chronic inflammatory 
environments.  PD-L2 is thought to control immune T-cell activation in lymphoid organs, whereas PD-
L1 serves to dampen unwarranted T-cell function in peripheral tissues.  Although healthy organs 
express little (if any) PD-L1, a variety of cancers were demonstrated to express abundant levels of this 
T-cell inhibitor.  PD-1 has been suggested to regulate tumor-specific T-cell expansion in subjects with 
melanoma (MEL).  This suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune 
evasion and should be considered as an attractive target for therapeutic intervention. 
Pembrolizumab is a potent and highly selective humanized monoclonal antibody (mAb) of the 
IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-L1 and 
PD-L2.  KeytrudaTM (pembrolizumab) is approved in the United Stated for the treatment of unresectable 
or metastatic melanoma, certain metastatic non-small cell lung cancers, and recurrent or metastatic head 
and neck squamous cell carcinoma (HNSCC) with disease progression on or after platinum-containing 
chemotherapy. 
 
Preclinical and Clinical Trial Data 
Refer to the Investigator’s Brochure for Preclinical and Clinical data. 
4.2 
Rationale 
 
Breast Cancer 
Breast Cancer remains the most common non-skin cancer in women and remains the number two cause 
of cancer mortality in women in the United States.  Metastatic breast cancer is incurable with a 5 year 
overall survival of 22%.  There are no curative therapies for metastatic breast cancer at this time.  
Nevertheless, immunotherapies in breast cancer and other solid tumors have provided long-term 
disease-free intervals of clinical benefit.  Indeed, some breast cancers generate immune recognition, 
though complete immunologic rejection remains rare at least for breast cancers (1, 2). It is thus not 
surprising that spontaneous regressions are rare for breast cancer.  Accordingly, the density of NK and 
cytotoxic T cell infiltrates within breast tumors is generally low, compared to melanoma or renal cell 
carcinoma (3, 4). Furthermore the circulating NK and T cells display significant dysfunction in the 
setting of breast cancer (5). Due to these concerns, breast cancer has not received much attention for 
immunotherapy until recently. We now know that  dampened immune responses in breast cancer are 
partly due to release of type 1 interferons, the recruitment of myeloid derived suppressor cells 
(MDSC’s), recruitment of T regulatory cells and expression of PD-L1 on some breast carcinomas (1, 
2).  Recent clinical data indicates that checkpoint blockade and other immunotherapies can break the 
immune privilege enjoyed by many breast cancers (6, 7).  Further, Cimino-Mathews et al. elegantly 
demonstrated that treatment-naive PBCs contain both PD-L1+ TILs (78% of studied tumors) and PD-
L1+ carcinoma cells (21% of tumors) which were primarily localized to the invasive fronts of tumor 
cell nests (2). Further PD-L1+ carcinomas were more likely to contain PD-L1+, CD3+, CD4+, CD8+, and 
FoxP3+ T cells, but not B cells. They also observed that all PD-L1+ primary breast cancers were 

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associated with peripheral lymphoid aggregates, where less than half of PD-L1 negative primary breast 
cancers had lymphoid aggregates. 
Clinical experience with immune modulators in breast cancer has been encouraging in the triple 
negative subset of patients and patients with pre-existing immune infiltrates (1, 6-8).  There is modest 
clinical outcome and survival data for immunotherapy in breast cancer as noted in the Nanda trial and 
from abstracts at national meetings (7, 9, 10), but data from large, randomized studies is not yet mature. 
Immunotherapy, including PD-1 blockade, is thought to prime the immune system more effectively 
when tumor antigens are released in the context of a locally stimulating microenvironment rather than 
in tolerogenic environments.  For example, a CTLA4 inhibitor performed better against solid tumors 
when given with local ablation by radiation (11) and with cryotherapy (12, 13).  Additionally, there are 
several reports of superior performance of combinations of immune modulators over single modality 
therapies (i.e., vaccines, TLR agonists, cytokines, checkpoint inhibitors, etc.)  Several combination 
trials of immunotherapy with radiation, chemotherapy, hormonal therapy or tumor ablation are 
ongoing.     
 
Rationale for the Trial and Selected Subject Population 
High Intensity Focused ultrasound (HIFU) is an ablative therapy which can heat tumors (2mm-5cm) 
rapidly to cell-lethal temperatures and simultaneously perturb the microenvironment, the 
microvasculature, and the lymphatics.  At typical energy levels, HIFU can preferentially induce 
controlled apoptotic cell death rather than liquefactive necrosis. HIFU does not involve radiation and 
is not believed to be mutagenic.  Instead, heat shock proteins, cytokine release and cellular mediated 
mechanisms predominate and are documented to result in systemic CD8+ T cell recognition of tumor 
antigens (14). HIFU has been demonstrated to be an effective method for inducing antigen exposure 
and presentation to dendritic cells, thus rending HIFU an auto-vaccine in some regards (15, 16). 
HIFU ablation of a single site of disease administered in combination with systemic immunotherapy 
may achieve control of systemic disease. Such a response would be tantamount to the described 
abscopal effect. In autochothonous mouse models, our group showed additive effects of combining 
HIFU with various immunotherapies (unpublished).  We have also studied HIFU for drug delivery in 
several ongoing HIFU studies using devices with 
IDE clearance. Other immune stimulating effects of 
HIFU have been recently reviewed by Unga and Wu 
(14, 17).  
The University of Virginia is an internationally 
recognized center for focused ultrasound research in 
pre-clinical and clinical studies. We are currently 
conducting the first clinical trial of the Theraclion 
HIFU device in the US for the treatment of breast 
fibroadenoma. No serious AE’s have been seen in 
over 200 patients treated with the Theraclion HIFU 
device in Europe.   
Positive results from the MSKCC clinical study of 
cryotherapy plus ipilimumab in early stage breast 
cancer (presented at ASCO 2014) further support the development of combinatorial studies for the 
treatment of breast cancer. These data and experience in a phase Ib metastatic breast cancer study 

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provide a strong rationale for the immune stimulating role of pembrolizumab in breast cancer (7).  
Furthermore, there is encouraging safety data for combinations of pembrolizumab with various 
chemotherapeutic agents, radiation and surgery.  We propose that the combination of HIFU and 
pembrolizumab will be safe and synergistic to allow better antigen presentation, immune recognition 
of breast cancer and possibly even result in improved disease control at local and distant sites of disease. 
The inclusion of patients with advanced metastatic disease is justified because there are no curative 
therapies for metastatic breast cancer and the existing therapies have intolerable toxicities.  
Additionally, the inclusion of patients who experience disease progression by rising tumor marker is in 
alignment with current standards of care in metastatic breast cancer.  Indeed, the earlier that progressive 
disease is identified, the more likely that patients will benefit from a later line of therapy and the less 
likely that a given patient will experience a major complication due to bulky disease. The same rationale 
is applied to minor subset of patients who become intolerant of endocrine therapies.  When intolerance 
occurs, the existing standard of care is to switch to cytotoxic therapies, but occasional patients will elect 
treatment holiday rather than risking treatment with a cytotoxic agent.  Thus, the sub-population of 
endocrine intolerant metastatic breast cancer patients should also be afforded the same opportunities to 
participate in clinical trials (see inclusion criteria number 4). 
 
High Intensity Focused Ultrasound (HIFU)  
The use of high intensity focused ultrasound (MRI guided or ultrasound guided) has been tested in 
different types of soft tissue cancer such as prostate cancer, liver cancer and breast cancer (18). High 
Intensity Focused Ultrasound (HIFU) is a non-invasive alternative to surgery.  In HIFU, high-energy 
ultrasound is used to deliver a large amount of sound energy to a focal point to rapidly induce tissue 
heating to 85° - 90°C. This initiates tissue coagulation followed by tissue necrosis to ablate the targeted 
area. To minimize non-target tissue damage, the ultrasound is focused using MRI or ultrasound. This 
study proposes to use an ultrasound-focused HIFU device, the EchoPulse (Theraclion).  Echopulse is a 
computer-driven system comprised of an Electronics Cabinet, an extra-corporal probe (VTU – 
Visualization Treatment Unit) mounted on an arm and moved by motors, a cooling unit (EPack) and 
an ultrasound imaging scanner. This device has been used in prior European studies of head and neck 
pathologies, including thyroid and parathyroid nodules, and in breast fibroadenoma (32, 33, 34, 35).  
Echopulse is CE marked by Theraclion for treating nodules within the thyroid and parathyroid glands 
and for breast fibroadenomas. 
 
HIFU in Head and Neck Malignancies  
Since November 1st 2007, EchoPulse (Theraclion) has been CE marked for HIFU treatment of neck 
pathologies. 11 patients with primary hyperparathyroidism have been treated and followed in a clinical 
trial. The mean follow-up is 9.5 months (1-28 months).  
The Echopulse device has been tested in patients (n=25) scheduled for thyroidectomy for multi-nodal 
goiter (19). Prior to thyroidectomy, HIFU was applied to a single thyroid nodule and the effect on size 
and function were evaluated pre- and post-treatment. Three patients were discontinued due to adverse 
events and 22 patients completed the study.  Reductions in node volumes were observed in 16 of 22 
patients (2 – 80% reduction). This pilot study was extended to include patients with benign thyroid 
nodules. Overall, 21 patients were treated with HIFU versus 11 untreated patients in the control group. 
The follow up of this study has been completed. No serious adverse events (SAE) were reported. The 
analysis is currently available (19). 

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The following side effects have been observed in patients with the HIFU device for primary 
hyperparathyroidism: 
• 
Mild to moderate pain during treatment 
• 
Potential fatigue following the treatment 
• 
Edema of the subcutaneous tissue which recovered within up to one month without any directed 
treatment. 
• 
Dysphonia which may last up to 3 months. Normal voices were recovered in all cases. 
• 
Mild to moderate decrease in the mobility of the vocal cord on the same side of the gland 
treated. This lasted for up to 6 months in rare cases. All cases were transient.  
 
 
HIFU in Breast Fibroadenoma  
EchoPulse was first evaluated for the treatment of breast fibroadenomas between May 2011 and 
February 2013 in a pilot feasibility study performed in four sites in France and Bulgaria.   Fifty-one 
fibroadenomas in 42 patients were treated. The average treatment time was 1h12min (0h26-2h33). 
Volume reductions are described in Table 1:  Volume reduction over time. The HIFU treatment was 
well tolerated. In 36% of the cases, post-treatment skin irritation and erythema were observed, although 
both toxicities spontaneously resolved 1 month following treatment (20).  
Table 1:  Volume reduction over time  
Follow-up period (months) 
Patients (n) 
Mean volume reduction (%) 
M2 
39 
33.6±19.2  
M4 
33 
48.7±22.7  
M6 
26 
57.5±15.7  
M9 
11 
66.2±11.9  
M12 
7 
68.8±11.4  
M18 
2 
69.2±5.0   
 
 
Rationale for Combination 
The goal of the proposed study is to establish the feasibility, safety, and 
effectiveness of non-invasive HIFU therapy in combination with 
pembrolizumab for the treatment of metastatic breast tumors. To 
date, there have been publications of excellent response rates to PD-
1 antibody therapy in triple negative breast cancer, but the responses 
in estrogen receptor positive breast cancer have been lower. 
In order to extend immunotherapy to a broader spectrum of the 
breast cancer population (such as estrogen receptor positive 
tumors), we propose to combine pembrolizumab with a local tissue 
injury to enhance antigen presentation to dendritic cells and render 
the microenvironment more stimulatory to immune activation (21).  It is known that an insult to a part 
of a tumor leads to an increase in activated, specific T cell responses to newly exposed tumor antigens 
throughout the whole tumor (22).  Sub-total thermal injury thus acts as an autologous vaccine, 
especially in the sub-lethal zone around an ablation site (23). Indeed, CTLA4 inhibition with 
cryoablation had an additive immune effect in breast cancer (24).  
Figure 2 

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We propose the use of a non-invasive thermal ablation combined with pembrolizumab to assess 
immune synergy. Our ablation modality of HIFU is a safe and readily available technology for delivery 
of both thermal and mechanical tissue disruption for multiple tumor types. HIFU can heat tumor rapidly 
to 45-90°C. We tune HIFU power and patterns to induce controlled apoptotic cell death rather than 
liquefactive necrosis (25). Thus HIFU treatment of tumors results in heat shock protein responses, 
cytokine release, dendritic cell (DC) maturation, migration as well as T and NK cell activation and 
trafficking (25-29).  We show here in Figure 3, our group’s work on HIFU in mouse studies. 
A 
B 
 
C 
 
Figure 3.  Direct and abscopal antitumor effects of ultrasound-mediated tumor cell apoptosis.  C57BL6 
mice bearing 2 subcutaneous B16 melanoma deposits, on the left flank (primary tumor) and right flank 
(secondary tumor), were treated with ultrasound (1.0 MHz, ~1.0 MPa, 100 burst count every 5 seconds, 10 
min duration) at the “primary” tumor (A).  Control mice were not treated.  The growth of each tumor was 
measured over time after treatment (or control) of the primary tumor.  US treatment of the primary tumor led 
to marked slowing of growth of the primary tumor (B), and also led to marked growth delay of the 
“secondary” tumor in the same mouse (C).  (unpublished data from Kumari Andarawewa) 
It is observed that sub-ablative tumor disruption by FUS is novel and immunologically relevant. Sub-
ablative FUS treatment results in recognition of a larger array of epitopes than surgery in clinical and 
preclinical studies (16, 25, 27). FUS combined with immunotherapy in mice results in increased 
myeloid, NK and T cell responses locally and systemically compared to either modality alone (20, 25-
30).  FUS alone was shown to induce immune response in tumors and specifically, sub-ablative FUS 
achieved controlled apoptosis with efficient antigen delivery to DC’s; NK and TIL infiltrations were 
also enhanced (25, 26, 29, 31).  FUS is also believed to help prevents T cell tolerance (15). FUS 
stimulates T cell infiltration into breast tumors as shown by studies examining the microenvironment 
(15, 16, 32, 24, 25). 
Additionally, HIFU may enhance drug delivery to the tumor site. FUS increases capillary leakage and 
local chemokine release, thus augmenting drug delivery and T-cell trafficking (25, 33-35).  Additional 
rationale is that anti-PD-1 antibodies and FUS have largely non-overlapping toxicities. The toxicities 
for both treatments are minimal. FUS is non-invasive and performed with mild sedation (20, 30, 31). 
We are currently studying HIFU in breast fibroadenomas and bone metastases from any solid tumor 
(NCT02078011 and NCT00656305). No serious AE’s have been seen in over 200 patients treated with 
HIFU for breast diseases to date.  HIFU is safer and easier to contour than other ablative therapies. 
Other therapies produce spherical ablation zones, whereas HIFU can be contoured and carefully tuned 
to sub-ablative power for individual tumors. Patients and providers are motivated by these technical 
improvements (27). 

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In this pilot study, we will test pembrolizumab therapy in combination with HIFU to assess for 
enhanced immune stimulation and antitumor effects at local ablation sites, distant, non-treated sites and 
in the blood.  Biopsy data from before and after therapy with pembrolizumab and HIFU will 
demonstrate both immunologic and tumor responses to the combined therapy proposed.  We will 
examine the tissue in the peripheral zone of ablation as well as distant metastatic sites for CD8 and 
CD4 T cells with additional analyses of MDSC’s, T-regulatory cells and cytokine responses as as tissue 
quantity permits. 
4.3 
Rationale for Dose Selection for Pembrolizumab 
The planned dose of pembrolizumab for this study is 200 mg every three weeks (Q3W). Based on the 
totality of data generated in the Keytruda development program, 200mg Q3W is the appropriate dose 
of pembrolizumab for adults across all indications and regardless of tumor type. As outlined below, 
this dose is justified by: 
• 
Clinical data from 8 randomized studies in melanoma and NSCLC indications demonstrating 
flat dose- and exposure-efficacy relationships from 2 mg/kg Q3W to 10 mg/kg  Q2W, 
representing an approximate 5- to 7.5-fold exposure range (refer to IB, Section 5.2.2) 
• 
Population PK analysis showing that both fixed dosing and weight-based dosing provides 
similar control of PK variability with considerable overlap in the distributions of exposures, 
supporting suitability of 200 mg Q3W 
• 
Clinical data showing meaningful improvement in benefit-risk including overall survival at 200 
mg Q3W across multiple indications, and 
• 
Pharmacology data showing full target saturation in both systemic circulation (inferred from 
pharmacokinetic [PK] data) and tumor (inferred from physiologically-based PK [PBPK] 
analysis) at 200 mg Q3W 
A fixed dose regimen will simplify the dosing regimen to be more convenient for physicians and to 
reduce potential for dosing errors.  A fixed dosing scheme will also reduce complexity in the logistical 
chain at treatment facilities and reduce wastage. 
4.4 
Rationale for Endpoints 
This study is designed primarily to test whether interfering with immune suppression by blocking the 
molecular interaction between the PD-1 receptor and its cognate ligand, PD-L1, increases the number 
and activation of TILs that are induced by the local ablative therapy.   
The study is also designed to examine the safety of HIFU and pembrolizumab. HIFU therapy for breast 
lesions and breast cancer is generally well tolerated. Based on our experience at UVA (n=20) there has 
been no evidence of grade 4 toxicities in patients who received HIFU.  Pembrolizumab has been studied 
in numerous clinical trials to date and was found to be well tolerated with no dose-limiting toxicities at 
the standard dose of 200 mg (see Investigator’s Brochure). Our proposed study is the first study to 
combine HIFU and pembrolizumab in humans and safety is our secondary endpoint. 
 
Biomarker Research 
This study will examine the effect of pembrolizumab in combination with HIFU on select immune 
mediators by estimating the difference in post-treatment expression of tissue immune biomarkers for 
two treatment groups. In addition, blood samples collected at various time points pre- and post- 

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treatment will allow us to evaluate the effect of this treatment on different subsets of circulating immune 
cells. Tissue quantity may limit some assays and therefore biomarker examinations are prioritized as 
indicated in Section 7.1.2.8.1. 
 
CD4/CD8 infiltrating effector T cells (TILs)  
As described in the background, the CD4/CD8 infiltrating effector T cells (TILs) are not frequently 
observed to be present in breast cancer, however, when present they correlate with better outcomes 
(36). HIFU is one modality that is suggested to increase homing of T cells to cancer sites (37). Our 
hypothesis is that targeting the host immunosuppression by blocking the PD-1/PDL-1 interaction may 
enhance the number or activity of TILs and potentially improve the outcomes of metastatic or 
unresectable breast cancer patients. 
T-Cell activation markers  
When activated, T-cells start to express activation markers such as CD45RO, CD57, CD69, Granzyme 
B, Ki67, and MHC-1. In order to study the effect of pembrolizumab plus HIFU on the activation of 
effector T-cells, expression of these activation markers in the biopsy samples and peripheral blood will 
be assessed at baseline and at the day 22 biopsy.  Similarly, peripheral blood will also be analyzed at 
all the time points listed in trial diagram in section 2.2.  Additional markers may be added or subtracted 
during the course of analysis as deemed necessary. 
Myeloid markers 
A major mechanism of resistance for immunotherapy in breast cancer is thought to be tumor associated 
macrophages and myeloid derived suppressor cells. A standard myeloid panel containing CD11b, 
CD33, HLA-DR, CD14 and CD15 is planned for flow cytometric analysis of tumor lysates.  Additional 
IHC staining using these markers may be performed if adequate tissue is available. 
T regulatory cells (T-regs)  
T regulatory cells (FoxP3+CD4+CD25+) are another subset of tumor infiltrating lymphocytes (TILs) but 
they are known for their immunosuppressive activity. Patients with breast tumors that have low T-regs 
were found to have better survival compared to tumors with high T-regs (38). Accordingly, the effect 
of adding pembrolizumab to FUS on the number of T-regs may be assessed in the tumor tissue and the 
peripheral blood depending on tissue availability.  
PD-L1 expression on breast tumor  
The expression of PD-L1 in breast cancer was reported in 8% to 38% of surgical samples and was 
found to negatively affect survival (39-41). Here we hypothesize that adding pembrolizumab will block 
the interaction of PDL1/2 with PD-1, releasing the break on the immune system and leading to an 
enhanced immune response against the breast cancer. Accordingly, the expression of PD-L1 in breast 
cancer tissues may be assessed in this trial if adequate tissue remains after primary biomarker analyses 
are exhausted.  
PD-1 expression on TILs and PBMC’s  
The program cell death (PD-1) is induced on T cells, B cells, and monocytes on activation and it 
interacts with its ligand PD-L1 to down modulate the immune system. It is of interest to evaluate how 
blocking the PD-1/PD-L1 interaction may affect the expression of PD-1 on T-cells.  Since PD-1 assays 
may be complicated by the presence of pembrolizumab, PD-1 may be assessed by a gene expression 
assay (qRT-PCR) on PBMC’s and/or tumor biopsy samples.  
 

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Chemokines 
This study may include additional analysis of chemokines and homing ligands on endothelial cells as a 
function of HIFU.  Trafficking of activated T cells to treated tumors is anticipated to be augmented by 
both HIFU and the application of pembrolizumab.  Potential assays for breast biopsy tissue may 
include, but are not limited to the following: CXCR4, CXCL12, CCL18 (co-assay with CD68), CXCL9, 
CXCL10, IL-10, and TGF-β.  Potential assays for any bone biopsies may include: CCL2, CX3CL1, 
CX3CR1, IL-10 and TGF-β.   
 
5.0 METHODOLOGY 
5.1 
Entry Criteria 
 
Diagnosis/Condition for Entry into the Trial 
• 
Subjects with histologically confirmed metastatic or unresectable breast cancer (male or 
female) 
 
Subject Inclusion Criteria 
In order to be eligible for participation in this trial, the subject must: 
1. Be willing and able to provide written informed consent/assent for the trial. 
2. Must be determined to have metastatic or unresectable disease, as determined by treating 
physician. (Must have at least evaluable disease, but does not need to be measurable disease by 
RECIST 1.1) 
3. Any receptor status (estrogen receptor, progesterone receptor, HER2 receptor). Patients who 
are HR+ should also no longer be candidates for hormonal-based therapy.  Patients who are 
HER2+ should have progressed on or no longer be candidates for available HER2 directed 
therapy. Hormonal therapy must be stopped prior to day 1 of treatment. 
4. Patients must have had at least one prior line of therapy for breast cancer in the 
metastatic/unresectable setting. Patients demonstrating a rising tumor marker during a line of 
therapy or demonstrating intolerance of a standard or investigational therapy meet this criteria 
(includes endocrine or chemotherapy or targeted therapy). 
5. Patients must have an accessible lesion in the breast/chest wall/axilla which has not been 
previously thermally ablated.  Prior breast irradiation is acceptable if the lesion has recurred or 
grown following radiation.  
The chest wall is defined per the National Cancer Institute at the National Institutes of Health 
(NCI) as: the skin, fat, muscles, bones, and other tissues that form a protective structure around 
vital organs in the area between the neck and the abdomen, including the heart, major blood 
vessels, lungs, and liver. The bones in the chest wall include the ribs, sternum (breastbone), 
and spine. The chest wall also helps support breathing and movement of the upper arms and 
shoulders. 

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“https://www.cancer.gov/publications/dictionaries/cancer-terms/def/chest-wall” 
[Accessed 
5/7/2019] 
6. Subjects must have at least one target lesion in breast/chest wall/axilla which is amenable to 
application of high intensity focused ultrasound: 
a. The distance from the skin: A targetable portion of the tumor must be 
≥ 5 mm from the skin 
b. the rib cage should not be in the prefocal ultrasound path or behind the target 
area of the lesion (minimum distance from the posterior aspect of the target 
area to rib cage must be at least 10 mm).  
c. subject’s tumor must be larger than 9 mm in the anterior-posterior dimension 
(measured by ultrasound).  
d. subject’s tumor must be greater than or equal to 0.3 cubic centimeters. 
7. Subject must be ≥ 18 years of age on day of signing informed consent. 
8. Be willing to provide tissue from a newly obtained core or excisional biopsy of a tumor lesion.   
9. Have a performance status of 0-2 on the ECOG Performance Scale. 
10. Demonstrate adequate organ function as defined in Table 2.   
Table 2:  Adequate Organ Function Laboratory Values 
System 
Laboratory Value 
Hematological 
 
Absolute neutrophil count (ANC) 
≥1,500 /mcL 
Platelets 
≥100,000 / mcL 
Hemoglobin 
≥9 g/dL or ≥5.6 mmol/L without transfusion or EPO dependency 
(within 7 days of assessment) 
Renal 
 
Serum creatinine OR 
Measured or calculateda creatinine 
clearance 
(GFR can also be used in place of 
creatinine or CrCl) 
≤1.5 X upper limit of normal (ULN) OR 
 
≥60 mL/min for subject with creatinine levels > 1.5 X 
institutional ULN 
Hepatic 
 
Serum total bilirubin 
≤ 1.5 X ULN OR 
 
Direct bilirubin ≤ ULN for subjects with total bilirubin levels > 
1.5 ULN 
AST (SGOT) and ALT (SGPT) 
≤ 2.5 X ULN  OR 
≤ 5 X ULN for subjects with liver metastases 
Albumin 
>2.5 mg/dL 
Coagulation 
International Normalized Ratio (INR) or 
Prothrombin Time (PT) 
 
Activated Partial Thromboplastin Time 
(aPTT) 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 

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aCreatinine clearance should be calculated per institutional standard. 
 
11. Female subject of childbearing potential should have a negative urine or serum pregnancy 
within 72 hours prior to receiving the first dose of study medication or study indicated 
ultrasound treatment.  If the urine test is positive or cannot be confirmed as negative, a serum 
pregnancy test will be required.   
12. Female subjects of childbearing potential (Section 5.7.2) must be willing to use an adequate 
method of contraception as outlined in Section 5.7.2 – Contraception,  for the course of the 
study through 120 days after the last dose of study medication. 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the 
subject. 
13. Male subjects of childbearing potential (Section 5.7.2) must agree to use an adequate method 
of contraception as outlined in Section 5.7.1- Contraception, starting with the first dose of study 
therapy through 120 days after the last dose of study therapy. 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the 
subject. 
 
Subject Exclusion Criteria 
The subject must be excluded from participating in the trial if the subject: 
1. Is currently participating and receiving study therapy or has participated in a study of an 
investigational agent and received study therapy or used an investigational device within 4 
weeks of the first dose of treatment. 
2. Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other form 
of immunosuppressive therapy within 7 days prior to the first dose of trial treatment.  Systemic 
corticosteroids of less than 10 mg per day of prednisone (or equivalent) are allowed. Topical 
corticosteroids are acceptable, including steroids with very low solubility administered nasally 
for local effects only (e.g. Nasonex®).  
  
3. Has a known history of active TB   (Bacillus Tuberculosis) 
 
4. Hypersensitivity to pembrolizumab or any of its excipients. 
5. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study Day 1 
or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents 
administered more than 4 weeks earlier. 
6. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 
weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from 
adverse events due to a previously administered agent. 
- 
Note:  Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and may 
qualify for the study. 

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- 
Note:  If subject received major surgery or radiation, they must have recovered 
adequately from the toxicity and/or complications from the intervention prior to 
starting therapy.   
- 
Note: anti-estrogen therapy must be stopped prior to study Day 1. 
7. Has a known additional malignancy that is progressing or requires active treatment.  Exceptions 
include basal cell carcinoma of the skin or squamous cell carcinoma of the skin that has 
undergone potentially curative therapy or in situ cervical cancer. 
8. Has known active central nervous system (CNS) metastases and/or carcinomatous meningitis.  
Subjects with previously treated brain metastases may participate provided they are stable 
(without evidence of progression by imaging within four weeks prior to registration and any 
neurologic symptoms have returned to baseline), have no evidence of new or enlarging brain 
metastases, and are not using steroids for at least 7 days prior to trial treatment.  This exception 
does not include carcinomatous meningitis which is excluded regardless of clinical stability.   
9. Has active autoimmune disease that has required systemic treatment in the past 2 years (i.e. 
with use of disease modifying agents, corticosteroids or immunosuppressive drugs). 
Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid replacement therapy 
for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment.  
10. Has a history of (non-infectious) pneumonitis/interstitial lung disease that required steroids or 
current pneumonitis/interstitial lung disease. 
11. Has an active infection requiring systemic therapy. 
12. Has a history or current evidence of any condition, therapy, or laboratory abnormality that 
might confound the results of the trial, interfere with the subject’s participation for the full 
duration of the trial, or is not in the best interest of the subject to participate, in the opinion of 
the treating investigator.   
13. Has known psychiatric or substance abuse disorders that would interfere with cooperation with 
the requirements of the trial. 
14. Is pregnant or breastfeeding, or expecting to conceive or father children within the projected 
duration of the trial, starting with the pre-screening or screening visit through 120 days after 
the last dose of trial treatment. 
15. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent within the prior 
24 weeks. 
16. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies). 
17. Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA 
[qualitative] is detected). 
18. Has received a live vaccine or live attenuated vaccine within 30 days of planned start of study 
therapy. Administration of killed vaccines is allowed. 

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Note:  Seasonal influenza vaccines for injection are generally inactivated flu vaccines and are 
allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live attenuated vaccines, 
and are not allowed. 
19. HIFU must not be applied to a breast with an implant. A region outside of the breast may be 
targeted as long as the targeted area is at least 10mm away from an implant. 
5.2 
Trial Treatments 
The treatment to be used in this trial is outlined below in Table 3:  Trial Treatment 
Table 3:  Trial Treatment   
Arm 
Drug 
Dose 
Dose 
Frequency 
Route of 
Administration 
Regimen/Treatment 
Period 
Use 
A 
Pembrolizumab 
200 mg 
Q3W 
IV infusion 
Days 22, 43, 64 and 
Day 1 of each ensuing 
3 week cycle 
Experimental 
B 
Pembrolizumab 
200 mg 
Q3W 
IV infusion 
Days 1, 22, 43, 64 and 
Day 1 of each ensuing 
3 week cycle 
Experimental 
A/B 
Focused Ultrasound Tumor ablation1 
Day 15 
Experimental 
1Focused Ultrasound ablation should target 50% of the tumor, up to 3 cubic centimeters, not the entire tumor 
volume. See eligibility criteria for minimum tumor size parameters. There is no maximum tumor size parameter. 
See also section 5.2.1.2. 
Trial treatment should begin on the day of randomization or as close as possible to the date on which 
treatment is allocated/assigned. 
 
Dose Selection/Modification & Focused Ultrasound Administration 
 Pembrolizumab Dose Selection: 
The rationale for selection of doses to be used in this trial is provided in Section 4.0 – Background and 
Rationale.   
The commercial Pembrolizumab product provided by Merck will be prepared and administered per 
standard practice.    
 Focused Ultrasound Administration 
HIFU will be administered to sites of disease located in the breast/chest wall/axilla. The treatment will 
be delivered using local anesthesia, conscious sedation with local anesthesia, or general anesthesia. The 
choice of anesthesia will be determined by the treating physician for each individual patient. The patient 
will be placed in the lateral decubitus position, depending on the side of the tumor with the arm placed 
over the patient's head. The breast is then immobilized.  To mitigate damage to the rib cage, the clinician 
will confirm that the rib cage is not in the prefocal ultrasound path or behind the focal point (minimum 
distance behind the focal point = 10 mm). As the risk of HIFU on the lung parenchyma is not known 
at this time, for those patients treated with chest wall lesions the beam energy should always be oriented 
so that it does not reach the lung. Based on the images recorded at the inclusion visit, the physician 

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performing the therapy will perform the ultrasound (US) localization of the targeted area of the tumor 
(approximately 50% of the tumor volume, up to 3 cubic centimeters total ablated volume).  
The treatment head that will be used has a focal length of 38 mm.  
 
The treatment procedure of Echopulse consists of six treatment steps:  
- Pre-treatment ultrasonography  
- Positioning  
- Planning  
- Energy setting  
- Generation of HIFU treatment pulses in the volume defined above  
- Post-treatment visualization and final report.  
 
The targeted area for ablation and final assessed ablation parameters of the HIFU treatment will be 
recorded in the CRF.  
 
When a HIFU session is prematurely interrupted, the reason of interruption will be recorded in the CRF 
(adverse event, technical failure, others).  Due to the wide variability in tumor size, shape, depth, 
subcutaneous fat distributions, and vascularity, the energy settings will necessarily vary between 
patients, but effort will be made to keep ablation target zone close to the 50% target range and a 
maximum of 3 cubic centimeter area. 
Following the HIFU procedure, local application of ice may be applied to the affected area. 
 
Dose Modification  
Adverse events (both non-serious and serious) associated with pembrolizumab exposure may represent 
an immunologic etiology.  These adverse events may occur shortly after the first dose or several months 
after the last dose of treatment. Pembrolizumab must be withheld for drug-related toxicities and severe 
or life-threatening AEs as per Table 4 below. See Section 5.6 for supportive care guidelines, including 
use of corticosteroids. 
Table 4:  Dose Modification and Toxicity Management Guidelines for Immune-related AEs Associated 
with Pembrolizumab Monotherapy and IO Combinations 
General instructions: 
1. Severe and life-threatening irAEs should be treated with IV corticosteroids followed by oral steroids. Other 
immunosuppressive treatment should begin if the irAEs are not controlled by corticosteroids. 
2. Study intervention must be permanently discontinued if the irAE does not resolve or the corticosteroid dose is not 
≤10 mg/day within 12 weeks of the last study intervention treatment.  
3. The corticosteroid taper should begin when the irAE is ≤ Grade 1 and continue at least 4 weeks. 
4. If study intervention has been withheld, study intervention may resume after the irAE decreased to ≤ Grade 1 after 
corticosteroid taper. 
irAEs 
Toxicity 
Grade 
(CTCAE 
v5.0) 
Action With 
Pembrolizumab 
Corticosteroid and/or 
Other Therapies 
Monitoring and Follow-up 

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Pneumonitis  
Grade 2 
Withhold  
•  Administer corticosteroids 
(initial dose of 1 to 2 mg/kg 
prednisone or equivalent) 
followed by taper 
•  Add prophylactic antibiotics 
for opportunistic infections 
•  Monitor participants for signs and 
symptoms of pneumonitis 
•  Evaluate participants with 
suspected pneumonitis with 
radiographic imaging and initiate 
corticosteroid treatment 
 
Recurrent 
Grade 2,  
Grade 3 or 
4  
Permanently 
discontinue 
Diarrhea/Coli
tis  
Grade 2 or 
3 
Withhold 
•  Administer corticosteroids 
(initial dose of 1 to 2 mg/kg 
prednisone or equivalent) 
followed by taper 
 
•  Monitor participants for signs and 
symptoms of enterocolitis (ie, 
diarrhea, abdominal pain, blood or 
mucus in stool with or without 
fever) and of bowel perforation 
(ie, peritoneal signs and ileus) 
•  Participants with ≥Grade 2 
diarrhea suspecting colitis should 
consider GI consultation and 
performing endoscopy to rule out 
colitis 
•  Participants with diarrhea/colitis 
should be advised to drink liberal 
quantities of clear fluids. If 
sufficient oral fluid intake is not 
feasible, fluid and electrolytes 
should be substituted via IV 
infusion 
Recurrent 
Grade 3 or 
Grade 4 
Permanently 
discontinue 
AST or ALT 
Elevation or 
Increased 
Bilirubin 
Grade 2 a 
Withhold 
•  Administer corticosteroids 
(initial dose of 0.5 to 1 mg/kg 
prednisone or equivalent) 
followed by taper 
•  Monitor with liver function tests 
(consider weekly or more 
frequently until liver enzyme 
value returned to baseline or is 
stable) 
Grade 3 b 
or 4 c 
Permanently 
discontinue 
•  Administer corticosteroids 
(initial dose of 1 to 2 mg/kg 

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prednisone or equivalent) 
followed by taper 
T1DM 
or 
Hyperglycem
ia 
New onset 
T1DM or  
Grade 3 or 
4 
hyperglyc
emia 
associated 
with 
evidence 
of 
β-cell 
failure 
Withhold d 
•  Initiate insulin replacement 
therapy for participants with 
T1DM 
•  Administer antihyperglycemic 
in participants with 
hyperglycemia 
 
•  Monitor participants for 
hyperglycemia or other signs and 
symptoms of diabetes 
Hypophysitis 
Grade 2 
Withhold 
•  Administer corticosteroids 
and initiate hormonal 
replacements as clinically 
indicated 
•  Monitor for signs and symptoms 
of hypophysitis (including 
hypopituitarism and adrenal 
insufficiency) 
Grade 3 or 
4 
Withhold 
or 
permanently 
discontinue d 
Hyperthyroidis
m 
Grade 2 
Continue 
•  Treat with nonselective beta-
blockers (eg, propranolol) or 
thionamides as appropriate 
•  Monitor for signs and symptoms 
of thyroid disorders 
Grade 3 or 
4 
Withhold 
or 
permanently 
discontinue d 
Hypothyroidi
sm 
Grade 2, 3 
or 4 
Continue 
•  Initiate thyroid replacement 
hormones (eg, levothyroxine 
or liothyronine) per standard 
of care 
•  Monitor for signs and symptoms 
of thyroid disorders 
Nephritis: 
grading 
according to 
increased 
creatinine or 
acute kidney 
injury 
Grade 2 
Withhold 
•  Administer corticosteroids 
(prednisone 1 to 2 mg/kg or 
equivalent) followed by taper 
•  Monitor changes of renal function 
Grade 3 or 
4 
Permanently 
discontinue 
Neurological 
Toxicities 
Grade 2 
Withhold 
•  Based on severity of AE 
administer corticosteroids 
•  Ensure adequate evaluation to 
confirm etiology and/or exclude 
other causes 
Grade 3 or 
4 
Permanently 
discontinue 
Myocarditis 
Grade 1 
Withhold 
•  Based on severity of AE 
administer corticosteroids 
•  Ensure adequate evaluation to 
confirm etiology and/or exclude 
other causes 
Grade 2, 3 
or 4 
Permanently 
discontinue 

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Exfoliative 
Dermatologic 
Conditions 
Suspected 
SJS, TEN, 
or DRESS 
Withhold 
•  Based on severity of AE 
administer corticosteroids 
•  Ensure adequate evaluation to 
confirm etiology or exclude other 
causes 
Confirme
d 
SJS, 
TEN, 
or 
DRESS 
Permanently 
discontinue 
All 
Other 
irAEs 
Persistent 
Grade 2 
Withhold 
•  Based on severity of AE 
administer corticosteroids 
•  Ensure adequate evaluation to 
confirm etiology or exclude other 
causes 
Grade 3 
Withhold 
or 
discontinue based 
on the event e  
Recurrent 
Grade 3 or 
Grade 4  
Permanently 
discontinue 
AE(s)=adverse event(s); ALT= alanine aminotransferase; AST=aspartate aminotransferase; CTCAE=Common Terminology Criteria for 
Adverse Events; DRESS=Drug Rash with Eosinophilia and Systemic Symptom; GI=gastrointestinal; IO=immuno-oncology; 
ir=immune related; IV=intravenous; SJS=Stevens-Johnson Syndrome; T1DM=type 1 diabetes mellitus; TEN=Toxic Epidermal 
Necrolysis; ULN=upper limit of normal. 
Note: Non-irAE will be managed as appropriate, following clinical practice recommendations. 
a AST/ALT: >3.0 to5.0 x ULN if baseline normal; >3.0 to 5.0 x baseline, if baseline abnormal;  
bilirubin:>1.5 to 3.0 x ULN if baseline normal; >1.5 to 3.0 x baseline if baseline abnormal 
b AST/ALT: >5.0 to 20.0 x ULN, if baseline normal; >5.0 to 20.0 x baseline, if baseline abnormal; bilirubin:>3.0 to 10.0 x ULN if 
baseline normal; >3.0 to 10.0 x baseline if baseline abnormal 
c AST/ALT: >20.0 x ULN, if baseline normal; >20.0 x baseline, if baseline abnormal;  
bilirubin: >10.0 x ULN if baseline normal; >10.0 x baseline if baseline abnormal 
d The decision to withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating physician. If 
control achieved or ≤ Grade 2, pembrolizumab may be resumed. 
e Events that require discontinuation include, but are not limited to: encephalitis and other clinically important irAEs (eg, vasculitis and 
sclerosing cholangitis). 
 
Dosing interruptions are permitted in the case of medical / surgical events or logistical reasons not 
related to study therapy (e.g., elective surgery, unrelated medical events, patient vacation, and/or 
holidays). Subjects should be placed back on study therapy within 3 weeks of the scheduled 
interruption, unless otherwise discussed with the Sponsor. The reason for interruption should be 
documented in the patient's study record 
Note: There is no dose modification for HIFU as it is only administered once in this protocol. 
 
Timing of Dose Administration 
Trial treatment should be administered on Day 1 of each cycle after all procedures/assessments have 
been completed as detailed on the Trial Flow Chart (Section 6.0).  Trial treatment may be administered 
up to 3 days before or after the scheduled Day 1 of each cycle due to administrative reasons. 
All trial treatments will be administered on an outpatient basis. 

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Pembrolizumab 200 mg will be administered as a 30 minute IV infusion every 3 weeks.  Staff should 
make every effort to target infusion timing to be as close to 30 minutes as possible.  However, given 
the variability of infusion pumps, a window of -5 minutes and +10 minutes is permitted (i.e., infusion 
time is 30 minutes: -5 min/+10 min). 
The commercial Pembrolizumab product provided by Merck will be prepared and administered per 
standard practice.  
 
Trial Blinding/Masking 
This is an open-label trial; therefore, the Sponsor, investigator and subject will know the treatment 
administered. 
5.3 
Randomization or Treatment Allocation 
Randomization will be discussed with participants during the process of informed consent and will 
occur after registration and within 7 days prior to the start of treatment.  The randomization codes are 
generated by the study statisticians and stored in the Cancer Center Clinical Trials Database.  
5.4 
Stratification 
No stratification planned. 
5.5 
Concomitant Medications/Vaccinations (allowed & prohibited) 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed during the 
ongoing trial.  If there is a clinical indication for one of these or other medications or vaccinations 
specifically prohibited during the trial, discontinuation from trial therapy or vaccination may be 
required.  The investigator should discuss any questions regarding this with the Merck Clinical team.  
The final decision on any supportive therapy or vaccination rests with the investigator and/or the 
subject's primary physician.  
 
Acceptable Concomitant Medications 
All treatments that the investigator considers necessary for a subject’s welfare may be administered at 
the discretion of the investigator in keeping with the community standards of medical care.  All 
concomitant medication will be recorded on the case report form (CRF) including all prescription, over-
the-counter (OTC), herbal supplements, and IV medications and fluids.  If changes occur during the 
trial period, documentation of drug dosage, frequency, route, and date may also be included on the 
CRF. 
All concomitant medications received within 28 days before the first dose of trial treatment and 30 days 
after the last dose of trial treatment should be recorded.  Concomitant medications administered after 
30 days after the last dose of trial treatment should be recorded for SAEs and ECIs as defined in Section 
7.2. 
 
Prohibited Concomitant Medications 
Subjects are prohibited from receiving the following therapies during the Screening and Treatment 
Phase (including retreatment for post-complete response relapse) of this trial: 

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• 
Antineoplastic systemic chemotherapy or biological therapy  
• 
Immunotherapy not specified in this protocol 
• 
Chemotherapy not specified in this protocol 
• 
Investigational agents other than pembrolizumab 
• 
Radiation therapy  
o Note:  Radiation therapy to a symptomatic solitary lesion or to the brain may be 
allowed at the investigator’s discretion.   
• 
Live vaccines within 30 days prior to the first dose of trial treatment and while participating in 
the trial.  Examples of live vaccines include, but are not limited to, the following: measles, 
mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and typhoid vaccine.  
• 
Systemic glucocorticoids for any purpose other than to modulate symptoms from an event of 
clinical interest of suspected immunologic etiology.  The use of physiologic doses of 
corticosteroids may be approved after consultation with the Sponsor. 
Subjects who, in the assessment by the investigator, require the use of any of the aforementioned 
treatments for clinical management (except glucocorticoids for irAE’s) should be removed from the 
trial.  Subjects may receive other medications that the investigator deems to be medically necessary. 
The Exclusion Criteria describes other medications which are prohibited in this trial. 
There are no prohibited therapies during the Post-Treatment Follow-up Phase. 
5.6 
Rescue Medications & Supportive Care 
 
Supportive Care Guidelines 
Subjects should receive appropriate supportive care measures as deemed necessary by the treating 
investigator.  Suggested supportive care measures for the management of adverse events with potential 
immunologic etiology are outlined below. Where appropriate, these guidelines include the use of oral 
or intravenous treatment with corticosteroids as well as additional anti-inflammatory agents if 
symptoms do not improve with administration of corticosteroids.   Note that several courses of steroid 
tapering may be necessary as symptoms may worsen when the steroid dose is decreased. For each 
disorder, attempts should be made to rule out other causes such as metastatic disease or bacterial or 
viral infection, which might require additional supportive care. The treatment guidelines are intended 
to be applied when the investigator determines the events to be related to pembrolizumab.  
Note: if after the evaluation the event is determined not to be related, the investigator does not need to 
follow the treatment guidance (as outlined below). Refer to Section 5.2.1 for dose modification.  
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or skin 
photography as part of evaluation of the event.  
• 
Pneumonitis:  
o For Grade 2 events, treat with systemic corticosteroids. When symptoms improve to 
Grade 1 or less, steroid taper should be started and continued over no less than 4 weeks. 

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o For Grade 3-4 events, immediately treat with intravenous steroids.  Administer 
additional anti-inflammatory measures, as needed. 
o Add prophylactic antibiotics for opportunistic infections in the case of prolonged 
steroid administration. 
• 
Diarrhea/Colitis:  
Subjects should be carefully monitored for signs and symptoms of enterocolitis (such as 
diarrhea, abdominal pain, blood or mucus in stool, with or without fever) and of bowel 
perforation (such as peritoneal signs and ileus).   
o All subjects who experience diarrhea/colitis should be advised to drink liberal 
quantities of clear fluids.  If sufficient oral fluid intake is not feasible, fluid and 
electrolytes should be substituted via IV infusion.  For Grade 2 or higher diarrhea, 
consider GI consultation and endoscopy to confirm or rule out colitis. 
o For Grade 2 diarrhea/colitis, administer oral corticosteroids.  
o For Grade 3 or 4 diarrhea/colitis, treat with intravenous steroids followed by high 
dose oral steroids.   
o When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks. 
• 
Hypophysitis: 
o For Grade 2 events, treat with corticosteroids. When symptoms improve to Grade 1 or 
less, steroid taper should be started and continued over no less than 4 weeks. 
Replacement of appropriate hormones may be required as the steroid dose is tapered. 
o For Grade 3-4 events, treat with an initial dose of IV corticosteroids followed by oral 
corticosteroids. When symptoms improve to Grade 1 or less, steroid taper should be 
started and continued over no less than 4 weeks. Replacement of appropriate hormones 
may be required as the steroid dose is tapered. 
• 
Hyperthyroidism or Hypothyroidism:  
Thyroid disorders can occur at any time during treatment. Monitor patients for changes in 
thyroid function (at the start of treatment, periodically during treatment, and as indicated based 
on clinical evaluation) and for clinical signs and symptoms of thyroid disorders. 
o Grade 2 hyperthyroidism events (and Grade 2-4 hypothyroidism): 
 
In hyperthyroidism, non-selective beta-blockers (e.g. propranolol) are 
suggested as initial therapy. 
 
In hypothyroidism, thyroid hormone replacement therapy, with levothyroxine 
or liothyroinine, is indicated per standard of care. 
o Grade 3-4 hyperthyroidism  
 
Treat with an initial dose of IV corticosteroid followed by oral corticosteroids. 
When symptoms improve to Grade 1 or less, steroid taper should be started 
and continued over no less than 4 weeks. Replacement of appropriate 
hormones may be required as the steroid dose is tapered. 
• 
Hepatic: 

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o For Grade 2 events, monitor liver function tests more frequently until returned to 
baseline values (consider weekly). 
 
Treat with IV or oral corticosteroids 
o For Grade 3-4 events, treat with intravenous corticosteroids for 24 to 48 hours.  
o When symptoms improve to Grade 1 or less, a steroid taper should be started and 
continued over no less than 4 weeks. 
• 
Nephritis: 
o For Grade 2 events, treat with corticosteroids. 
o For Grade 3-4 events, treat with systemic corticosteroids. 
o When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks.  
• 
Management of Infusion Reactions: Signs and symptoms usually develop during or shortly 
after drug infusion and generally resolve completely within 24 hours of completion of infusion.  
Table 5 below shows treatment guidelines for subjects who experience an infusion reaction 
associated with administration of pembrolizumab (MK-3475). 
Table 5:  Infusion Reaction Treatment Guidelines 
 
NCI CTCAE Grade 
 
Treatment 
 
Premedication at subsequent 
dosing 
Grade 1 
Mild reaction; infusion interruption 
not indicated; intervention not 
indicated 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
None 
Grade 2 
Requires infusion interruption but 
responds promptly to symptomatic 
treatment (e.g., antihistamines, 
NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated for 
< =24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
If symptoms resolve within one hour of stopping 
drug infusion, the infusion may be restarted at 
50% of the original infusion rate (e.g., from 100 
mL/hr to 50 mL/hr).  Otherwise dosing will be 
held until symptoms resolve and the subject 
should be premedicated for the next scheduled 
dose. 
Subjects who develop Grade 2 toxicity despite 
adequate premedication should be 
permanently discontinued from further trial 
treatment administration. 
Subject may be premedicated 1.5h 
(± 30 minutes) prior to infusion of 
pembrolizumab (MK-3475) with: 
 
Diphenhydramine 50 mg po (or 
equivalent dose of antihistamine). 
 
Acetaminophen 500-1000 mg po 
(or equivalent dose of antipyretic). 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly responsive 
to symptomatic medication and/or 
brief interruption of infusion); 
recurrence of symptoms following 
initial improvement; hospitalization 
indicated for other clinical sequelae 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
No subsequent dosing 

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NCI CTCAE Grade 
 
Treatment 
 
Premedication at subsequent 
dosing 
(e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or ventilatory 
support indicated 
Pressors 
Corticosteroids 
Epinephrine 
 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued from 
further trial treatment administration. 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period of drug 
administration. 
 
 
5.7 
Diet/Activity/Other Considerations 
 
Diet 
Subjects should maintain a normal diet unless modifications are required to manage an AE such as 
diarrhea, nausea or vomiting. 
 
Contraception 
Pembrolizumab may have adverse effects on a fetus in utero.  Furthermore, it is not known if 
pembrolizumab has transient adverse effects on the composition of sperm.   
For this trial, male subjects will be considered to be of non-reproductive potential if they have 
azoospermia (whether due to having had a vasectomy or due to an underlying medical condition).   
Female subjects will be considered of non-reproductive potential if they are either:  
(1) postmenopausal (defined as at least 12 months with no menses without an alternative medical cause; 
in women < 45 years of age a high follicle stimulating hormone (FSH) level in the postmenopausal 
range may be used to confirm a post-menopausal state in women not using hormonal contraception 
or hormonal replacement therapy. In the absence of 12 months of amenorrhea, a single FSH 
measurement is insufficient.);  
OR  
(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy or bilateral tubal 
ligation/occlusion, at least 6 weeks prior to screening;  
OR  
(3) has a congenital or acquired condition that prevents childbearing. 
Female and male subjects of reproductive potential must agree to avoid becoming pregnant or 
impregnating a partner, respectively, while receiving study drug and for 120 days after the last dose of 
study drug by complying with one of the following:   
(1) practice abstinence† from heterosexual activity;  

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OR  
(2) use (or have their partner use) acceptable contraception during heterosexual activity.   
Acceptable methods of contraception are‡: 
 Single method (one of the following is acceptable): 
• intrauterine device (IUD) 
• vasectomy of a female subject’s male partner  
• contraceptive rod implanted into the skin 
  
Combination method (requires use of two of the following): 
• diaphragm with spermicide (cannot be used in conjunction with cervical cap/spermicide) 
• cervical cap with spermicide (nulliparous women only)   
• contraceptive sponge (nulliparous women only)  
• male condom or female condom (cannot be used together) 
• hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin-only pill), 
contraceptive skin patch, vaginal contraceptive ring, or subcutaneous contraceptive injection 
 †Abstinence (relative to heterosexual activity) can be used as the sole method of contraception if it is 
consistently employed as the subject’s preferred and usual lifestyle and if considered acceptable by 
local regulatory agencies and ERCs/IRBs.  Periodic abstinence (e.g., calendar, ovulation, sympto-
thermal, post-ovulation methods, etc.) and withdrawal are not acceptable methods of contraception.  
‡If a contraceptive method listed above is restricted by local regulations/guidelines, then it does not 
qualify as an acceptable method of contraception for subjects participating at sites in this 
country/region. 
Subjects should be informed that taking the study medication may involve unknown risks to the fetus 
(unborn baby) if pregnancy were to occur during the study.  In order to participate in the study subjects 
of childbearing potential must adhere to the contraception requirement (described above) from the day 
of study medication initiation (or 14 days prior to the initiation of study medication for oral 
contraception) throughout the study period up to 120 days after the last dose of trial therapy.  If there 
is any question that a subject of childbearing potential will not reliably comply with the requirements 
for contraception, that subject should not be entered into the study. 
 
Use in Pregnancy 
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab, the subject will 
immediately be removed from the study.  The site will contact the subject at least monthly and 
document the subject’s status until the pregnancy has been completed or terminated.  The outcome of 
the pregnancy will be reported to the Sponsor and to Merck without delay and within 24 hours to the 
Sponsor and within 2 working days to Merck if the outcome is a serious adverse experience (e.g., death, 
abortion, congenital anomaly, or other disabling or life-threatening complication to the mother or 
newborn).   
The study investigator will make every effort to obtain permission to follow the outcome of the 
pregnancy and report the condition of the fetus or newborn to the Sponsor.   If a male subject 
impregnates his female partner the study personnel at the site must be informed immediately and the 
pregnancy reported to the Sponsor and to Merck and followed as described above and in Section 7.2.5. 

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Use in Nursing Women 
It is unknown whether pembrolizumab is excreted in human milk.  Since many drugs are excreted in 
human milk, and because of the potential for serious adverse reactions in the nursing infant, subjects 
who are breast-feeding are not eligible for enrollment. 
5.8 
Subject Withdrawal/Discontinuation Criteria 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the discretion 
of the investigator should any untoward effect occur.  In addition, a subject may be withdrawn by the 
investigator or the Sponsor if enrollment into the trial is inappropriate, the trial plan is violated, or for 
administrative and/or other safety reasons.  Specific details regarding discontinuation or withdrawal are 
provided in Section 7.1.5 – Other Procedures. 
A subject must be discontinued from the trial for any of the following reasons: 
• 
The subject or legal representative (such as a parent or legal guardian) withdraws consent. 
• 
Confirmed radiographic disease progression 
Note: A subject may be granted an exception to continue on treatment with confirmed 
radiographic progression if clinically stable or clinically improved, please see Section 5.8.1 
• 
Unacceptable adverse experiences as described in Section 5.2.2. 
• 
Intercurrent illness that prevents further administration of treatment 
• 
Investigator’s decision to withdraw the subject 
• 
The subject has a confirmed positive serum pregnancy test 
• 
Noncompliance with trial treatment or procedure requirements 
• 
The subject is lost to follow-up 
• 
Completed 24 months of uninterrupted treatment with pembrolizumab or 35 administrations of 
study medication, whichever is later. 
Note: 24 months of study medication is calculated from the date of first dose. Subjects who stop 
pembrolizumab after 24 months may be eligible for up to one year of additional study treatment 
if they progress after stopping study treatment provided they meet the requirements detailed in 
Section 7.1.6.5. 
• 
Administrative reasons 
The End of Treatment and Follow-up visit procedures are listed in Section 6 (Protocol Flow Chart) and 
Section 7.1.6 (Visit Requirements).  After the end of treatment, each subject will be followed for 30 
days for adverse event monitoring (serious adverse events will be collected for 90 days after the end of 
treatment as described in Section 7.2).  Subjects who discontinue for reasons other than progressive 
disease will have post-treatment follow-up for disease status until disease progression, initiating a non-

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study cancer treatment, withdrawing consent or becoming lost to follow-up.  After documented disease 
progression each subject will be followed by telephone for overall survival until death, withdrawal of 
consent, or the end of the study, whichever occurs first. 
 
Treatment after Initial Radiologic Progression 
If radiologic imaging shows progressive disease (PD), tumor assessment may be repeated ≥4 weeks 
later in order to confirm PD with the option of continuing treatment 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, with the exception of radiated lesions, which will only be considered when 
evaluating increased tumor burden. The decision to continue study treatment after the first evidence of 
disease progression is at the Investigator’s discretion and will be based on the clinical status of the 
subject.  Subjects may receive study treatment while waiting for confirmation of PD if they are 
clinically stable as defined by the following criteria: 
• 
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 
Subjects that are deemed clinically unstable are not required to have repeat imaging for confirmation. 
 
Discontinuation of Study Therapy after CR after Cycle 4  
Discontinuation of treatment may be considered for subjects who have attained a confirmed CR that 
have been treated for at least 10 weeks with pembrolizumab and had at least two treatments with 
pembrolizumab beyond the date when the initial CR was declared.  Subjects who then experience 
radiographic disease progression may be eligible for up to one year of additional treatment with 
pembrolizumab via the Second Course Phase at the discretion of the investigator if no cancer treatment 
was administered since the last dose of pembrolizumab, the subject meets the safety parameters listed 
in the Inclusion/Exclusion criteria, and the trial is open.  Subjects will resume therapy at the same dose 
and schedule at the time of initial discontinuation.  Additional details are provided in Section 7.1.6.5. 
 
Treatment with pembrolizumab after SD or PR   
Treatment with pembrolizumab for subjects who have attained a SD or PR should continue every 3 
weeks until the subject reaches a confirmed disease progression, achieves confirmed CR as per Section 
5.8.2 or experiences an adverse event meeting criteria for discontinuation as per Section 5.8.  For 
patients with long term stable disease or long term PR not meeting CR criteria, a subject may continue 
treatment for up to 2 years.  Subjects experiencing SD or PR may elect to discontinue pembrolizumab 
treatment any time. Subjects who then experience radiographic disease progression may be eligible for 
up to one year of additional treatment with pembrolizumab via the Second Course Phase at the 
discretion of the investigator if no cancer treatment was administered since the last dose of 
pembrolizumab, the subject meets the safety parameters listed in the Inclusion/Exclusion criteria, and 

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the trial is open.  Subjects will resume therapy at the same dose and schedule at the time of initial 
discontinuation.  Additional details are provided in Section 7.1.6.5. 
5.9 
Subject Replacement Strategy 
 
Replacement of Study Participants 
A participant who is enrolled but who does not receive study drug or any of the study related procedures 
may be replaced.  Every attempt will be made to evaluate any data from these participants for endpoint 
assessment.   
5.10 Clinical Criteria for Early Trial Termination 
Early trial termination will be the result of the criteria specified below: 
• 
Quality or quantity of data recording is inaccurate or incomplete 
• 
Poor adherence to protocol and regulatory requirements 
• 
Incidence or severity of adverse drug reaction in this or other studies indicates a potential health 
hazard to subjects 
• 
Plans to modify or discontinue the development of the study drug 
In the event of Merck decision to no longer supply study drug, ample notification will be provided so 
that appropriate adjustments to subject treatment can be made. 
 
 

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6.0 TRIAL FLOW CHART 
6.1 
Study Flow Chart 
ARM A 
Trial Period: 
 
Treatment Cyclesa 
End of 
Treatment 
Post-Treatment 
Treatment Cycle: 
Main 
Study 
Screening 
(Visit 1) 
Cycle 1 
2  
3 
4 
May be repeated beyond 8 
cycles  
Disconh  
Safety 
Follow-up- 
30 days 
post discon  
Follow-Up 
Every 12 
weeks up to 
2yrsi 
Survival 
Follow-Upn 
Annually 
C1D
1 
C1D
15 
5 
6 
7 
 
8 
Days: 
1 
15 
22 
43 
64 
85 
106 
127 
148 
Scheduling Window (Days): 
see 
footnotes 
± 3 
 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
At time of 
Discon 
± 3 
±3wks  
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics and Medical History 
X  
 
 
 
 
 
 
 
 
 
 
 
 
 
Prior and Concomitant Medication Review 
X  
X  
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Ultrasound  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Focused Ultrasound Treatment 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Pembrolizumab Infusion 
 
 
 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
Post-study anticancer therapy status 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
Survival Status 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Review Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xj 
Xj 
 
Full Physical Examination 
Xb  
 
 
 
 
 
 
 
 
 
 
 
 
 
Pain Assessment (VAS Scale) 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
Directed Physical Examination 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Vital Signs and Weight 
Xc  
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
ECOG Performance Status 
Xb  
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Pregnancy Test – Urine or Serum β-HCG 
X 
 
X 
Xf 
 
 
 
 
 
 
 
 
 
 
PT/INR and aPTT 
Xb  
 
 
X 
X 
X 
X 
 
 
 
X 
 
 
 
CBC with Differential 
Xb  
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 

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Trial Period: 
 
Treatment Cyclesa 
End of 
Treatment 
Post-Treatment 
Treatment Cycle: 
Main 
Study 
Screening 
(Visit 1) 
Cycle 1 
2  
3 
4 
May be repeated beyond 8 
cycles  
Disconh  
Safety 
Follow-up- 
30 days 
post discon  
Follow-Up 
Every 12 
weeks up to 
2yrsi 
Survival 
Follow-Upn 
Annually 
C1D
1 
C1D
15 
5 
6 
7 
 
8 
Days: 
1 
15 
22 
43 
64 
85 
106 
127 
148 
Scheduling Window (Days): 
see 
footnotes 
± 3 
 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
At time of 
Discon 
± 3 
±3wks  
 
Comprehensive Serum Chemistry Panelo 
Xb  
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urinalysis 
 
X  
 
 
X 
 
X 
 
X 
 
 
 
 
 
T3, FT4 and TSH 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
 
HIV/Hep Cd 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor Imaging - CT(or MRI) 
chest/abdomen/pelvis 
head when indicated 
Xg 
 
 
 
 
Xg 
 
 
 
Xg 
X 
 
 
 
Symptom Diary 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Breast tumor biopsym 
 
X  
 
X 
 
 
 
 
 
 
 
 
 
 
Optional tumor biopsies 
 
 
 
 
 
Xk 
 
 
 
 
 
 
 
 
Correlative Studies Blood Collectionl 
 
X 
 
X 
X 
X 
 
 
 
 
 
 
 
 
a Cycles are 21 days 
 
 
b Pre-study, within 10 days of registration.   
 
c Pre-study, within 2 weeks of registration. 
d HIV/Hep C testing required if known or suspected history or exposure 
 
f Must be completed within 72 hours prior to receiving the first dose of study drug. 
g Baseline tumor imaging should be within 28 days of registration. Tumor imaging is planned for within 4 days of receipt of study drug on cycle #4. Imaging is to 
be every 12 weeks (+ 1 week) for any patients continuing on therapy beyond cycle #4. 
h If a subject is discontinued and the assessments have been completed as part of another study visit, the assessments do not need to be repeated. Tumor imaging 
does not need to be repeated if scans have been completed within the past 8 weeks. 
i Follow-up visits may be discontinued at (1) the start of new anti-cancer treatment, (2) disease progression, (3) death, (4) withdraw of consent or lost to follow-
up, (5) the end of the follow-up visit period, or (6) the end of the study, whichever occurs first. Any visits for subsequent therapy may replace protocol required 
survival follow-up visits. Phone follow-up is acceptable.  

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j All AEs occurring within 30 days after the last dose of trial treatment will be recorded. SAEs (related and unrelated to trial treatment), UADEs and ECIs occurring 
up until 90 days following cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer therapy, whichever comes first, 
will be recorded. Afterwards, only SAEs, UADEs and ECIs that are related to trial treatment will be reported. The 90 day SAE collection may be collected by 
phone. 
k Optional tumor biopsies of HIFU treated lesion and distant tumor site where clinically safe. 
l Bloods for immunologic testing should be collected prior to study drug infusion and  will require 4 tubes (10 ml tubes). 
m Breast biopsy target is minimum of 6 core needle passes. For the cycle 2 biopsy, three of the needle passes should target the central ablated zone and three 
should target the peri-ablation zone. 
n Survival follow-up may be completed by phone. 
o Refer to Table 6 for a complete list of analyses to be completed as part of the comprehensive chemistry panel. 
 
 

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ARM B 
Trial Period: 
 
Treatment Cyclesa 
End of 
Treatment 
Post-Treatment 
Treatment Cycle: 
Main 
Study 
Screening 
(Visit 1) 
Cycle 1 
2  
3 
4 
May be repeated beyond 8 
cycles  
Disconh  
Safety 
Follow-up- 
30 days 
post discon  
Follow-Up 
Every 12 
weeks up to 
2yrsi 
Survival 
Follow-Upn 
Annually 
C1D
1 
C1D
15 
5 
6 
7 
8 
Days: 
1 
15 
22 
43 
64 
85 
106 
127 
148 
Scheduling Window (Days): 
See 
footnotes 
± 3 
 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
At time of 
Discon 
± 3 
± 3wks  
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics and Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prior and Concomitant Medication Review 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Ultrasound 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Focused Ultrasound Treatment 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Pembrolizumab Infusion 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
Post-study anticancer therapy status 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
Survival Status 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Review Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xj 
Xj 
 
Full Physical Examination 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pain Assessment (VAS Scale) 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
Directed Physical Examination 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Vital Signs and Weight 
Xc 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
ECOG Performance Status 
Xb 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Pregnancy Test – Urine or Serum β-HCG 
Xf 
 
X 
 
 
 
 
 
 
 
 
 
 
 
PT/INR and aPTT 
Xb 
 
 
X 
X 
X 
X 
 
 
 
X 
 
 
 
CBC with Differential 
Xb 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Comprehensive Serum Chemistry Panelo 
Xb 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 

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Trial Period: 
 
Treatment Cyclesa 
End of 
Treatment 
Post-Treatment 
Treatment Cycle: 
Main 
Study 
Screening 
(Visit 1) 
Cycle 1 
2  
3 
4 
May be repeated beyond 8 
cycles  
Disconh  
Safety 
Follow-up- 
30 days 
post discon  
Follow-Up 
Every 12 
weeks up to 
2yrsi 
Survival 
Follow-Upn 
Annually 
C1D
1 
C1D
15 
5 
6 
7 
8 
Days: 
1 
15 
22 
43 
64 
85 
106 
127 
148 
Scheduling Window (Days): 
See 
footnotes 
± 3 
 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
At time of 
Discon 
± 3 
± 3wks  
 
Urinalysis 
 
X 
 
 
X 
 
X 
 
X 
 
 
 
 
 
T3, FT4 and TSH 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
 
HIV/Hep Cd 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor Imaging - CT(or MRI) 
chest/abdomen/pelvis  
head when indicated 
Xg 
 
 
 
 
Xg 
 
 
 
Xg 
X 
 
 
 
Symptom Diary 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Breast tumor biopsym 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
Optional tumor biopsies 
 
 
 
 
 
Xk 
 
 
 
 
 
 
 
 
Correlative Studies Blood Collectionl 
 
X 
 
X 
X 
X 
 
 
 
 
 
 
 
 
a Cycles are 21 days 
b Pre-study, within 10 days of registration.  
c Pre-study, within 2 weeks of registration. 
d HIV/Hep C testing required if known or suspected history or exposure 
f Must be completed within 72 hours prior to receiving the first dose of study drug. 
g Baseline tumor imaging should be within 28 days of registration. Tumor imaging is planned for within 4 days of receipt of study drug on cycle #4. Imaging is to 
be every 12 weeks (+ 1 week) for any patients continuing on therapy beyond cycle #4. 
h If a subject is discontinued and the assessments have been completed as part of another study visit, the assessments do not need to be repeated. Tumor imaging 
does not need to be repeated if scans have been completed within the past 8 weeks. 
i Follow-up visits may be discontinued at (1) the start of new anti-cancer treatment, (2) disease progression, (3) death, (4) withdraw of consent or lost to follow-
up, (5) the end of the follow-up visit period, or (6) the end of the study, whichever occurs first. Any visits for subsequent therapy may replace protocol required 
survival follow-up visits. Phone follow-up is acceptable. 

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j All AEs occurring within 30 days after the last dose of trial treatment will be recorded. SAEs (related and unrelated to trial treatment), UADEs and ECIs occurring 
up until 90 days following cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer therapy, whichever comes first, 
will be recorded. Afterwards, only SAEs, UADEs and ECIs that are related to trial treatment will be reported. The 90 day SAE collection may be collected by 
phone. 
k Optional tumor biopsies of HIFU treated lesion and distant tumor site where clinically safe. 
l Bloods for immunologic testing should be collected prior to study drug infusion and will require 4 tubes (10 ml tubes). 
m Breast biopsy target is minimum of 6 core needle passes. For the cycle 2 biopsy, three of the needle passes should target the central ablated zone and three 
should target the peri-ablation zone. 
n Survival follow-up may be completed by phone. 
o Refer to Table 6 for a complete list of analyses to be completed as part of the comprehensive chemistry panel. 

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Study Flow Chart- Second Course Phase 
 
 
 
Treatment cycles (3-Week 
Cycles) 
 
End of Treatment 
 
 
 
To be repeated beyond 
cycle 3 of second course 
 
 
 
Treatment Cycle/Title 
1 
Cycle 2  
Cycle 3  
Discontinuation of 
pembrolizumabf 
Safety follow-up 
Discontinuation of 
pembrolizumab 
Follow-up visits g  
Scheduling Window (days) 
±3 
±3 
±3 
±3 
±3 
±10 
 
 
 
 
At the time of 
discontinuation of 
pembrolizumab 
30 days post-
discontinuation of 
pembrolizumab 
Every 12 weeks post 
discontinuation up to 2 
years from initiating 
second-course treatment 
or per footnote 
Eligibility Criteria 
Xa 
 
 
 
 
 
Physical Exam/vitalsb 
X 
X 
X 
X 
X 
 
AE assessment 
X 
X 
X 
X 
X 
Xh 
Prior and concomitant 
medication review 
X 
X 
X 
X 
X 
X 
Weight 
X 
X 
X 
 
 
 
ECOG PS 
X 
X 
X 
X 
 
 
Pregnancy test-urine or 
serum β-HCG 
Xc 
 
 
 
 
 
CBC with diff  
X 
X 
X 
X 
X 
 
Comprehensive chem.  paneli 
X 
X 
X 
X 
X 
 
T3, FT4 and TSH 
X 
 
X 
X 
X 
 
Urinalysis 
X 
 
X 
X 
X 
 
Optional Biopsyd 
X 
 
 
X 
 
 
Pembrolizumab 
X 
X 
X 
 
 
 
Tumor Imaging - CT(or 
MRI) chest/abdomen/pelvis 
 
per standard clinical practice 
or a minimum of every 12 
weeks 
Xe 
 
Xe 
Symptom Diary 
X 
X 
X 
X 
X 
 
Post-study anticancer 
therapy status 
 
 
 
 
 
X 
Survival Status 
 
 
 
 
 
 

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a Subjects who either a) attain a CR and discontinue treatment or b) discontinue treatment after 24 months on pembrolizumab for reasons other than 
disease progression or intolerability may restart trial treatment if they meet the criteria specified in Section 7.1.6.4. 
b A complete physical exam should be completed at cycle 1. Symptom-directed physical exams may be conducted at all other visits. 
c Must be completed within 72 hours prior to receiving day 1 of this second course of study drug. 
d Optional:  If subjects develop metastatic deposits accessible to biopsy/excision with minimal morbidity, a specimen may be collected. 
eTumor imaging will be completed every 12 weeks or per standard clinical practice.  Tumor imaging does not need to be repeated if scans have been 
completed within the past 8 weeks.   
f If a subject is discontinued and the assessments have been completed as part of a regularly scheduled visit, the assessments do not need to be 
repeated.   
g Follow-up visits may be discontinued at (1) the start of new anti-cancer treatment, (2) disease progression, (3) death, (4) withdraw of consent or lost 
to follow-up, (5) the end of the follow-up visit period, or (6) the end of the study, whichever occurs first. Any visits for subsequent therapy may 
replace protocol required survival follow-up visits. Phone follow-up is acceptable. 
h  All AEs occurring within 30 days after the last dose of trial treatment will be recorded. SAEs (related and unrelated to trial treatment) and ECIs 
occurring up until 90 days following cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer therapy, 
whichever comes first, will be recorded. Afterwards, only SAEs and ECIs that are related to trial treatment will be reported. The 90 day SAE 
collection may be collected by phone. 
i Refer to Table 6 for a complete list of analyses to be completed as part of the comprehensive chemistry panel.

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7.0 TRIAL PROCEDURES 
7.1 
Trial Procedures 
The Trial Flow Chart - Section 6.0 summarizes the trial procedures to be performed at each visit.  
Individual trial procedures are described in detail below.  It may be necessary to perform these 
procedures at unscheduled time points if deemed clinically necessary by the investigator. 
Furthermore, additional evaluations/testing may be deemed necessary by the Sponsor and/or Merck for 
reasons related to subject safety. In some cases, such evaluation/testing may be potentially sensitive in 
nature (e.g., HIV, Hepatitis C, etc.), and thus local regulations may require that additional informed 
consent be obtained from the subject.  In these cases, such evaluations/testing will be performed in 
accordance with those regulations. 
 
Administrative Procedures 
 Informed Consent 
The Investigator must obtain documented consent from each potential subject prior to participating in 
a clinical trial. 
7.1.1.1.1 
General Informed Consent 
Consent must be documented by the subject’s dated signature or by the subject’s legally acceptable 
representative’s dated signature on a consent form along with the dated signature of the person 
conducting the consent discussion.  
A copy of the signed and dated consent form should be given to the subject before participation in the 
trial. 
The initial informed consent form, any subsequent revised written informed consent form and any 
written information provided to the subject must receive the IRB/ERC’s approval/favorable opinion in 
advance of use.  The subject or his/her legally acceptable representative should be informed in a timely 
manner if new information becomes available that may be relevant to the subject’s willingness to 
continue participation in the trial.  The communication of this information will be provided and 
documented via a revised consent form or addendum to the original consent form that captures the 
subject’s dated signature or by the subject’s legally acceptable representative’s dated signature. 
Specifics about a trial and the trial population will be added to the consent form template at the protocol 
level.   
The informed consent will adhere to IRB/ERC requirements, applicable laws and regulations and 
Sponsor requirements. 
 Inclusion/Exclusion Criteria 
All inclusion and exclusion criteria will be reviewed by the investigator or qualified designee to ensure 
that the subject qualifies for the trial.  

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 Registration 
All participants must sign the consent form prior to determination of eligibility for this study.  All 
participants who meet the inclusion/exclusion criteria may be registered.  Registration will occur 
following verification of eligibility by the treating physician. Participants should receive their first study 
treatment within 2 weeks of registration.  
 Medical History 
A medical history will be obtained by the investigator or qualified designee.  Medical history will 
include all active conditions, and any condition diagnosed within the prior 10 years that are considered 
to be clinically significant by the Investigator.  Details regarding the disease for which the subject has 
enrolled in this study will be recorded separately and not listed as medical history.   
 Prior and Concomitant Medications Review 
7.1.1.5.1 
Prior Medications 
The investigator or qualified designee will review prior medication use, including any protocol-
specified washout requirement, and record prior medication taken by the subject within 28 days before 
starting the trial.  Treatment for the disease for which the subject has enrolled in this study will be 
recorded separately and not listed as a prior medication.  
7.1.1.5.2 
Concomitant Medications 
The investigator or qualified designee will record medication, if any, taken by the subject during the 
trial.  All medications related to reportable SAEs and ECIs should be recorded as defined in Section 
7.2. 
 Disease Details and Treatments 
7.1.1.6.1 
Disease Details 
The investigator or qualified designee will obtain prior and current details regarding disease status.  
7.1.1.6.2 
Prior Treatment Details 
The investigator or qualified designee will review all prior cancer treatments including systemic 
treatments, radiation and surgeries. 
7.1.1.6.3 
Subsequent Anti-Cancer Therapy Status 
The investigator or qualified designee will review all new anti-neoplastic therapy initiated after the last 
dose of trial treatment.  If a subject initiates a new anti-cancer therapy within 30 days after the last dose 
of trial treatment, the 30 day Safety Follow-up visit must occur before the first dose of the new therapy.  
Once new anti-cancer therapy has been initiated the subject will move into survival follow-up.  

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 Assignment of Randomization Number 
The randomization codes are generated by the study statisticians and stored in the UVA Cancer Center 
Clinical Trials Database.   
 Trial Compliance (Medication/Diet/Activity/Other) 
Treatment compliance may be evaluated through drug accountability assessments and through the 
evaluation of subject medical records and CRF documents. 
 
Clinical Procedures/Assessments 
 Adverse event (AE) Monitoring 
The investigator or qualified designee will assess each subject to evaluate for potential new or 
worsening AEs as specified in the Trial Flow Chart and more frequently if clinically indicated.  Adverse 
experiences will be graded and recorded throughout the study and during the follow-up period 
according to NCI CTCAE Version 4.0 (see Section 11.2).  Toxicities will be characterized in terms 
regarding seriousness, causality, toxicity grading, and action taken with regard to trial treatment. 
Please refer to Section 7.2 for detailed information regarding the assessment and recording of AEs. 
 Full Physical Exam 
The investigator or qualified designee will perform a complete physical exam during the screening 
period.  Clinically significant abnormal findings should be recorded as medical history.  A full physical 
exam should be performed during screening,  
 Directed Physical Exam 
For cycles that do not require a full physical exam per the Trial Flow Chart, the investigator or qualified 
designee will perform a directed physical exam as clinically indicated prior to trial treatment 
administration.   
 Vital Signs 
The investigator or qualified designee will take vital signs at screening, prior to the administration of 
each dose of trial treatment and at treatment discontinuation as specified in the Trial Flow Chart 
(Section 6.0).  Vital signs should include temperature, pulse, respiratory rate, weight and blood 
pressure.  Height will be measured at screening only. 
 Eastern Cooperative Oncology Group (ECOG) Performance Scale 
The investigator or qualified designee will assess ECOG status (see Section 11.1) at screening, prior to 
the administration of each dose of trial treatment and discontinuation of trial treatment as specified in 
the Trial Flow Chart.   

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 Tumor Imaging and Assessment of Disease 
Tumors will be assessed by CT scan (or MRI) of the chest, abdomen, and pelvis at baseline and at cycle 
4 as per Flow Chart 6.1 above. After completion of cycle 4, imaging will be performed every 4 cycles 
(approximately 12 weeks) as per usual standard of care. For subjects with history of brain metastases, 
imaging of the head will be performed at screening to determine stability of brain metastases as 
indicated in Section 5.1.3 criterion 8. 
 Ultrasound Imaging 
Ultrasound imaging will be performed during screening to confirm presence of a lesion within the 
Echopulse treatment parameters as indicated in Section 5.1.2 criterion 6. 
 Tumor Tissue Collection and Correlative Studies Blood Sampling 
7.1.2.8.1 
Core Biopsies  
Tumor tissue biopsies will occur at baseline and at cycle 2 as per Flow Chart 6.1 above. Optional tumor 
biopsies are permitted at cycle 4 where deemed safe.  For the core biopsies, 14-18 gauge needles may 
be used for tissue sampling.  Ultrasound guidance or CT guidance may be used at the time of the biopsy.  
The tissue specimens will be collected in the following priority:  
• 
(1) Formalin-fixed for paraffin embedding (TMA for IHC and TCR secquencing) 
• 
(1) RPMI for single cell suspensions (flow cytometric analyses)  
• 
(1) Trizol for RNA extraction (gene expression analyses) 
 
Leftover samples may be banked and stored for future biomedical research 
7.1.2.8.2 
Blood Collection for Research Analyses 
Bloods for correlative studies will be collected prior to study drug infusion at baseline and at cycles 2, 
3 and 4 as per Flow Chart 6.1 above. 
The following blood samples for research will be collected and processed by the UVA Biorepository 
and Tissue Research Facility (BTRF). 
• 
40 cc blood collected in heparinized green top tubes for lymphocytes.  
Leftover samples may be banked and stored for future biomedical research. 
 Patient-Rated Pain Assessment  
The pain associated with the investigational procedure will be assessed prior to the HIFU treatment and 
immediately following the HIFU treatment (C1D15) to evaluate pain associated with the procedure. 
Additional pain assessments will be made at Cycle 2. Pain will be rated by each subject using a standard 
Visual Analog Scale (VAS). 
 
HIFU Device Performance Parameters 
The following data will be collected during the HIFU treatment: 
- Total duration of treatment session 

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- Energy settings used during procedure 
 
Laboratory Procedures/Assessments 
Details regarding specific laboratory procedures/assessments to be performed in this trial are provided 
below. Laboratory tests for hematology, chemistry, urinalysis, and others are specified in Table 6.   

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Table 6:  Laboratory Tests 
Hematology 
Chemistry 
Urinalysis 
Other 
Hematocrit 
Albumin 
Blood 
Serum β-human chorionic gonadotropin† 
Hemoglobin 
Alkaline phosphatase 
Glucose 
  (β-hCG)† 
Platelet count 
Alanine aminotransferase (ALT) 
Protein 
PT (INR) 
WBC (total and differential) 
Aspartate aminotransferase (AST) 
Specific gravity  
aPTT 
Red Blood Cell Count 
Lactate dehydrogenase (LDH) 
Microscopic exam (If abnormal)  
Total thriiodothyronine (T3) 
Absolute Neutrophil Count 
Carbon Dioxide ‡ 
results are noted 
Free tyroxine (T4) 
Absolute Lymphocyte Count 
  (CO2 or biocarbonate) 
Urine pregnancy test † 
Thyroid stimulating hormone (TSH) 
 
Uric Acid 
 
 
 
Calcium 
 
 
 
Chloride 
 
Blood for correlative studies 
 
Glucose 
 
  
 
Phosphorus 
 
  
 
Potassium   
 
  
 
Sodium 
 
  
 
Magnesium 
 
  
 
Total Bilirubin 
 
  
 
Direct Bilirubin (If total bilirubin is 
elevated above the upper limit of 
normal) 
 
 
 
Total protein 
 
 
 
Blood Urea Nitrogen 
 
 
† Perform on women of childbearing potential only. If urine pregnancy results cannot be confirmed as negative, a serum pregnancy test will be required.   
‡ If considered standard of care in your region. 
 
 
 

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Laboratory tests for screening or entry into the Second Course Phase should be performed within 10 
days prior to the first dose of treatment.  After Cycle 1, pre-dose laboratory procedures can be conducted 
up to 72 hours prior to dosing.  Results must be reviewed by the investigator or qualified designee and 
found to be acceptable prior to each dose of trial treatment.  
Sample collection, storage and shipment instructions for serum samples will be provided in the 
Laboratory Manual. 
Sample collection, storage and shipment instructions for blood samples will be provided in the 
Laboratory Manual. 
 
Other Procedures 
 Withdrawal/Discontinuation 
When a subject discontinues/withdraws prior to trial completion, all applicable activities scheduled for 
the final trial visit should be performed at the time of discontinuation.  Any adverse events which are 
present at the time of discontinuation/withdrawal should be followed in accordance with the safety 
requirements outlined in Section 7.2 - Assessing and Recording Adverse Events.  Subjects who a) attain 
a CR or b) complete 24 months of treatment with pembrolizumab may discontinue treatment with the 
option of restarting treatment if they meet the criteria specified in Section 7.1.6.5.  After discontinuing 
treatment following assessment of CR, these subjects should return to the site for a Safety Follow-up 
Visit (described in Section 7.1.6.3.1) and then proceed to the Follow-Up Period of the study (described 
in Section 7.1.6.4). 
 Blinding/Unblinding 
 
Visit Requirements 
Visit requirements are outlined in Section 6.0 - Trial Flow Chart.   Specific procedure-related details 
are provided above in Section 7.1 - Trial Procedures. 
 Screening 
A member of the study team will explain the purpose of the study and the study-related procedures to 
potential subjects.  Subjects will be asked to provide written informed consent prior to the initiation of 
any study-related procedures.  The results from assessments performed as part of a subject’s clinical 
care prior to receipt of informed consent may be utilized to fulfill a screening requirement, if the 
assessments were completed with the required window for screening. 
 Treatment Period 
The treatment period will begin on Day 1 and will continue until the subject completes the treatment 
regimen or discontinues/withdraws from treatment (please refer to Section 5.8). 
7.1.6.2.1 
End of Treatment Visit:  This visit will occur at the time that a subject is discontinued 
from the study. 

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 Post-Treatment Visits 
7.1.6.3.1 
Safety Follow-Up Visit 
The mandatory Safety Follow-Up Visit should be conducted approximately 30 days after the last dose 
of trial treatment or before the initiation of a new anti-cancer treatment, whichever comes first.  All 
AEs that occur prior to the Safety Follow-Up Visit should be recorded.  Subjects with an AE of Grade 
> 1 will be followed until the resolution of the AE to Grade 0-1 or until the beginning of a new anti-
neoplastic therapy, whichever occurs first.  SAEs that occur within 90 days of the end of treatment or 
before initiation of a new anti-cancer treatment should also be followed and recorded.  Subjects who 
receive pembrolizumab treatment beyond Cycle 4 and are eligible for retreatment with pembrolizumab 
(as described in Section 7.1.6.5) may have up to two safety follow-up visits, one after the Treatment 
Period and one after the Second Course Phase. 
 Follow-up Visits 
Subjects who discontinue trial treatment for a reason other than disease progression will move into the 
Follow-Up Phase and should be assessed every 12 weeks (± 7 days) by radiologic imaging to monitor 
disease status unless the patient started on new anti-neoplastic therapy.  Every effort should be made to 
collect information regarding disease status until the start of new anti-neoplastic therapy, disease 
progression, death, or end of the study or if the subject begins retreatment with pembrolizumab as 
detailed in Section 7.1.6.5.  Information regarding post-study anti-neoplastic treatment will be collected 
if new treatment is initiated. 
Subjects who are eligible to receive retreatment with pembrolizumab according to the criteria in Section 
7.1.6.5 will move from the follow-up phase to the Second Course Phase when they experience disease 
progression.    
7.1.6.4.1 
Survival Follow-up 
Once a subject experiences confirmed disease progression or starts a new anti-cancer therapy, the 
subject moves into the survival follow-up phase. Subjects who experience confirmed disease 
progression or who start a new anti-cancer therapy, will also move into survival follow-up and should 
be contacted by telephone annually to assess for survival status until death, withdrawal of consent, or 
the end of the study, whichever occurs first.  
 
 Second Course Phase (Retreatment Period) 
Subjects who stop pembrolizumab with SD or better may be eligible for up to one year of additional 
pembrolizumab therapy if they progress after stopping study treatment.  This retreatment is termed the 
Second Course Phase of this study and is only available if the study remains open and the subject meets 
the following conditions: 
• 
Either  
o Stopped initial treatment with pembrolizumab after attaining an investigator-determined 
confirmed CR according to RECIST 1.1, and 
 
Was treated for at least 24 weeks with pembrolizumab before discontinuing therapy 

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 
Received at least two treatments with pembrolizumab beyond the date when the 
initial CR was declared 
 
 
OR 
o Had SD, PR or CR and stopped pembrolizumab treatment after 24 months of study therapy 
for reasons other than disease progression or intolerability 
AND 
• 
Experienced an investigator-determined confirmed radiographic disease progression after 
stopping their initial treatment with pembrolizumab 
• 
Did not receive any anti-cancer treatment since the last dose of pembrolizumab 
• 
Meets the safety parameters listed in the inclusion/exclusion criteria 
Subjects who restart treatment will be retreated at the same dose and dose interval as when they last 
received pembrolizumab.  Treatment will be administered for up to one additional year. 
Visit requirements are outlined in Section 6.0 – Trial Flow Chart. 
7.2 
Assessing and Recording Adverse Events 
 
Time Span for Recording Adverse Events 
All adverse events that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be excluded 
from the trial, or are the result of a protocol-specified intervention, including but not limited to washout 
or discontinuation of usual therapy, diet, placebo treatment or a procedure. 
From the time of treatment allocation/randomization through 30 days following cessation of treatment, 
all adverse events must be reported by the investigator. Such events will be recorded at each 
examination on the Adverse Event case report forms/worksheets.  The reporting timeframe for adverse 
events meeting any serious criteria is described in Section 7.2.6. The investigator will make every 
attempt to follow all subjects with non-serious adverse events for outcome. 
Adverse events will not be collected for subjects during the pre-screening period (for determination of 
archival tissue status) as long as that subject has not undergone any protocol-specified procedure or 
intervention.  If the subject requires a blood draw, fresh tumor biopsy etc., the subject is first required 
to provide consent to the main study and AEs will be captured according to guidelines for standard AE 
reporting.  
 
Definitions 
Adverse Event (AE):  An adverse event is defined as any untoward medical occurrence in a patient or 
clinical investigation subject administered a pharmaceutical product and which does not necessarily 
have to have a causal relationship with this treatment. An adverse event can therefore be any 
unfavorable and unintended sign (including an abnormal laboratory finding, for example), symptom, 
or disease temporally associated with the use of a medicinal product or protocol-specified procedure, 

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whether or not considered related to the medicinal product or protocol-specified procedure.  Any 
worsening (i.e., any clinically significant adverse change in frequency and/or intensity) of a preexisting 
condition that is temporally associated with the use of the Merck’s product, is also an adverse event. 
Changes resulting from normal growth and development that do not vary significantly in frequency or 
severity from expected levels are not to be considered adverse events.   
Merck product includes any pharmaceutical product, biological product, device, diagnostic agent or 
protocol-specified procedure, whether investigational (including placebo or active comparator 
medication) or marketed, manufactured by, licensed by, provided by or distributed by Merck for human 
use. 
Adverse events may occur during the course of the use of Merck product in clinical trials, or as 
prescribed in clinical practice, from overdose (whether accidental or intentional), from abuse and from 
withdrawal. 
Progression of the cancer under study is not considered an adverse event.  
Unexpected AE – Any adverse event not listed in Section 7.2.9.  
 
Serious AE: A serious adverse event is any adverse event occurring at any dose during the study that:  
• 
Results in death;  
• 
Is life threatening;  
• 
Results in persistent or significant disability/incapacity;  
• 
Results in or prolongs an existing inpatient hospitalization;  
• 
Is a congenital anomaly/birth defect;  
• 
Is another important medical event  
 
Note: In addition to the above criteria, adverse events meeting either of the below criteria, although not 
serious per ICH definition, are reportable to the Merck in the same timeframe as SAEs to meet certain 
local requirements. Therefore, these events are considered serious by Merck for collection purposes  
• 
Is a new cancer (that is not a condition of the study);  
• 
Is associated with an overdose;  
 
Unanticipated Adverse Device Effect: An unanticipated adverse device effect (UADE) is any serious 
adverse event on health or safety or any life-threatening problem or death caused by, or associated with, 
a device, if that effect, problem, or death was not previously identified in nature, severity, or degree of 
incidence in the investigational plan or application (including a supplementary plan or application), or 
any other unanticipated serious problem associated with a device that relates to the rights, safety, or 
welfare of subjects. 
 
Device Failure: A device has failed if it does not perform according to labeling and negatively impacts 
the treatment while used according to the labeling. 
 
Device Malfunction: A device malfunction is an unexpected change to the device that is contradictory 
to the labeling and may or may not affect device performance. 
 
Device failure and malfunctions- All investigational device failures and malfunctions will be 
documented on the CRF and reported in the clinical results. 

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User Error- User errors that result in the inability to use the device (ex., contamination) should not be 
reported as a device malfunctions. 
 
Unanticipated problem - An unanticipated problem is any event/experience that meets ALL 3 criteria 
below:  
• 
Is unexpected in terms of nature, severity or frequency given the research procedures that are 
described in the protocol-related documents AND in the characteristics of the participant 
population being studied.  
• 
Is related or possibly related to participation in research. This means that there is a reasonable 
possibility that the incident may have been caused by the procedures involved in the research 
study.  
• 
The incident suggests that the research placed the participant or others at greater risk of harm 
than was previously known or recognized OR results in actual harm to the participant or others.  
 
Protocol Violation- A protocol violation is defined as any change, deviation, or departure from the 
study design or procedures of a research project that is NOT approved by the institution’s IRB prior to 
its initiation or implementation, OR deviation from standard operating procedures, Good Clinical 
Practices (GCPs), federal, state or local regulations. Protocol violations may or may not be under the 
control of the study team or UVa staff. These protocol violations may be major or minor violations.  
 
Suspected Adverse Reaction (as defined in 21 CFR 312.32 (a))- Any adverse event for which there 
is a reasonable possibility that the drug caused the adverse event. For the purposes of IND safety 
reporting, “reasonable possibility” means there is evidence to suggest a causal relationship between the 
drug and the adverse event. 
 
 
Attribution Assessment 
Attribution – The determination of whether an adverse event is related to a medical treatment or 
procedure.  Please refer to Table 7 for additional guidance on evaluation of attribution. 
Definite – Applies to those adverse events which, the investigator feels are incontrovertibly related to 
study drug or HIFU procedure.  An adverse event may be assigned an attribution of definitely related 
if or when (must have all of the following): 
• 
It follows a reasonable temporal sequence from administration of the test drug or HIFU 
procedure. 
• 
It could not be reasonably explained by the known characteristics of the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to the subject. 
• 
It disappears or decreases on cessation or reduction in dose with re-exposure to drug.  (Note: 
This is not to be constructed as requiring re-exposure of the subject; however, the group of 
definitely related can only be used when a recurrence is observed.) 
• 
It follows a known pattern of response to the test drug or HIFU procedure. 
 

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Probable – Applies to those adverse events for which, after careful consideration at the time they are 
evaluated, are felt with a high degree of certainty to be related to the test drug or HIFU procedure.  An 
adverse event may be considered probably related if or when (must have three of the following): 
• 
It follows a reasonable temporal sequence from administration of the test drug or HUIFU 
procedure. 
• 
It could not be reasonably explained by the known characteristics of the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to the subject. 
• 
It disappears or decreases on cessation or reduction in dose.  There are important exceptions 
when an adverse event does not disappear upon discontinuation of the drug, yet drug-
relatedness clearly exists (e.g. bone marrow depression, fixed drug eruptions, tardive 
dyskinesia). 
• 
It follows a known pattern of response to the test drug or HIFU procedure. 
 
Possible – Applies to those adverse events for which, after careful consideration at the time they are 
evaluated, a connection with the test drug administration or HIFU procedure appears unlikely but 
cannot be ruled out with certainty.  An adverse event may be considered possibly related if or when 
(must have two of the following): 
• 
It follows a reasonable temporal sequence from administration of the test drug 
or HIFU procedure. 
• 
It could not readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to the 
subject. 
• 
It follows a known pattern of response to the test drug or HIFU procedure. 
 
Unlikely – Applies to those adverse events for which, after careful consideration at the time they are 
evaluated, are judged to be unrelated to the test drug or HIFU procedure.  An adverse event may be 
considered unlikely if or when (must have two of the following): 
• 
It does not follow a reasonable temporal sequence from administration of the 
test drug or HIFU procedure. 
• 
It could readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to the 
subject. 
• 
It does not follow a known pattern of response to the test drug or HIFU 
procedure. 
• 
It does not reappear or worsen when the drug is re-administered. 
 
Unrelated – Applies to those adverse events, which after careful consideration, are clearly and 
incontrovertibly due to extraneous causes (disease, environment, etc.). 
 
 
Definition of an Overdose for This Protocol and Reporting of Overdose to the Sponsor 
and to Merck 
For purposes of this trial, an overdose of pembrolizumab will be defined as any dose of 1,000 mg or 
greater (≥5 times the indicated dose).  No specific information is available on the treatment of overdose 

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of pembrolizumab. Appropriate supportive treatment should be provided if clinically indicated. In the 
event of overdose, the subject should be observed closely for signs of toxicity.  Appropriate supportive 
treatment should be provided if clinically indicated. 
If an adverse event(s) is associated with (“results from”) the overdose of a Merck product, the adverse 
event(s) is reported as a serious adverse event, even if no other seriousness criteria are met. 
If a dose of Merck’s product meeting the protocol definition of overdose is taken without any associated 
clinical symptoms or abnormal laboratory results, the overdose is reported as a non-serious Event of 
Clinical Interest (ECI), using the terminology “accidental or intentional overdose without adverse 
effect.” 
All reports of overdose with and without an adverse event must be reported within 24 hours to the 
Sponsor and within 2 working days hours to Merck Global Safety. (Attn: Worldwide Product Safety; 
FAX 215 993-1220) 
 
Reporting of Pregnancy and Lactation to the Sponsor and to Merck 
Although pregnancy and lactation are not considered adverse events, it is the responsibility of 
investigators or their designees to report any pregnancy or lactation in a subject (spontaneously 
reported to them) that occurs during the trial. 
Pregnancies and lactations that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be excluded 
from the trial, or are the result of a protocol-specified intervention, including but not limited to washout 
or discontinuation of usual therapy, diet, placebo treatment or a procedure.   
Pregnancies and lactations that occur from the time of treatment allocation/randomization through 120 
days following cessation of Sponsor’s product, or 30 days following cessation of treatment if the 
subject initiates new anticancer therapy, whichever is earlier, must be reported by the investigator.  All 
reported pregnancies must be followed to the completion/termination of the pregnancy. Pregnancy 
outcomes of spontaneous abortion, missed abortion, benign hydatidiform mole, blighted ovum, fetal 
death, intrauterine death, miscarriage and stillbirth must be reported as serious events (Important 
Medical Events). If the pregnancy continues to term, the outcome (health of infant) must also be 
reported. 
Such events must be reported within 24 hours to the Sponsor and within 2 working days to Merck 
Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220) 
 
Immediate Reporting of Adverse Events to the Sponsor and to Merck 
For the time period beginning when the consent form is signed until treatment allocation/randomization, 
any serious adverse event, or follow up to a serious adverse event, including death due to any cause 
other than progression of the cancer under study that occurs to any subject must be reported within 24 
hours to the Sponsor and within 2 working days to Merck Global Safety if it causes the subject to be 
excluded from the trial, or is the result of a protocol-specified intervention, including but not limited to 
washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. 
For the time period beginning at treatment allocation/randomization through 90 days following 
cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer 
therapy, whichever is earlier, any serious adverse event, or follow up to a serious adverse event, 
including death due to any cause other than progression of the cancer under study whether or not related 

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to the Merck product, must be reported within 24 hours to the Sponsor and within 2 working days to 
Merck Global Safety. 
Additionally, any serious adverse event, considered by an investigator who is a qualified physician to 
be related to Merck product that is brought to the attention of the investigator at any time following 
consent through the end of the specified safety follow-up period specified in the paragraph above, or at 
any time outside of the time period specified in the previous paragraph also must be reported 
immediately to the Sponsor and to Merck Global Safety. 
All subjects with serious adverse events must be followed up for outcome. 
SAE reports and any other relevant safety information are to be forwarded to the Merck Global 
Safety facsimile number:  +1-215-993-1220 
A copy of all 15 Day Reports and Annual Progress Reports is submitted as required by FDA, European 
Union (EU), Pharmaceutical and Medical Devices agency (PMDA) or other local regulators. 
Investigators will cross reference this submission according to local regulations to the Merck 
Investigational Compound Number (IND, CSA, etc.) at the time of submission.  Additionally 
investigators will submit a copy of these reports to Merck & Co., Inc. (Attn: Worldwide Product Safety; 
FAX 215 993-1220) at the time of submission to FDA. 
 Events of Clinical Interest 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest (ECI) 
and must be reported within 24 hours to the Sponsor and within 2 working days to Merck Global Safety. 
(Attn: Worldwide Product Safety; FAX 215 993-1220). 
For the time period beginning when the consent form is signed until treatment allocation/randomization, 
any ECI, or follow up to an ECI, that occurs to any subject must be reported within 24 hours to the 
Sponsor and within 2 working days to Merck Global Safety if it causes the subject to be excluded from 
the trial, or is the result of a protocol-specified intervention, including but not limited to washout or 
discontinuation of usual therapy, diet, placebo treatment or a procedure. 
For the time period beginning at treatment allocation/randomization through 90 days following 
cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer 
therapy, whichever is earlier, any ECI, or follow up to an ECI, whether or not related to Merck product, 
must be reported within 24 hours to the Sponsor and within 24 hours to Merck Global Safety. 
Events of clinical interest for this trial include: 
1.  an overdose of Merck product, as defined in Section 7.2.3 - Definition of an Overdose for This 
Protocol and Reporting of Overdose to the Sponsor, that is not associated with clinical symptoms or 
abnormal laboratory results.  
2.  an elevated AST or ALT lab value that is greater than or equal to 3X the upper limit of normal and 
an elevated total bilirubin lab value that is greater than or equal to 2X the upper limit of normal and, at 
the same time, an alkaline phosphatase lab value that is less than 2X the upper limit of normal, as 
determined by way of protocol-specified laboratory testing or unscheduled laboratory testing.* 
*Note:  These criteria are based upon available regulatory guidance documents. The purpose of the 
criteria is to specify a threshold of abnormal hepatic tests that may require an additional evaluation 
for an underlying etiology.  

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 Protocol-Specific Exceptions to Serious Adverse Event Reporting  
Efficacy endpoints as outlined in this section will not be reported to Merck as described in 
Section7.2.6.- Immediate Reporting of Adverse Events to the Sponsor and to Merck, unless there is 
evidence suggesting a causal relationship between the drug and the event. Any such event will be 
submitted to the Sponsor within 24 hours and to Merck Global Safety within 2 working days either by 
electronic or paper media. 
Specifically, the suspected/actual events covered in this exception include any event that is disease 
progression of the cancer under study. 
The Sponsor will monitor unblinded aggregated efficacy endpoint events and safety data to ensure the 
safety of the subjects in the trial. Any suspected endpoint which upon review is not progression of the 
cancer under study will be forwarded to Merck Global Safety as a SAE within 2 working days of 
determination that the event is not progression of the cancer under study 
Hospitalization related to convenience (e.g.transportation issues etc.) will not be considered a SAE. 
 
 
Evaluating Adverse Events 
An investigator who is a qualified physician will evaluate all adverse events according to the NCI 
Common Terminology for Adverse Events (CTCAE), version 4.0. Any adverse event which changes 
CTCAE grade over the course of a given episode will have each change of grade recorded on the 
adverse event case report forms/worksheets. 
All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 

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Table 7:  Evaluating Adverse Events 
An investigator who is a qualified physician, will evaluate all adverse events as to: 
V4.0 CTCAE 
Grading 
Grade 1 
Mild; asymptomatic or mid symptoms; clinical or diagnostic observations only; intervention not indicated. 
Grade 2 
Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental ADL. 
 
Grade 3 
Severe or medically significant but not immediately life-threatening; hospitalization or prolongation or hospitalization indicated; 
disabling; limiting self-care ADL. 
 
Grade 4 
Life threatening consequences; urgent intervention indicated. 
 
Grade 5 
Death related to AE 
Seriousness 
A serious adverse event is any adverse event occurring at any dose or during any use of Merck product that: 
 
†Results in death; or 
 
†Is life threatening; or places the subject, in the view of the investigator, at immediate risk of death from the event as it occurred (Note: This does not include an 
adverse event that, had it occurred in a more severe form, might have caused death.); or 
 
†Results in a persistent or significant disability/incapacity (substantial disruption of one’s ability to conduct normal life functions); or 
 
†Results in or prolongs an existing inpatient hospitalization (hospitalization is defined as an inpatient admission, regardless of length of stay, even if the 
hospitalization is a precautionary measure for continued observation. (Note: Hospitalization for an elective procedure to treat a pre-existing condition that has not 
worsened is not a serious adverse event.  A pre-existing condition is a clinical condition that is diagnosed prior to the use of a Merck product and is documented in 
the patient’s medical history.); or 
 
†Is a congenital anomaly/birth defect (in offspring of subject taking the product regardless of time to diagnosis);or 
 
Is a new cancer (that is not a condition of the study) (although not serious per ICH definition, is reportable to the Sponsor within 24 hours and to Merck within 2 
working days to meet certain local requirements); or 
 
Is an overdose (whether accidental or intentional).  Any adverse event associated with an overdose is considered a serious adverse event for collection purposes. An 
overdose that is not associated with an adverse event is considered a non-serious event of clinical interest and must be reported within 24 hours to the Sponsor and to 
Merck within 2 working days.. 

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Other important medical events that may not result in death, not be life threatening, or not require hospitalization may be considered a serious adverse event when, 
based upon appropriate medical judgment, the event may jeopardize the subject and may require medical or surgical intervention to prevent one of the outcomes 
listed previously (designated above by a †). 
Duration 
Record the start and stop dates of the adverse event. If less than 1 day, indicate the appropriate length of time and units 
Action taken  
Did the adverse event cause Merck product to be discontinued? 
Relationship to 
Merck Product  
Did Merck product cause the adverse event? The determination of the likelihood that Merck  product caused the adverse event will be provided by an investigator 
who is a qualified physician. The investigator’s signed/dated initials on the source document or worksheet that supports the causality noted on the AE form, ensures 
that a medically qualified assessment of causality was done. This initialed document must be retained for the required regulatory time frame. The criteria below are 
intended as reference guidelines to assist the investigator in assessing the likelihood of a relationship between the test drug and the adverse event based upon the 
available information. 
The following components are to be used to assess the relationship between Merck product and the AE; the greater the correlation with the components and 
their respective elements (in number and/or intensity), the more likely Merck product caused the adverse event (AE): 
 
Exposure 
Is there evidence that the subject was actually exposed to Merck product such as: reliable history, acceptable compliance assessment (pill count, 
diary, etc.), expected pharmacologic effect, or measurement of drug/metabolite in bodily specimen? 
 
Time Course 
Did the AE follow in a reasonable temporal sequence from administration of Merck product?  
Is the time of onset of the AE compatible with a drug-induced effect (applies to trials with investigational medicinal product)? 
 
Likely Cause 
Is the AE not reasonably explained by another etiology such as underlying disease, other drug(s)/vaccine(s), or other host or environmental factors 
 

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Relationship 
The following components are to be used to assess the relationship between the test drug and the AE: (continued) 
to Merck 
Product 
(continued)  
Dechallenge 
Was Merck product discontinued or dose/exposure/frequency reduced? 
If yes, did the AE resolve or improve? 
If yes, this is a positive dechallenge. If no, this is a negative dechallenge. 
(Note: This criterion is not applicable if: (1) the AE resulted in death or permanent disability; (2) the AE resolved/improved despite continuation of 
the Sponsor’s product; or (3) the trial is a single-dose drug trial); or (4) Sponsor’s product(s) is/are only used one time.) 
 
Rechallenge 
Was the subject re-exposed to Merck product in this study? 
If yes, did the AE recur or worsen? 
If yes, this is a positive rechallenge. If no, this is a negative rechallenge. 
(Note: This criterion is not applicable if: (1) the initial AE resulted in death or permanent disability, or (2) the trial is a single-dose drug trial); or (3) 
Sponsor’s product(s) is/are used only one time). 
NOTE: IF A RECHALLENGE IS PLANNED FOR AN ADVERSE EVENT WHICH WAS SERIOUS AND WHICH MAY HAVE BEEN 
CAUSED BY MERCK PRODUCT, OR IF REEXPOSURE TO MERCK PRODUCT POSES ADDITIONAL POTENTIAL SIGNIFICANT RISK 
TO THE SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE SPONSOR AS PER DOSE MODIFICATION 
GUIDELINES IN THE PROTOCOL. 
 
Consistency 
with Trial 
Treatment 
Profile 
Is the clinical/pathological presentation of the AE consistent with previous knowledge regarding Merck product or drug class pharmacology or 
toxicology? 
The assessment of relationship will be reported on the case report forms /worksheets by an investigator who is a qualified physician according to his/her best clinical judgment, including 
consideration of the above elements. 
Record one of the following 
Use the following scale of criteria as guidance (not all criteria must be present to be indicative of Merck product relationship). 
Yes, there is a reasonable 
possibility of Merck product 
relationship. 
There is evidence of exposure to Merck product.  The temporal sequence of the AE onset relative to the administration of Merck product is reasonable.  
The AE is more likely explained by Merck product than by another cause. 
No, there is not a reasonable 
possibility of Merck product 
relationship 
Subject did not receive the Merck product OR temporal sequence of the AE onset relative to administration of Merck product is not reasonable OR 
the AE is more likely explained by another cause than the Merck product.  (Also entered for a subject with overdose without an associated AE.) 

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Adverse Event Classifications 
Adverse events (AEs) are classified into sections, specified in the CTCAE v4.03.  For specific 
classifications pertaining to the protocol, we specify the following: 
Hematologic/Metabolic- Any AE coded under one of the following CTCAE v4.03 categories 
should be reported under the Hematologic/Metabolic adverse event classification: 
 
Table 8:   Hematologic/Metabolic Classifications 
Section 
AE 
Blood and lymphatic 
Anemia 
Leukocytosis 
Investigations 
ALL EXCEPT:  
Carbon monoxide diffusing capacity decreased 
Ejection fraction decreased 
Forced expiratory volume decreased 
Vital capacity abnormal 
Weight gain 
Weight loss 
Metabolism and nutrition 
disorders 
ALL EXCEPT: 
Alcohol intolerance 
Anorexia 
Dehydration 
Glucose intolerance 
Iron overload 
Obesity 
Tumor lysis syndrome 
 
Non-hematologic/Non-Metabolic- Any AE not reported under hematologic/metabolic, 
ocular, or allergic/autoimmune, should be reported under the non-hematologic/non-metabolic 
adverse event classification. 
 
Allergic/Autoimmune – Only AEs coded as Immune System Disorder: Allergic reaction, 
autoimmune disorder, or anaphylaxis should be reported under the Allergic/Autoimmune 
adverse event classification. Other AEs coded under Immune System Disorder should be 
reported under Non-hematologic/Non-metabolic. 
 
 
Agent-Specific Expected Adverse Events List 
 Pembrolizumab 
Treatment-related adverse reactions are described in Section 7 of the Investigator’s Brochure. 
 

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 Adverse Effects Considered Expected for HIFU 
Data for potential adverse effects related to the HIFU treatment are described in the Echopulse 
User’s Manual. 
 
 Adverse events expected from biopsies  
Adverse events expected from biopsies (highest grade expected—Grade 2) 
• 
Bleeding 
• 
Bruising 
• 
Pain 
• 
Lymphedema 
• 
Delayed wound healing 
• 
Scarring 
• 
Numbness 
• 
Gross hematuria and/or dysuria and urinary frequency (prostate biopsies) 
• 
hematochezia (prostate biopsies) 
• 
Infection 
 
 Dose Limiting Toxicities 
A DLT of pembrolizumab is defined as an unacceptable, drug-related toxicity requiring permanent 
discontinuation, per Table 4 (Dose Modification Guidelines for Drug-Related Adverse Events).   
 
 Recording and Reporting Adverse Events 
   Process for Recording Adverse Events 
Dose-limiting toxicities (DLTs) 
DLTs will be entered into Oncore within 5 calendar days of the study team learning of the event. DLTs 
that are deemed serious and unexpected will be submitted to the IRB per institutional guidelines (see 
below). 
Other AEs 
AEs must be recorded into the University of Virginia Cancer Center OnCore database per the following 
guidelines: 
 
 
 
 
 

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Table 9:  Recording AEs into the OnCore Database 
 
    Recording Laboratory Values 
Laboratory values specified in Table 6 will be recorded in the UVA Cancer Center database, graded 
using the CTCAE v4.03 (if a grading category exists) and reported as described in Section 7.2.11.  Any 
abnormal laboratory values captured which are not included in the list, but are considered to be pertinent 
positive clinical signs/symptoms will be recorded in the UVA Cancer Center database and reported as 
described in Section 7.2.11.  If there is any doubt on the part of study personnel concerning what 
constitutes a pertinent positive finding, the Sponsor-Investigator will be consulted. 
 UVA IRB Reporting Requirements 
The University of Virginia is responsible for reporting to the UVA IRB-HSR per the following 
guidelines: 
 
 
 
 
 
 
 
High Risk Studies  
Reporting requirements for AEs that occur within 30 days of the last dose of protocol specified treatment 
 
Grade 1 
Grade 2 
Grade 3 
Grade  
4 & 5 
Expected 
and 
unexpecte
d 
 
Expecte
d 
 
 
Unexpect
ed 
Expected 
 
Unexpected 
Expected 
and 
Unexpected 
Without 
hospitalizati
on 
With 
hospitalizati
on 
Without 
hospitalizati
on 
With 
hospitalizati
on 
Unrelated 
Unlikely 
OnCore 
30 daysa 
OnCore 
30 days 
OnCore 
30 days 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
7 days 
Possible 
Probable 
Definite 
OnCore 
30 daysa 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
7 days 
OnCore 
7 days 
OnCore 
(24-hrs)* 
7 days 
 
*Enter into OnCore database within 24 hours if unexpected and definitely related to protocol specified treatment 
Hospitalization defined as an inpatient hospital stay or prolongation of a hospital stay equal to or greater than 24 hours 
a Grade 1 unexpected or expected hematologic/metabolic events will be recoreded in the Cancer Center Database; however, 
regardless of attribution, these events do not have to be reported.  

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Table 10:  UVA IRB-HSR Reporting 
Type of Event 
To whom will it be 
reported: 
Time 
Frame 
for 
Reporting 
How reported? 
Any internal event resulting in death 
that is deemed DEFINITELY related 
to (caused by) study participation 
(Note:  An internal event is one that 
occurs in a subject enrolled in a UVa 
protocol.) 
IRB-HSR 
Within 24 hours 
IRB Online and phone call 
www.irb.virginia.edu/ 
Internal, Serious, Unexpected adverse 
event. 
 
IRB-HSR 
Within 7 calendar 
days from the time 
the study team 
received knowledge 
of the event. 
 
Timeline includes 
submission of signed 
hardcopy of AE form. 
IRB Online 
 
www.irb.virginia.edu/ 
 
For Device Studies:  Unanticipated 
adverse device effects (internal) 
IRB-HSR 
Within 10 day 
calendar days of the 
study team receiving 
knowledge of the 
event 
IRB Online 
 
www.irb.virginia.edu/ 
 
Unanticipated Problems that are not 
adverse events or protocol violations  
This would include a Data Breach.   
IRB-HSR 
 
 
Within 7 calendar 
days from the time 
the study team 
received knowledge 
of the event.  
Unanticipated Problem report form.  
http://www.virginia.edu/vprgs/irb/H
SR_docs/Forms/Reporting_Require
ments-Unanticipated_Problems.doc  
Protocol Violations (The IRB-HSR 
only requires that MAJOR violation 
be reported, unless otherwise 
required by your sponsor, if 
applicable.) 
 
Or  
 
Enrollment Exceptions 
IRB-HSR 
 
 
Within 7 calendar 
days from the time 
the study team 
received knowledge 
of the event.  
 
Protocol Violation and Enrollment 
Exception Reporting Form 
 
 
http://www.virginia.edu/vprgs/irb/hs
r_forms.html 
Data Breach  
The UVa 
Corporate 
Compliance and 
Privacy Office and 
 
ITC:  if breach 
involves  
electronic data-  
 
UVa Police if 
breach includes 
such things as 
stolen computers.  
As soon as possible 
and no later than 24 
hours from the time 
the incident is 
identified. 
 
As soon as possible 
and no later than 24 
hours from the time 
the incident is 
identified. 
 
 
IMMEDIATELY.  
UVa Corporate Compliance and 
Privacy Office- Phone 924-9741 
 
ITC:  Information Security Incident 
Reporting procedure,  
http://www.itc.virginia.edu/security/
reporting.html 
Phone- (434) 924-7166 
 

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  Reporting to the FDA 
The Sponsor-Investigator for the study (the UVA PI or designee) is responsible for providing safety 
updates to the FDA per the following guidelines.  The reporting times refer to the time the study team 
received knowledge of the event. 
FDA Reporting Requirements for Pembrolizumab related adverse events 
• 
Serious and unexpected suspected adverse reactions will be reported to the FDA no later than 
15 calendar days after the sponsor determines that the requirements for an IND safety report 
have been met. The FDA will be notified using an FDA Form 3500a.  
• 
Unexpected fatal or life-threatening suspected adverse reactions will be reported to the FDA 
no later than 7 calendar days after the Sponsor receives the initial information of the event. The 
FDA will be notified using an FDA Form 3500a.  
Other adverse event information will be sent to the FDA in the IND annual report. 
FDA Reporting Requirements for HIFU:  Unanticipated adverse device effects (UADE) 
• 
Unanticipated adverse device effects (UADEs) will be reported to the FDA no later than 10 
calendar days after the Sponsor-Investigator receives the initial information of the event. 
Other adverse event information will be sent to the FDA in the IND annual report. 
  Reporting to the Echopulse Manufacturer 
All unanticipated adverse device effects (UADEs) will be reported to the Echopulse Manufacturer 
(Theraclion) no later than 5 calendar days after the Sponsor-Investigator receives the initial information 
of the event. 
 Sponsor Responsibility for Reporting Adverse Events 
All Adverse Events will be reported to regulatory authorities, IRB/IECs and investigators in accordance 
with all applicable global laws and regulations.  
8.0 STATISTICAL ANALYSIS PLAN 
8.1 
Statistical Analysis Plan Summary 
This is a pilot study of high intensity focused ultrasound (HIFU) and pembrolizumab, and is proposed 
as a pilot two-arm design.  All patients will receive the FDA approved dosing of pembrolizumab and 
allocation to arms is randomized.  Participants from arm A will first receive HIFU ablation and then a 
pembrolizumab infusion 1 week after an ablative procedure.  Participants from arm B will first receive 
pembrolizumab at baseline and then undergo the HIFU ablation two weeks later.  The goal is to obtain 
preliminary data on the safety of HIFU and pembrolizumab and to obtain estimates of change in 
immune parameters (proportion of activated CD8 tumor infiltrating lymphocytes (TILs) is primary) 
pre- and post-treatment.  The trial will not be powered for cross arm comparison, but will nevertheless 
provide useful pilot data for the design of a larger trial of combined therapies.   
Safety stopping rules will be employed within each study arm and will be judged by dose limiting 
toxicities (DLTs), defined in Section 7.2.10.  The primary objectives include assessing adverse events 

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and change in the proportion of CD8+ to CD4+ tumor infiltrating lymphocytes (TILs) in the primary 
ablation zone.  Secondary endpoints include assessing change in CD8+ T-cell responses at peri-ablation 
zones, clinical responses at local and distant metastatic sites, disease free survival (DFS), and overall 
survival (OS).  Exploratory endpoints include assessing change in T-cells in peripheral blood, markers 
of T-cell activation, gene expression profiling, and enumeration of myeloid derived suppressor cells.   
8.2 
Statistical Analysis Plan 
Target sample size is 12 participants, which was chosen as a feasible number that could be accrued 
within a 2 year accrual period.  Participants will be randomized 1:1 to treatment arms A and B with 
block randomization using blocks of size 2 or 4.  Participants are considered evaluable if they satisfy 
all inclusion and exclusion criteria and have adequate endpoint measurements during respective cohort 
timelines. Adjusting for a 10% unevaluable/drop-out rate, maximum target accrual is estimated at 15 
participants.   
The purpose is to assess the adverse events profile of pembrolizumab and focused ultrasound therapy 
and estimate the difference in the TILs at baseline and 3 weeks within each arm, not to make definitive 
comparisons between arms.  With 6 participants per arm, there is limited power to make comparisons 
between arms.  Lu et. al. (2009) data estimates the difference in means of the ratio of CD4+ and CD8+ 
cells for patients treated with HIFU versus no HIFU to be 0.57, with standard deviations ranging from 
0.27 to 0.40.  These data provide an indication of the magnitude that could be detected in this study at 
baseline and 3 weeks, where it is assumed that the no HIFU participants in Lu et. al. are comparable to 
baseline measurements in our study.  Using these data as a guideline, with n=6, we have 80% power to 
detect an effect size of 1.44 for the within-arm change in ratio of CD4+ and CD8+ cells at baseline and 
3 weeks.  Depending on the variability of the data, this is equivalent to detecting differences of 0.39 
and 0.58, for assumed standard deviations of 0.27 and 0.40, respectively.  The populations will include 
all intention to treat participants. 
Safety stopping rules will be employed within each arm and will be judged by dose limiting toxicities 
(DLT).  If the first two participants within an arm or 3 out of the 6 participants within an arm experience 
a DLT, that arm will be deemed too toxic and further accrual to that arm will be closed.  This decision 
rule is based on Wald’s sequential probability ratio test assuming lower and upper DLT proportions of 
0.1 and 0.3, respectively, and type I and II error rates of 10%.   
Adverse events and DLTs will be summarized by frequency and magnitude for each arm and overall.  
Change in the proportion of CD8+ to CD4+ tumor infiltrating lymphocytes (TILs) in the primary 
ablation zone will be estimated by arm.  Additionally change in CD8+ T-cell responses at peri-ablation 
zones and clinical response at local and distant metastatic sites measured by abscopal tumor shrinkage 
at non-ablated sites, will be estimated for each arm.  The Kaplan Meier estimator will be used to 
estimate survival curves for DFS and OS.  Exploratory endpoints including change in T-cells in 
peripheral blood, markers of T-cell activation, gene expression profiling, and enumeration of myeloid 
derived suppressor cells will be estimated by arm. 
If highly favorable responses are seen in this pilot patient population, then this study may be expanded 
by means of an amendment to more rigorously define response criteria in either or both arms. 

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9.0 LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL SUPPLIES 
9.1 
Investigational Product and Device 
The investigator shall take responsibility for and shall take all steps to maintain appropriate records and 
ensure appropriate supply, storage, handling, distribution and usage of investigational product and 
device in accordance with the protocol and any applicable laws and regulations. 
Clinical drug supplies will be provided by Merck as summarized in Table 8. 
Table 8:  Product Descriptions   
Product Name & Potency 
Dosage Form 
Pembrolizumab 50 mg 
Lyophilized Powder for Injection 
Pembrolizumab 100 mg/ 4mL 
Solution for Injection 
 
Theraclion will provide the Echopulse device and EPacks, a cooling and coupling set that is used to 
enable wave transmission and to protect the skin during the HIFU treatment. EPacks are composed of 
a special liquid, tubing and a membrane and are described further in the user manual. 
9.2 
Packaging and Labeling Information 
Clinical supplies (drug and device) will be affixed with a clinical label in accordance with regulatory 
requirements. 
Echopulse and ePack labeling information can be found in the Echopulse user manual. 
9.3 
Clinical Supplies Disclosure 
This trial is open-label; therefore, the subject, the trial site personnel, the Sponsor and/or designee are 
not blinded to treatment. Drug identity (name, strength) is included in the label text; random 
code/disclosure envelopes or lists are not provided. 
9.4 
Storage and Handling Requirements 
Clinical supplies must be stored in a secure, limited-access location under the storage conditions 
specified on the label.   
Receipt and dispensing of trial medication must be recorded by an authorized person at the trial site. 
Clinical supplies may not be used for any purpose other than that stated in the protocol. 
9.5 
Returns and Reconciliation 
The investigator is responsible for keeping accurate records of the clinical drug supplies received from 
Merck or designee, the amount dispensed to and returned by the subjects and the amount remaining at 
the conclusion of the trial.  

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Upon completion or termination of the study, all unused and/or partially used investigational product 
will be destroyed at the site per institutional policy. It is the Investigator’s responsibility to arrange 
for disposal of all empty containers, provided that procedures for proper disposal have been established 
according to applicable federal, state, local and institutional guidelines and procedures, and provided 
that appropriate records of disposal are kept. 
10.0 ADMINISTRATIVE AND REGULATORY DETAILS 
10.1 Study Conduct and Ethical Considerations 
This study will be conducted in accordance with the standards of Good Clinical Practice, all applicable 
federal, state, and local laws, and in accord with the ethical principles that originated in the Declaration 
of Helsinki.  The Principal Investigator (PI)  is responsible for the conduct of the clinical trial at the site 
and the PI will ensure that staff are trained and carry out the study in accord with the protocol 
specifications.  The PI will ensure that all study site personnel are aware that the study protocol and all 
data generated are confidential and should not be disclosed to third parties (with the exception of local 
and national regulatory bodies which require access for oversight purposes).  
10.2 UVA Institutional Review Board for Health Sciences Research 
The UVA Institutional Review Board for Health Sciences Research (UVA IRB-HSR) will approve all 
aspects of this study, including the clinical trial protocol, informed consent documents, and patient 
materials.  Modifications to the protocol or consent form will be reviewed and approved by the UVA 
IRB-HSR prior to implementation, except when necessary to eliminate apparent immediate hazards to 
the study participants. The study will undergo continuing IRB review based on the level of risk as 
assessed by the IRB.  This review will take place no less than annually. Reporting to the UVA IRB-
HSR will occur as specified in Section 7.2.7. 
10.3 Consent Forms and the Consenting Process 
Consent forms will be written in accord with 21 CFR 50 and will be reviewed and approved by the 
UVA IRB-HSR prior to use. Participants will be given a consent form to review and a member of the 
study team will be available to answer any questions.   Informed consent will be obtained from each 
participant prior to conducting any study-specific procedures or administering study drug. 
10.4 Maintenance of Study Documents 
Study documents and records will be retained in accordance with local IRB requirements and the 
regulations specified in 21 CFR 312. 
10.5 Compliance with Trial Registration and Results Posting Requirements 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and the Food and 
Drug Administration Amendments Act (FDAAA), the Sponsor of the trial is solely responsible for 
determining whether the trial and its results are subject to the requirements for submission to the 
Clinical Trials Data Bank, http://www.clinicaltrials.gov.  Information posted will allow subjects to 
identify potentially appropriate trials for their disease conditions and pursue participation by calling a 
central contact number for further information on appropriate trial locations and trial site contact 
information.     

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10.6 Data Collection 
Data will be collected using a centralized electronic case report form called ON-line Clinical Oncology 
Research Environment = Oncore. 
 Endpoint Data 
Endpoint data will be collected using HITC IML data forms, participant-specific binders, and the HITC 
laboratory database. 
The HITC laboratory database, which has password-restricted access, is stored on the UVA Health 
System Computing Services secured server. 
10.7 Data Safety Monitoring Plan 
The University of Virginia Cancer Center Data and Safety Monitoring Committee (CC DSMC) will 
provide oversight of the conduct of this study.  The CC DSMC will report to the UVA Protocol Review 
Committee (PRC). 
The UVA CC DSMC will review the following: 
• 
All adverse events 
• 
Audit results 
• 
Application of study designed stopping/decision rules 
• 
Whether the study accrual pattern warrants continuation/action 
• 
Protocol violations 
 
10.8 DSMC Monitoring Schedule 
The UVA CC DSMC will meet every month for aggregate review of data.  Tracking reports of the 
meetings are available to the PI for review.  Issues of immediate concern by the DSMC are brought to 
the attention of the sponsor (and if appropriate to the PRC and IRB) and a formal response from the 
sponsor is requested.   Per the UVA Cancer Center NIH approved institutional plan, this study will be 
audited approximately every 6 months. 

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11.0 APPENDICES 
11.1 ECOG Performance Status 
Grade 
Description 
0 
Normal activity. Fully active, able to carry on all pre-disease performance 
without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous activity, but 
ambulatory and able to carry out work of a light or sedentary nature (e.g., 
light housework, office work). 
2 
In bed <50% of the time. Ambulatory and capable of all self-care, but unable 
to carry out any work activities. Up and about more than 50% of waking 
hours. 
3 
In bed >50% of the time. Capable of only limited self-care, confined to bed 
or chair more than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-care. 
Totally confined to bed or chair. 
5 
Dead. 
* As published in Am. J. Clin. Oncol.:  Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., 
McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative Oncology 
Group. Am J Clin Oncol 5:649-655, 1982. The Eastern Cooperative Oncology Group, Robert Comis 
M.D., Group Chair. 
 
11.2 Common Terminology Criteria for Adverse Events V4.0 (CTCAE) 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 will be utilized for adverse event reporting. 
(http://ctep.cancer.gov/reporting/ctc.html) 
11.3 Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 Criteria for Evaluating 
Response in Solid Tumors 
RECIST version 1.1* will be used in this study for assessment of tumor response. While either CT or 
MRI may be utilized, as per RECIST 1.1, CT is the preferred imaging technique in this study. 
* As published in the European Journal of Cancer: 
E.A. Eisenhauer, P. Therasse, J. Bogaerts, L.H. Schwartz, D. Sargent, R. Ford, J. Dancey, S. Arbuck, 
S. Gwyther, M. Mooney, L. Rubinstein, L. Shankar, L. Dodd, R. Kaplan, D. Lacombe, J. Verweij. New 
response evaluation criteria in solid tumors: Revised RECIST guideline (version 1.1). Eur J Cancer. 
2009 Jan;45(2):228-47. 
 
 

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11.4 Summary of Changes 
Version 
Date 
Description of Changes 
04-13-21 
Section 4.3: Updated the rationale for pembrolizumab dose selection per updated 
Merck protocol template language 
Section 5.1.3: Added to exclusion criterion #10 to state that subjects must not have a 
history of interstitial lung disease or have current interstitial lung disease. Added to 
exclusion criterion #18 to state that subjects must not have received a live attenuated 
vaccine within 30 days of planned start of study therapy  
Section 5.2.2: Revised dose modification table and toxicity management table (Table 
4) per updated Merck protocol template language 
Section 5.6.1: Revised supportive care guidelines per updated Table 4 
03-12-21 
Section 5.1: Clarified exclusion criterion #19 to state that HIFU must not be applied 
within 10mm of an implant.  
Section 5.2.1.2: Clarified that approximately 50% of the tumor volume should be 
treated with focused ultrasound ablation 
Section 6.1: Removed footnote “e” from the study flow chart to reflect available 
footnotes.  
08-28-19 
Section 4.2.2: added rationale to address inclusion of patients who experience disease 
progression by rising tumor marker and patients who are intolerant of standard 
therapy. 
Section 5.1.2: added text to inclusion criteria 4 to allow patients who experience 
disease progression by rising tumor marker and patients who are intolerant of 
standard therapy. 
05-07-19 
Section 5.1.2: defined chest wall per NCI. 
11-30-17 
Section 5.2.2: replaced Table 4 with revised Merck provided table “Dose 
Modification and Toxicity Management Guidelines for Immune-related AEs 
Associated with Pembrolizumab”, edited to include language regarding AEs 
resolving to “grade 0-1 or baseline” under general instructions #2. 
11-20-17 
1. Replaced references to week time points with day or cycle for consistency 
throughout protocol.  
2. Section 2.2: replaced trial diagram with updated diagram including day and cycle 
timepoints and reference to HIFU treated lesion and distant tumor site for optional 
biopsies during cycle 4. 
3. Section 5.1.2: edited criterion 9 to allow for ECOG performance status of 2 
4. Section 5.1.3: corrected criterion 8 to indicate brain imaging for subjects with 
history of brain metastases are to be “within” four weeks of “registration”   
5. Section 5.2.2: edited table 4 to include the phrase “or baseline” under the “All 
Other Drug-Related Toxicity”.  This change will allow patients to restart 
treatment if they resolve to baseline. 
6. Section 6.1:  
-added ultrasound imaging at screening  
-added “head when indicated” regarding brain imaging for subjects with history 
of brain metastases. 

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-removed footnote “e Focused Ultrasound treatment should take place on day 15 
of cycle 1 (±2 days)” as it conflicts with intended HIFU treatment window ± 3 
days indicated in flow chart header. 
-clarified optional biopsies “of HIFU treated lesion and distant tumor site” in 
footnote “k” 
7. Section 7.1.2.6: added statement regarding head imaging at screening for subjects 
with history of brain metastases. 
8. Added section 7.1.2.7 to address screening ultrasound to confirm lesion to receive 
HIFU treatment within the Echopulse treatment parameters. 
 
9-28-17 
Section 5.1.2: removed text “all screening labs should be performed within 10 
days of treatment initiation” from exclusion criteria 10 as it conflicts with section 
6.1 footnote “b” indicating that screening labs should be completed within 10 
days of registration which is the intended timeline. 
8-24-17 
Section 6.1: 
-Arm A & B study chart: footnote “h” was moved to the discontinuation visit 
header and reworded to indicate “If a subject is discontinued and the assessments 
have been completed as part of another study visit, the assessments do not need 
to be repeated. Tumor imaging does not need to be repeated if scans have been 
completed within the past 8 weeks.” 
- Second course phase study chart: footnote “e” was updated to indicate that 
tumor imaging would not need to be repeated if done within 8 weeks and footnote 
“f” redundant text regarding tumor imaging was removed. 
08-14-17 
1. Updated Table of Contents 
2. Section 3.3: removed reference to lab manual. 
3. Section 4.4.1: removed references to lab manual and referenced section 7.1.2.7 
4. Section 5.2.1.2: removed proprietary information figure 4, figure 5, and 
corresponding text. 
5. Section 6.1:  
-Arm A study chart: added Day 15 AE assessment   
-Arm A & B study charts: added day 15 pregnancy test, 4 week imaging window 
in footnote “h”, text indicating that the 90 day SAE collection may be completed 
by phone in footnote “j”, and footnote “o” referring to Table 6 for the complete 
list of comprehensive chemistry labs.  
-Second course phase study chart: added cycle 1 thyroid test, text indicating that 
the 90 day SAE collection may be completed by phone in footnote “h”, and 
footnote “i” referring to list of comprehensive chemistry labs.  
-Added study day number and imaging sites to all study calendars. 
6. Section 7.1.2.6: added language to specify imaging sites. 
7. Added sections 7.1.2.7.1 and 7.1.2.7.2 to describe tissue and blood analyses. 
06-19-17 
1. Corrected hyperlinks throughout the study document. 
2. Updated Table of Contents 
3. Section 7.2.6-removed reference to section 7.2.3.3 and reference to section 
7.2.5.2. 
06-13-17 
1. 
Updated Table of Contents 
2. Section 5.1.1:  revised entry criteria to clarify that the intent is to enroll patients 
with metastatic or unresectable breast cancer. 
3. Section 5.1.2 (#3):  revised entry criteria per FDA recommendation to specify 
that patients who are HR+ should also no longer be candidates for hormonal-based 

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therapy.  Patients who are HER2+ should have progressed on or no longer be 
candidates for available HER2 directed therapy. 
4. Section 5.1.2(#5 and #6):  added “chest wall” to the disease description. 
5. Section 5.2.1.2:   
• 
Revised to clarify that HIFU will be administered to sites of disease 
located in the breast/chest wall/axilla. 
• 
Revised to add the following statements per FDA recommendation 
a) To mitigate damage to the rib cage, the clinician will confirm 
that the rib cage is not in the prefocal ultrasound path or behind 
the focal point (minimum distance behind the focal point = 10 
mm). 
b)  As the risk of HIFU on the lung parenchyma is not known at this 
time, for those patients treated with chest wall lesions the beam 
energy should always be oriented so that it does not reach the 
lung. 
c) Following the HIFU procedure, local application of ice may be 
applied to the affected area. 
6. Sections 6.1:   
• 
Added Pain Assessment (VAS Scale) to the study calendars (C1D15 and 
C2) per FDA recommendation. 
• 
Footnote “m”: revised to clarify that for the biopsies three of the needle 
passes should target the central ablated zone and three should target the 
peri-ablation zone. 
7. Section 7.1.1.6:  Deleted the following text to be consistent with the revisions to 
the entry criteria: 
Participants who reach week 10 of pembrolizumab treatment and will be 
continuing with pembrolizumab treatment may receive hormonal or HER2 
therapy concomitantly if indicated. 
8. Section 7.1.2.7:  Revised to provide more details about the biopsies (e.g. gauge 
of needles and use of ultrasound or CT guidance). 
Tumor tissue biopsies will occur at baseline and at cycle 2 as per Flow Chart 6.1 
above. Optional tumor biopsies are permitted at cycle 4 where deemed safe.  For 
the core biopsies, 14-18 gauge needles may be used for tissue sampling.  
Ultrasound guidance or CT guidance may be used at the time of the biopsy.  
 
 
9. Section 7.1.2.8:  Added the following text to describe the patient-rated pain 
assessments:   
The pain associated with the investigational procedure will be assessed prior to 
the HIFU treatment and immediately following the HIFU treatment (C1D15) to 
evaluate pain associated with the procedure. Additional pain assessments will be 
made at Cycle 2. Pain will be rated by each subject using a standard Visual 
Analog Scale (VAS). 

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10. Editorial corrections (e.g. spacing, font, spelling) corrected throughout the study 
protocol. 
05-15-17 
1. Updated Table of Contents 
2. Updated Schema 
3. Corrected typographical errors in Sections 5.2.1.2, 5.2.3, and 5.8. 
4. Section 6.1: removed footnotes “b” informed consent, inclusion/exclusion, 
demographics, history and medication review at screening as the 10 day window 
does not apply. Clarified that baseline imaging should be completed within 28 
days of registration in footnote “g”. 
5. Section 7.2.1: removed duplicate language. 
6. Section 7.2.3: edited to include HIFU procedure in attribution assessments. 
7. Section 7.2.6: removed repetitive language addressed in section 7.2.2. 
8. Section 9: edited to include Echopulse device. 
05-03-17 
1. Added IND number to the Title Page 
2. Updated Table of Contents 
3. Corrected typographical errors in Sections 6.1, 7.2.9.2, and 7.2.11.5 
4. Edited formatting for consistency throughout protocol. 
05-01-17 
1. Updated Table of Contents 
2. Sections 5.2.1.1 and 5.2.3: removed pharmacy manual references and refer to 
standard practice for pembrolizumab preparation and administration. 
3. Section 5.2.1.2: added detail regarding the HIFU treatment procedure. 
4. Section 6.1: removed “of pembro” from end of treatment and safety follow up, 
divided follow-up and survival follow-up into separate columns in the study flow 
chart, added UADEs to footnote “j” and added footnote “n” indicating that 
survival follow up may be completed by phone. 
5. Section 7.1.3: added section to address HIFU device performance parameters 
6. Section 7.2.2: added definitions for unanticipated adverse device effects, device 
failure and malfunctions. 
7. Section 7.2.9.2: referred to the Echopulse user manual for expected adverse 
effects. 
8. Sections 7.2.11.3, 7.2.11.4 & 7.2.11.5: added UADE reporting requirements. 
9. Clarified reference to HIFU treatment area in cubic centimeters throughout 
03-27-17 
1. Section 7.1.5.5: edited to match Merck IIT language regarding second course 
treatment eligibility following complete response 
02-17-17 
1. Updated Table of Contents page numbers. 
2. Section 2.1: defined HIFU. 
3. Section 2.2: clarified that subjects may have an optional biopsy at week 10. 
4. Section 3: primary objective regarding adverse event profile shifted to secondary 
objectives. Secondary objectives shifted to exploratory objectives. 
5. Section 4.1.1: updated to reflect pembrolizumab current approved indications. 
6. Section 4.4: shifted to reflect adverse event profile moving to secondary 
endpoint. 
7. Section 5.1.2: clarified that subjects must have at least one list of therapy in the 
metastatic setting. 
8. Sectrio.5.1.3: clarified permitted steroid use, pneumonitis and implant exclusion. 
9. Section 5.2.2: Table 4 edited to match current Merck template, discontinuation 
for grade 4 diarrhea/colitis. 

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10. Sections 5.8.2 and 7.1.5.3.1: edited to indicate subjects must receive 
pembrolizumab for a minimum of 10 weeks to be considered for retreatment. 
11. Section 6.1: edited the study flow chart to indicate imaging is to be completed at 
cycle 8 (not 7) and that correlative bloods should be collected prior to study drug 
infusion. 
12. Section 7.1.1.5.2: added a statement that subjects continuing to receive 
pembrolizumab beyond week 10 may receive hormonal or HER2 therapy. 
13. Section 7.1.2.6: edited to indicate imaging will be performed every 4 cycles. 
14. Section 7.1.5.5: edited to match current Merck template regarding requirements 
for retreatment.  
15. Section 8.2: edited to indicate that analysis will include discontinued subjects.  
16. Corrected minor typographical errors throughout the document. 
12-20-16 
1. Updated Table of Contents 
2. Section 5.8.3: added a new section to address pembrolizumab treatment in 
subjects experiencing stable disease or partial response. 
3. Section 7.1.2.7: added a statement addressing correlative blood samples. 
4. Section 7.1.5.5: removed separate second course treatment inclusion language 
and refer to inclusion/exclusion criteria. 
5. Section 7.2.3: added a new section to define adverse event levels of attribution 
(unrelated, unlikely, possibly, probably, definite). 
6. Editorial changes and correction were made throughout the study document. 
11-09-16 
1. Added signature page 
2. Updated Table of Contents 
3. Sections 2.1, 2.2, 6.1: Revised language for the biopsy collection to clarify that 1) 
optional biopsies of distant tumor sites may occur at week 10 and 2) additional 
biopsies of the HIFU treated lesion may also be taken at week 10. 
4. Section 2.2, Table 3, Section 6.1, Section 8.1 
    Moved HIFU administration from week 2 (day 8) to week 3 (day 15). 
5. Sections 4.4.1, 8.2:  Deleted requirement for having the PD-L1 testing completed 
by Qualtek.  PD-L1 testing will not be a required test for this study. 
6. Section 6.1: Study Flow Chart 
• 
Removed scheduling window from the screening visit and reference the 
footnotes section. 
• 
Added prior and concomitant medication review to the safety follow-up 
visit 
• 
Revised the day for HIFU—C1, D15 
• 
Added a pregnancy test at cycle 2 (Arm A) 
• 
Added a line for the symptom diary 
• 
Clarified language for the optional tumor biopsies 
• 
Revised footnote i (Arms A and B) and footnote g (second course 
treatment) so that the 2 footnotes are consistent. 
• 
Clarified in footnote l that bloods for immunologic testing will be 
collected in 10 ml tubes. 
7. Section 8.2:  Revised accrual period to 2 years. 
8. Editorial changes and corrections were made throughout the study document. 
 
 

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TRIPLE-NEGATIVE BREAST CANCER (MTNBC). J CLIN ONCOL 34, 2016 
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OF METASTASES AFTER TREATMENT WITH LOCAL RADIATION AND CTLA-
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RECEIVING PREOPERATIVE CRYOABLATION (CRYO) AND/OR IPILIMUMAB 
(IPI). J CLIN ONCOL 32, 2014 (ABSTR) 
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