A Phase 2 Trial of Pembrolizumab Plus Bevacizumab in Patients With Metastatic Melanoma or Non-small Cell Lung Cancer With Untreated Brain Metastases
Phase: PHASE2
Conditions: Melanoma, Non-small Cell Lung Cancer, Brain Metastasis
Sponsor: Yale University

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SPONSOR: Yale University 
 
TITLE: A phase 2 trial of pembrolizumab plus bevacizumab in patients with metastatic 
melanoma or non‐small cell lung cancer with untreated brain metastases. 
 
IND NUMBER: 129774 
 
Coordinating Center: 
Yale Cancer Center 
 
Principal Investigator: 
Harriet Kluger, M.D. 
Section of Medical Oncology 
Yale Cancer Center 
333 Cedar Street, WWW‐213 
New Haven, CT 06520 
Tel: (203) 737‐2572 
Fax: (203) 785‐3788 
Harriet.Kluger@yale.edu 
 
Co‐Principal Investigators: 
Sarah Goldberg, M.D., M.P.H. 
Section of Medical Oncology 
Yale Cancer Center 
333 Cedar St., FMP130 
New Haven, CT 06520 
Tel: (203) 785‐7564 
Fax: (203) 785‐3788 
Sarah.Goldberg@yale.edu 
 
Veronica Chiang, M.D. 
Department of Neurosurgery 
333 Cedar Street, TMP4 
New Haven, CT 06520 
Tel: (203) 785‐2808 
Fax: (203) 785‐2098 
Veronica.Chiang@yale.edu
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CONTENTS 
Contents 
1.0 TRIAL SUMMARY ............................................................................................................ 6 
2.0 TRIAL SYNOPSIS ............................................................................................................. 6 
3.0 TRIAL DESIGN ................................................................................................................ 11 
3.1Trial Design and duration ............................................................................................. 11 
3.2 Trial Diagram ................................................................................................................ 13 
3.3 OBJECTIVE(S) & HYPOTHESIS(ES) .......................................................................... 16 
3.3.1  Primary Objective(s) & Hypothesis(es) ...................................................................... 16 
3.3.2 
Secondary Objective(s) & Hypothesis(es) ............................................................. 16 
3.3.3 
Exploratory Objective ............................................................................................ 17 
4.0 BACKGROUND & RATIONALE .................................................................................. 17 
4.1.1 
Pharmaceutical and Therapeutic Background .................................................... 17 
4.1.2 
Preclinical and Clinical Trial Data for pembrolizumab ...................................... 18 
4.2 Rationale ............................................................................................................................ 19 
4.2.1 Rationale for combining pembrolizumab and bevacizumab .............................. 19 
4.2.2. Rationale for Trial and Selected Subject Population ............................................ 21 
4.2.3 Rationale for Dose Selection/Regimen/Modification .............................................. 22 
4.2.4. Rationale for Endpoints ........................................................................................... 23 
5.0 METHODOLOGY ........................................................................................................... 24 
5.1 Entry Criteria ................................................................................................................ 24 
5.1.1. Diagnosis/Condition for Entry into the Trial ..................................................... 24 
5.1.2 Subject Inclusion Criteria ..................................................................................... 24 
5.1.3 Subject Exclusion Criteria .................................................................................... 26 
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5.2 Trial Treatments ........................................................................................................... 28 
5.2.1 Dose Selection/Modification .................................................................................. 28 
5.2.2 Timing of Dose Administration ............................................................................ 38 
5.2.3 Duration of Therapy .............................................................................................. 38 
5.2.4 Treatment Beyond Progression ............................................................................ 39 
5.2.5 Duration of Follow-up ........................................................................................... 39 
5.3 Concomitant Medications/Vaccinations (allowed & prohibited) ............................. 39 
5.3.1 Acceptable Concomitant Medications .................................................................. 39 
5.3.2 Prohibited Concomitant Medications .................................................................. 40 
5.4 Local Therapy ............................................................................................................... 40 
5.5 Rescue Medications & Supportive Care ..................................................................... 41 
5.5.1 Supportive Care Guidelines ..................................................................................... 41 
5.5.2 Supportive Care Guidelines for Events of Clinical Interest (ECIs) and Immune- 
related Adverse Events (irAEs)............................................................................. 43 
5.5.3. Supportive Care Guidelines for Pneumonitis.......................................................... 44 
5.6 Diet/Activity/Other Considerations ............................................................................. 44 
5.6.1 Diet ....................................................................................................................... 44 
5.6.2 Contraception ......................................................................................................... 45 
5.6.3 Use in Pregnancy .................................................................................................... 45 
5.6.4 Use in Nursing Women .......................................................................................... 46 
5.7 Subject Withdrawal/Discontinuation Criteria ........................................................... 46 
5.7.1 Discontinuation of Study Therapy after CR ....................................................... 47 
6.0 TRIAL FLOW CHART ................................................................................................... 48 
6.1  
Study Flow Chart .................................................................................................... 48 
7.0 TRIAL PROCEDURES ................................................................................................... 51 
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7.1 Administrative Procedures .......................................................................................... 51 
7.1.1  Informed Consent ................................................................................................... 51 
7.1.1.2 General Informed Consent ................................................................................. 51 
7.1.2 Inclusion/Exclusion Criteria ..................................................................................... 51 
7.1.3 Medical History .......................................................................................................... 51 
7.1.4 Prior and Concomitant Medications Review .......................................................... 52 
7.1.5  Disease Details and Treatments ............................................................................. 52 
7.2 Clinical Procedures/Assessments ................................................................................. 52 
7.2.1 Adverse Event (AE) Monitoring ........................................................................... 52 
7.2.2 Full Physical Exam ................................................................................................ 53 
7.2.3 Directed Physical Exam ......................................................................................... 53 
7.2.4 Vital Signs ............................................................................................................... 53 
7.2.5 Eastern Cooperative Oncology Group (ECOG) Performance Scale ................ 53 
7.2.6 Tumor Imaging and Assessment of Disease ........................................................ 53 
7.2.7 Tumor Tissue Collection and Correlative Studies Blood Sampling .................. 53 
7.3 Laboratory Procedures/Assessments .......................................................................... 54 
7.4 Other Procedures .......................................................................................................... 56 
7.4.1 Withdrawal/Discontinuation ................................................................................. 56 
7.5 Visit Requirements ....................................................................................................... 56 
7.5.1 Safety Follow-Up Visit ........................................................................................... 56 
7.5.2 Follow-up Visits ...................................................................................................... 56 
7.6 Assessing and Recording Adverse Events .................................................................. 57 
7.6.1 Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Sponsor and to Merck ........................................................................................ 58 
7.6.2 Reporting of Pregnancy and Lactation to the Sponsor and to Merck .............. 58 
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7.6.3 Immediate Reporting of Adverse Events to the Sponsor and to Merck ........... 59 
7.6.4 Reporting to the Food and Drug Administration ............................................... 60 
7.6.5 Reporting to the Yale Human Investigation Committee .................................... 60 
7.6.6 Evaluating Adverse Events ................................................................................... 61 
7.6.7 Sponsor Responsibility for Reporting Adverse Events ...................................... 64 
7.6.8 Events of Clinical Interest ..................................................................................... 64 
8.0 STATISTICAL ANALYSIS PLAN................................................................................. 64 
8.1 Statistical Design ........................................................................................................... 64 
8.2 Analytic Plan for Primary Objectives: ....................................................................... 67 
8.3 Analytic Plan for Secondary Objectives: .................................................................... 67 
8.4 Exploratory Objective .................................................................................................. 68 
9.0  
LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL 
SUPPLIES ......................................................................................................................... 69 
9.1 Investigational Product ................................................................................................ 69 
9.2 Packaging and Labeling Information ......................................................................... 69 
9.3 Clinical Supplies Disclosure ......................................................................................... 69 
9.4 Storage and Handling Requirements .......................................................................... 69 
9.5 Returns and Reconciliation .......................................................................................... 69 
10.0 ADMINISTRATIVE AND REGULATORY DETAILS ............................................. 70 
10.1 Compliance with Trial Registration and Results Posting Requirements ............... 70 
10.2 Quality Management System ..................................................................................... 70 
10.2.1 Monitoring ............................................................................................................ 70 
10.2.2 Audit and inspection ............................................................................................ 71 
10.2.3 Data Safety Monitoring Committee (DSMC) .................................................... 71 
11.0 BIOMARKER STUDIES ............................................................................................... 72 
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11.1 Tissue-based correlative studies: ............................................................................... 72 
11.2 Blood-based studies: ................................................................................................... 73 
11.3 Collection and Handling of Specimens ..................................................................... 74 
12.0  
MEASUREMENT OF RESPONSE ...................................................................... 74 
12.1 Brain Metastasis Response Assessment ..................................................................... 74 
12.2 Brain Metastasis Measurable disease ......................................................................... 74 
12.3 Brain Metastasis Nonmeasurable disease .................................................................. 75 
12.4 Modified Response Criteria for Brain Metastases .................................................... 75 
12.5 Systemic Disease Response Assessment ..................................................................... 75 
12.6 Evaluation of Best Overall Response .......................................................................... 76 
13.0 APPENDICES ................................................................................................................. 78 
13.1 ECOG Performance Status ........................................................................................ 78 
13.2 Common Terminology Criteria for Adverse Events V5.0 (CTCAE) ..................... 78 
14.0 REFERENCES ................................................................................................................ 79 
 
 
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1.0 TRIAL SUMMARY 
 
Abbreviated Title 
Pembrolizumab and bevacizumab in untreated brain metastases 
Trial Phase 
II 
Clinical Indication 
Untreated brain metastases from melanoma or non-small cell lung cancer 
Trial Type 
Open label 
Type of control 
None 
Route of administration 
IV 
Trial Blinding 
NA 
Treatment Groups 
Two cohort phase II trial, one for melanoma patients and one for non-small 
cell lung cancer patients 
Number of trial subjects 
53 
Estimated enrollment period 
January 1, 2016 – December 31, 2022 
Estimated duration of trial 
96 months 
Duration of Participation 
36 months 
 
2.0 TRIAL SYNOPSIS 
 
Concept and Rationale: Important progress has recently been made in treating metastatic 
melanoma and non-small cell lung cancer (NSCLC) using pembrolizumab, an inhibitor of 
PD-1, a negative immune check-point regulator found on cytotoxic T-cells_ENREF_1. 
Approximately 34% of patients with melanoma and 25% with NSCLC have partial or complete 
responses to this drug at optimal doses, and additional patients have prolonged stable 
disease. An ongoing study of pembrolizumab in patients with brain metastases from 
melanoma or NSCLC has shown that while the drug has substantial activity in brain 
metastases, peri-lesional edema can result in significant morbidity. Bevacizumab, an 
antibody to VEGF has been shown in a number of prior clinical studies to reduce peri- 
lesional edema in the CNS. Moreover, in preclinical models the addition of VEGF inhibitors 
to PD-1 inhibitors has been shown to enhance anti-tumor immunity, providing further 
rationale for combining pembrolizumab and bevacizumab in this patient population. 
 
Every year there are almost 50,000 patients from these diseases who will develop brain 
metastases. Melanoma in particular tends to metastasize to the brain frequently, and the 
incidence on autopsy is up to 70%. Brain metastases are present in 10% of patients with 
NSCLC at diagnosis, and another 30% develop CNS disease over the course of their disease. 
Multifocal disease is common in both of these diseases, with about half of patients with CNS 
disease presenting with more than one brain lesion. 
 
Many effective drugs currently in development have not been well studied for CNS 
penetration, and patients with brain metastases are excluded from most clinical trials. With 
recent advances in delivery of local therapies, particularly stereotactic radiosurgery (SRS), 
local control of brain metastases has improved. However, SRS still has limitations and 
complications such as radiation necrosis, cerebral edema, and delayed tumor hemorrhage. 
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Beyond these local therapies, effective systemic therapies that are active in the CNS may be of 
significant benefit to patients. 
The purpose of this trial is to study the activity of pembrolizumab in combination with 
bevacizumab in patients with untreated brain metastases from melanoma or NSCLC to 
determine activity and safety of the drug combination. Furthermore, in patients who undergo 
resection of biopsy of a brain metastasis, we will evaluate biomarkers predictive of treatment 
benefit, and will also conduct correlative biomarker studies on extra-cerebral specimens in all 
patients in whom a systemic biopsy is feasible or in archival tumor tissue when available. 
Confirmed, objective CNS responses were seen in 11 of the first 20 melanoma patients, for a 
brain metastasis response rate of 55%. The primary endpoint of the study for the melanoma 
cohort has been met. We will validate the findings in the melanoma cohort in the next 20 
melanoma patients. The NSCLC component is a pilot study  
Primary Objectives/Endpoints: 
(1) To determine the brain metastasis response rate in patients with melanoma or NSCLC 
with untreated brain metastases, treated systemically with pembrolizumab plus bevacizumab. 
Secondary Objectives/Endpoints: 
1) To determine the incidence of steroid use for control of cerebral edema during 
treatment with pembrolizumab plus bevacizumab in patients with metastatic 
melanoma or NSCLC to the brain compared to previous study of patients treated with 
pembrolizumab alone. 
2) To determine the best overall response rate (ORR) in patients with brain metastases 
from melanoma or NSCLC treated with combination pembrolizumab plus 
bevacizumab. 
3) To evaluate median progression free survival (PFS) and overall survival (OS) in 
patients with melanoma or NSCLC metastatic to the brain, treated with 
pembrolizumab plus bevacizumab. 
4) To determine the safety of pembrolizumab in combination with bevacizumab in 
patients with untreated brain metastases from melanoma or NSCLC 
Exploratory objective: 
To study PD-L1 expression and other potential predictive biomarkers in CNS, tumors 
and blood, and correlate results with response to pembrolizumab plus bevacizumab. 
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Study Design: This is a phase II study with the 2 tumor types treated in separate cohorts. Key 
eligibility criteria include advanced melanoma or non-squamous NSCLC with at least 1 brain 
metastasis that is at least 5mm but smaller than 2cm in size, and no requirement for systemic 
steroids to control peri-lesional CNS edema. Patients who have had prior resection of a CNS 
lesion will be required to provide a tumor block for correlative studies and all patients   will   be  
required to provide an extra-cerebral specimen when feasible 
Pembrolizumab will be administered on day 1 of every cycle until disease progression or 
withdrawal from study. Bevacizumab will be administered in addition to pembrolizumab on 
day 1 of cycles 1, 2, 3, and 4 (or alternative cycles if bevacizumab is held during these 
cycles).  Three weeks constitutes one cycle. 
Efficacy evaluation will be performed every 6 weeks for the first 3 months of treatment, and 
every 9 weeks thereafter, including MRI of the brain and CT or PET scans of systemic 
disease. Patients will continue on study until they have disease progression, toxicities that 
preclude continuing the study drug, withdrawal from study, development of other severe 
illness, neurologic or systemic complications following local therapy to any lesion, 
termination of study, or death. Dose reductions for severe immune-related toxicities will not 
be allowed, however, discontinuation of one of the drugs will be allowed for toxicity if the 
investigator determines that the other drug is providing clinical benefit. Patients may remain 
on study after disease progression if they are deemed by the investigator to be deriving 
clinical benefit from treatment. 
Number of Patients: 
A total of 40 melanoma patients and 13 NSCLC patients will be enrolled for a total of 
53 patients. The study will accrue for approximately 24 additional months and will be open 
for approximately 12 additional months after the last patient is accrued as patients on study 
are being followed. 
 
 
 
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Statistical Methods 
 
The primary goal of this study is to determine the efficacy and safety of pembrolizumab plus 
bevacizumab in patients with untreated brain metastases from melanoma or NSCLC. The 
primary endpoint is the brain metastasis response rate (BMRR). A drug with minimal activity 
would be expected to have a BMRR of 10%. The study was initially designed so that this 
combination would be considered worthy of further study in patients with untreated brain 
metastases if its true BMRR is similar to the systemic response rate with pembrolizumab 
(Melanoma - 34%, NSCLC with PD-L1 positive tumors - 25%).As of February 2019, 20 
patients had been accrued to the melanoma cohort of the trial and brain metastasis responses 
were observed in 55%, 95% CI: 0.32-0.77) Therefore, the statistical plan was amended to 
include an additional 20 patients to the melanoma cohort to validate the findings in the initial 
cohort. The initial pre-defined criterion that the combination of pembrolizumab and 
bevacizumab would not be worthy of further study if the BMRR was <10% was modified to 
30%, which is the lower bound of the 95% confidence interval from the first 20 melanoma 
patients. To account for the uncertainty of the historical response rate, we will now follow the 
approach proposed by Thall and Simon (1994),63 and after enrolling and evaluating the 
outcomes of the 20 patients in the confirmatory cohort, we will conclude the combination 
worthy of further study if there are at least 8 responses in these 20 patients.  
 
A pilot study of 13 NSCLC will be conducted. See statistical analyses section for more details. 
 
 
 
 
 
 
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INVESTIGATOR SIGNATURE PAGE 
 
Protocol Title: A phase 2 trial of pembrolizumab plus bevacizumab in patients with 
metastatic melanoma or non-small cell lung cancer with untreated brain metastases 
 
Protocol Version: 12 
 
By signing this agreement, I, the Site Investigator named above, acknowledge receipt of this 
protocol version. I have read this protocol in its entirety and agree to conduct this study 
according to this protocol, Good Clinical Practices and all applicable codes of federal 
regulations (CFRs) and guidelines. 
 
 
Site Investigator’s Printed Name:  _______________________ 
 
 
 
Signature:  ______________________________ 
 
 
 
Date:  ________________________________ 
 
 
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3.0 
TRIAL DESIGN 
 
3.1 
Trial Design and duration 
 
This is a phase II study for melanoma and a pilot study for NSCLC. Patients will be treated 
in separate cohorts. After establishing eligibility criteria, target lesions in the CNS will be 
chosen and will be followed by modified RECIST (mRECIST) criteria to determine best 
brain metastasis response. When feasible, after obtaining informed consent, patients may 
undergo local therapy (resection or laser interstitial thermocoagulation therapy - LITT) to the 
brain. Biopsy of tumor tissues from extra-cerebral sites will be studied for PD-L1 and other 
biomarkers (see section 11.0 below) as potential predictors of sensitivity to pembrolizumab 
and bevacizumab, although it should be noted that the presence of a biomarker is not necessary 
for melanoma patients to go on trial. Expression of PD-L1 determined by Central and/or 
local testing of PD-L1 IHC by any FDA-approved assay or an assay performed in a CLIA 
laboratorywill be required for eligibility for NSCLC patients. This will be followed by 
treatment with pembrolizumab 200mg IV every 3 weeks. Bevacizumab 7.5 mg/kg will be 
administered on Day 1 of cycles 1, 2, 3, and 4 (or alternative cycles if bevacizumab is held 
during these cycles). Day 1 of the study will be defined as the first day a patient receives 
pembrolizumab. Each cycle is 3 weeks. 
 
Clinically Evaluable Lesion(s): A clinically evaluable lesion is at least one asymptomatic, 
untreated brain metastasis that measures at least 5 mm in minimum cross-sectional diameter 
and < 20 mm in maximum cross-sectional diameter as determined by brain MRI at baseline, 
and is determined by the investigator to be safe to follow clinically without local therapy. If 
MRI slice thickness is >2.5mm, the minimum cross-sectional diameter must be at least twice 
the MRI slice thickness. An untreated brain metastasis is defined as a lesion not present at 
the time of whole brain radiation therapy or included in a stereotactic radiotherapy field (or 
within 2mm of a treated lesion), or any lesion that is new or unequivocally progressing since 
prior radiation therapy. At time of enrollment, the clinically evaluable lesion(s) will be 
defined. 
 
Patients will proceed directly to therapy with bevacizumab and pembrolizumab. If, at any 
time while on study, the patient develops symptoms related to any cerebral metastases the 
patient may have brain imaging prior to the pre-defined imaging time points and proceed to 
local therapy of the lesion(s) if indicated. 
 
Efficacy evaluation will be performed every 6 weeks for the first 3 months and every 9 
weeks thereafter, including PET or CT scans of systemic disease. Brain metastasis response 
will be determined using modified RECIST (mRECIST) criteria. Patients will continue on 
study until they have overall disease progression in either their clinically evaluable CNS 
lesions (by mRECIST criteria) or in their systemic metastases (by RECIST 1.1 criteria), 
toxicities that preclude continuing the study drugs, withdrawal from study, development of 
other severe illness, neurologic or systemic complications following local therapy to any 
lesion, termination of study, or death. There will be no dose reduction for either 
pembrolizumab or bevacizumab but one drug may be held as outlined below. If a patient 
develops symptoms related to ANY lesion, local therapy may be administered to that lesion. 
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Patients with new symptoms from CNS lesions, or progressing lesions may be treated with local 
therapy to the brain metastases. These patients can continue therapy with both drugs or one of the drugs 
if the patient is otherwise deemed to be deriving clinical benefit. If patients develop clear intralesional 
or perilesional hemorrhage they can stay on study with cessation of bevacizumab. 
 
Treatment beyond progression: If the treating physician determines that a patient is deriving clinical 
benefit from therapy, treatment beyond progression (as defined by mRECIST for CNS lesions and 
RECIST 1.1 for extracerebral lesions) will be allowed. 
 
Discontinuation of bevacizumab OR pembrolizumab and continuation of monotherapy: Patients who 
develop toxicity clearly attributable to one drug who are felt to be benefitting from therapy will be 
allowed to remain on study. Examples include proteinuria, or thromboembolic events attributed to 
bevacizumab and severe autoimmune toxicity not controllable with steroids from pembrolizumab. 
 
The plan is to enroll an additional 40 melanoma patients and 13 NSCLC patients in a pilot study 
for 53 patients total.  
 
 
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3.2 Trial Diagram 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PD‐L1 positive 
PD‐L1 
negative 
or 
unevaluable 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CR, PR, SD 
PD 
 
 
 
 
 
 
Evaluate patients with untreated brain metastases and/or post‐treatment progressing brain 
metastases for eligibility and select clinically evaluable lesions 
Obtain archival or fresh 
tumor tissue if available 
Obtain archival or fresh tumor tissue for PD‐L1 
status*** 
Eligible 
Ineligible 
Initiate pembrolizumab 200mg q 3w + bevacizumab 7.5mg/kg on D1 of C1, C2, C3 and C4* 
Response evaluation for brain and body q6w for 3 months and then 
q9w thereafter 
Continue on treatment if 
stable or responding** 
Consider local therapy to isolated growing 
lesions 
Continue on treatment 
Remove from study** 
*Bevacizumab may be administered during later cycles if held during cycles 1‐4, with the goal of administering a total of 4 cycles of combination
pembrolizumab and bevacizumab 
** Subjects who experience PD may continue on study if they are determined to be deriving clinical benefit from the study drugs and they continue
to meet all other criteria for treatment 
*** Subjects with PD‐L1 test results from outside the study are not required to repeat testing for determination of eligibility as long as
no systemic 
therapy was administered after the test results were obtained. If patients do not undergo PD‐L1 testing for eligibility, fresh or archival
tissue is still 
required at study entry for correlative studies. 
 
Cohort A: 
Melanoma 
Cohort B: 
NSCLC 
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3.3 OBJECTIVE(S) & HYPOTHESIS(ES) 
 
3.3.1  Primary Objective(s) & Hypothesis(es) 
 
1) Primary Objective: To determine the brain metastasis response rate in patients with 
melanoma or NSCLC treated with pembrolizumab plus bevacizumab. 
 
Hypothesis: The combination of pembrolizumab and bevacizumab will result in 
enhanced anti-tumor activity. 
 
3.3.2 Secondary Objective(s) & Hypothesis(es) 
 
(1) Objective: To determine the incidence of steroid use for control of cerebral edema 
during treatment with pembrolizumab and bevacizumab in combination in patients 
with metastatic melanoma or NSCLC. 
 
Hypothesis: The combination of pembrolizumab and bevacizumab will result in 
reduced steroid use to control CNS edema compared to a historical cohort of patients 
treated with pembrolizumab alone. 
 
(2) Objective: To determine the best overall response rate (ORR) in patients with brain 
metastases from melanoma or NSCLC treated with combination pembrolizumab and 
bevacizumab. 
 
Hypothesis: The combination of pembrolizumab and bevacizumab will result in 
enhanced anti-tumor activity compared to a historical cohort of patients with 
pembrolizumab alone. 
 
(3) Objective: To evaluate median progression free survival (PFS) and overall survival 
(OS) in patients with melanoma or NSCLC metastatic to the brain, treated with 
pembrolizumab plus bevacizumab. 
 
Hypothesis: The combination of pembrolizumab and bevacizumab will result in 
longer PFS and OS compared to a historical cohort of patients with pembrolizumab 
alone. 
 
(4) Objective: To determine the safety and toxicity of pembrolizumab in combination 
with bevacizumab in patients with untreated brain metastases 
 
Hypothesis: The combination will result in an improved central nervous system 
toxicity profile and less perilesional edema than pembrolizumab monotherapy 
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3.3.3 Exploratory Objective 
 
(1)  Objective: To study PD-L1 expression and other potential predictive biomarkers in 
CNS, tumors and blood, and correlate results with response to pembrolizumab plus 
bevacizumab. 
 
 
Hypothesis: Patients with high PD-L1 tumor content AND high TIL content, 
particularly increased CD-8 TILs, will be more likely to respond to the combination 
of pembrolizumab and bevacizumab. 
 
4.0 
BACKGROUND & RATIONALE 
 
4.1 
Background 
 
Although immune-modulating antibodies are becoming the standard of care for treating 
melanoma and other malignancies, little is known regarding the effects of these agents on 
brain metastases. Ten to 40% of patients with metastatic melanoma develop brain metastases 
during their lifetime and > 75% have metastases at autopsy 1-5. Among patients with non- 
small cell lung cancer (NSCLC), 10% have brain metastases at presentation and another 30% 
develop them over the course of their disease. Survival after the development of brain 
metastases is as dismal in those with NSCLC as it is for melanoma. Multifocal disease is 
common in both of these malignancies, with about half of patients with CNS disease 
presenting with more than one brain lesion 6. Typical local management involves surgery or 
stereotactic radiosurgery (SRS), depending on the size and number of lesions, while whole 
brain radiation (WBRT) is used for patients with multiple lesions, or large lesions 7,8. However, 
SRS has limitations and can cause complications such as radiation necrosis, cerebral edema 
and delayed tumor hemorrhage 9. With the advent of active systemic therapies in these 
diseases, it is possible that brain metastases might be controlled with these newer drugs, 
similar to control of extra-cerebral metastases. The ability of systemic therapies to cross the 
leaky blood brain barrier found in tumors is the subject of ongoing investigations 3,10,11. To 
date, most systemic therapy trials exclude patients with active brain metastases because 
of poor prognosis and unknown CNS penetration, and their activity in CNS metastases is 
typically understudied 3,12. 
4.1.1 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
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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- 
(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) has recently been approved in the 
United Stated for the treatment of patients with unresectable or metastatic melanoma and 
disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF 
inhibitor. 
 
 
4.1.2 Preclinical and Clinical Trial Data for pembrolizumab 
 
Please refer to the Investigator’s Brochure for additional preclinical and clinical data. 
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4.2 
Rationale 
 
4.2.1 Rationale for combining pembrolizumab and bevacizumab 
 
Pembrolizumab Rationale: 
Antibodies blocking either PD-1 or its ligand PD-L1 are the most active of the immune 
modulating antibodies studied in clinical trials to date. Initial trials of antibody-mediated 
blockade of PD-1 alone showed promising results with durable tumor regression or 
prolonged disease stabilization in patients with advanced solid tumors including melanoma13- 
15 and lung cancer 13. Results from a phase 1b study of pembrolizumab, a monoclonal 
antibody against PD-1, in metastatic melanoma showed an overall response rate of 34% and 
a median PFS of 36 months 15. Eighty percent of patients had a continued response to 
therapy. Based on this study, pembrolizumab, is now approved by the FDA for the treatment 
of metastatic melanoma 14. A randomized phase III trial comparing pembrolizumab to 
ipilimumab in the frontline setting demonstrated a response rate of 34% in patients receiving 
pembrolizumab 16. Recent data regarding activity of pembrolizumab in previously untreated 
NSCLC was presented at ASCO, 2014 and showed an overall response rate of 26% with 
100% of patients having an ongoing response 17. Additional studies have been conducted 
showing response rates that vary based on PD-L1 status and cut-points for positivity 18-21. A 
phase III trial is underway comparing pembrolizumab to standard chemotherapy in NSCLC. 
In almost all trials conducted to date, clinical response to PD-1/PD-L1 pathway antagonists 
has been strongly associated with pre-treatment tumor cell or tumor infiltrating lymphocyte 
(TIL) surface expression of PD-L1. Correlative data also suggest that in many patients, pre- 
treatment tumor PD-L1 expression is induced by adjacent cytokine-producing T-cells; 
however, a subset of tumors can express PD-L1 in the absence of T-cell infiltration, 
presumably as a result of aberrant cell signaling 22. Tumors expressing PD-L1 but lacking 
TIL, and conversely tumors containing non-cytokine producing TIL and absent PD-L1 
expression, are less likely to respond to PD-1/PD-L1 pathway antagonists. 
 
Even in the subgroup of patients most likely to respond to PD-1/PD-L1 pathway antagonists 
(i.e., tumors containing TIL and associated PD-L1 expression), combinations may be 
necessary to higher rates of durable responses. Particularly for patients with  metastatic disease 
to the brain, the addition of a second agent in combination with pembrolizumab may allow 
for improved responses with decreased deleterious inflammatory effects, such as peri- lesional 
edema. Optimal approaches to such combinations are influenced by both preclinical studies 
and results from post-treatment biopsies conducted on patients in our institution with brain 
metastases treated with pembrolizumab, in which there can be peri-lesional edema with tumor 
regression or so-called pseudoprogression (necrosis and associated inflammation). Data 
from a phase II trial of pembrolizumab in patients with metastatic melanoma or non- small 
cell lung cancer with untreated brain metastases in our institution showed an acceptable safety 
profile; responses have also been seen, however, in some patients, early cerebral edema 
has required discontinuation of therapy and/or treatment with steroids to control 
inflammation. In a survival analysis of 23 melanoma patients enrolled on this trial, 48% of 
patients were alive at 24 months, demonstrating durable responses and responses were 
concordant between the brain and extracerebral sites.   In the preliminary results from the 
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phase II portion of this trial combining pembrolizumab and bevacizumab, 11 out of 20 
patients with melanoma had a response in brain metastases as of February 2019. 
 
Refer to the Investigator’s Brochure (IB)/approved labeling for detailed background 
information on pembrolizumab. 
 
Bevacizumab Rationale: 
Bevacizumab, a recombinant humanized monoclonal antibody blocking angiogenesis by 
vascular endothelial growth factor A (VEGF-A) inhibition, is a compelling combination 
partner for PD-1 pathway antagonists in patients with metastatic disease to the brain. VEGF 
decreases dendritic cell function and subsequently antigen presentation and T cell activation 
while promoting the development of myeloid-derived suppressor cells.23,24 VEGF is 
commonly found in the tumor microenvironment where it functions in immune evasion by 
altering the tumor vasculature to reduce lymphocyte adhesion to vessel walls within the 
microenvironment, thus contributing to decreased trafficking across endothelium into tumor 
deposits.25-27 Restoration of dendritic cell and T cell function may improve T cell response 
and result in overall improved clinical activity. 
 
In a murine melanoma model, the combination of VEGF blockade and adoptive 
immunotherapy was synergistic, resulting in improved antitumor activity, prolonged survival 
and increased trafficking of T cells into tumors.28 Other murine models have tested combined 
inhibition of PD-L1 and VEGF pathway in the syngeneic colorectal cancer model MC-38, 
showing synergism between the drugs. In addition, in the melanoma Cloudman model, 
bevacizumab was synergistic with PD-1 pathway blockade.29,30 
 
Synergistic effects of immunotherapy and VEGF blockade have been observed clinically in 
patients with melanoma receiving anti-CTLA-4 and bevacizumab.31 In a cohort of 10 patients 
with metastatic renal cell carcinoma treated with bevacizumab and  MPDL3280A, McDermott 
et al.32 reported partial response (PR) in 4 patients and an additional 5 patients achieved 
stable disease (SD). Treatment was well-tolerated with no unexpected toxicities. Responses 
were observed in a variety of other tumors.33 Specific to metastatic melanoma, Phase 1 
studies were recently initiated combining bevacizumab with MPDL3280A (anti-PD- L1) and 
a large randomized phase 2 trial is ongoing comparing MPDL3280A with bevacizumab 
versus MPDL3280A with sunitinib versus MPDL3280A alone in previously untreated 
patients with metastatic renal cell carcinoma. 
 
For NSCLC, bevacizumab is an approved drug for patients with non-squamous histology in 
first-line therapy when added to chemotherapy. Initial studies showed a median survival of 
12.3 months with the addition of bevacizumab to paclitaxel plus carboplatin compared to 
10.3 months with chemotherapy alone.34 As predicted, patients with brain metastases were 
excluded from this trial because of the risk of CNS hemorrhage. However, as early as 2009, 
bevacizumab was explored for the treatment of brain metastases in solid tumors. A phase 2 
trial, AVF3752g (PASSPORT), specifically addressed safety in patients with NSCLC and 
previously treated brain metastases who underwent systemic therapy with bevacizumab.35 
CNS hemorrhage was rare.   Subsequently, bevacizumab was retrospectively studied in a 
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small cohort of patients with NSCLC and active brain metastases who received bevacizumab 
alone and in combination with chemotherapy.36 One of 6 patients had an asymptomatic 
grade 1 intra-tumoral hemorrhage which occurred in the setting of concurrent 
anticoagulation. Notably, these patients required less corticosteroids when given 
bevacizumab. In another study, 18 patients with untreated brain metastases from various 
malignancies were treated with bevacizumab based therapy; 60% had PRs and overall the 
edema was reduced.37 
 
Bevacizumab has long been established as a safe and effective treatment of glioblastoma 
(GBM). Angiogenesis in brain tumors such as GBM leads to a highly permeable blood brain 
barrier which results in disruption of autoregulated cerebral blood flow.38 Angiogenesis in 
the brain promotes intravascular fluid extravasation into the extracellular spaces, otherwise 
known as vasogenic edema. If severe, this may lead to ischemia in the brain and ultimately, 
deterioration of neurologic function. Initial studies of bevacizumab for the treatment of GBM 
showed clinical activity, decreased tumor size, increased progression-free survival (PFS) and 
a decreased steroid requirement for edema.39,40 The risk of cerebral hemorrhage appears to be 
independent of bevacizumab therapy.41   Many studies have investigated the effects of 
bevacizumab in the treatment radiation necrosis in a variety of brain tumors, and it has been 
shown to be highly effective.42-45,46 . These studies, while small, suggested that bevacizumab 
may have some inflammatory antitumor effects in addition to restoration of vascular 
permeability of the blood brain barrier, which might improve drug delivery. 
 
4.2.2. Rationale for Trial and Selected Subject Population 
 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been established.47 Antagonists of PD-1 and PD-L1 have been shown to 
produce significant clinical activity in patients with metastatic melanoma and NSCLC. Current 
research efforts with these agents are directed towards identifying patients who are most 
likely to benefit from treatment and also to develop combinations that increase clinical 
activity in both the ‘responsive’ and non-responsive populations. In almost all trials 
conducted to date, clinical response to PD-1/PD-L1 pathway antagonists has been strongly 
associated with pre-treatment tumor cell or tumor infiltrating lymphocyte (TIL) surface 
expression of PD-L1.48,49 Correlative data also suggest that in many patients, pre-treatment 
tumor PD-L1 expression is induced by adjacent cytokine-producing T-cells; however, a 
subset of tumors can express PD-L1 in the absence of T-cell infiltration, presumably as a 
result of aberrant T-cell signaling22. Lack of PD-L1 expression suggests that TILs are either 
unable to produce cytokines or cannot recognize tumor antigens. Tumors expressing PD-L1 
but lacking TIL, and conversely tumors containing non-cytokine producing TIL and absent 
PD-L1 expression, are unlikely to respond to PD-1/PD-L1 pathway antagonists. 
 
Even in the subgroup of patients that are most likely to respond to PD-1/PD-L1 pathway 
antagonists (i.e., with tumors containing TIL and associated PD-L1 expression), combination 
therapies may be necessary to achieve very high rates of durable complete responses. We 
know that pembrolizumab has activity in untreated brain metastases in a subset of patients, 
however, in our institutional experience from an ongoing phase II trial of pembrolizumab in 
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patients with melanoma or NSCLC and untreated brain metastases, some patients develop 
peri-lesional edema. This might limit the ability to administer pembrolizumab and often 
requires steroids. A number of lines of evidence support the synergistic effects of the 
combination of bevacizumab and pembrolizumab. We propose a phase 2 trial of these two 
agents in patients with metastatic melanoma and a pilot study of NSCLC patients with 
untreated brain metastases. We postulate that bevacizumab would substantially decrease the 
cerebral inflammatory effects of pembrolizumab and vasogenic edema, and may have some 
antitumor efficacy, as well. It is expected that the results of this trial will produce sufficient 
data to determine if a subsequent randomized trial is justified for further development of this 
combination in melanoma and NSCLC as well as other metastatic malignancies. 
 
 
4.2.3 Rationale for Dose Selection/Regimen/Modification 
 
An open-label Phase I trial (Protocol 001) has been conducted to evaluate the safety and 
clinical activity of single agent pembrolizumab. The dose escalation portion of this trial 
evaluated three dose levels, 1 mg/kg, 3 mg/kg, and 10 mg/kg, administered every 2 weeks 
(Q2W) in subjects with advanced solid tumors. All three dose levels were well tolerated and 
no dose-limiting toxicities were observed. This first in human study of pembrolizumab 
showed evidence of target engagement and objective evidence of tumor size reduction at all 
dose levels (1 mg/kg, 3 mg/kg and 10 mg/kg Q2W).  No MTD has been identified to date. 
 
 
A population pharmacokinetic analysis has been performed using serum concentration time 
data from 476 patients. Within the resulting population PK model, clearance and volume 
parameters of pembrolizumab were found to be dependent on body weight. The relationship 
between clearance and body weight, with an allometric exponent of 0.59, is within the range 
observed for other antibodies and would support both body weight normalized dosing or a 
fixed dose across all body weights. Pembrolizumab has been found to have a wide 
therapeutic range based on the melanoma indication.  The differences in exposure for a 200 
mg fixed dose regimen relative to a 2 mg/kg Q3W body weight based regimen are 
anticipated to remain well within the established exposure margins of 0.5 – 5.0 for 
pembrolizumab in the melanoma indication. The exposure margins are based on the notion of 
similar efficacy and safety in melanoma at 10 mg/kg Q3W vs. 2 mg/kg Q3W (i.e. 5-fold 
higher dose and exposure). The population PK evaluation revealed that there was no 
significant impact of tumor burden on exposure. In addition, exposure was similar between 
the NSCLC and melanoma indications. Therefore, there are no anticipated changes in 
exposure between different indication settings. 
 
The choice of the 200 mg Q3W as an appropriate dose for the switch to fixed dosing is based 
on simulations performed using the population PK model of pembrolizumab showing that the 
fixed dose of 200 mg every 3 weeks will provide exposures that 1) are optimally consistent 
with those obtained with the 2 mg/kg dose every 3 weeks, 2) will maintain individual patient 
exposures in the exposure range established in melanoma as associated with maximal efficacy 
response and 3) will maintain individual patients exposure in the exposure range established 
in melanoma that are well tolerated and safe. 
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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. 
 
Rationale for administering pembrolizumab at a flat dose of 200mg every 3 weeks and 
bevacizumab at 7.5 mg/kg on day 1 of cycles 1, 2, 3 and 4: 
 
A phase II trial of pembrolizumab in patients with melanoma or NSCLC and untreated brain 
metastases conducted at Yale is ongoing. Interim analysis shows good anti-tumor activity. 
However, a number of patients have had to hold doses or take steroids due to peri-lesional 
edema. Our ongoing trial is utilizing a dose of 10mg/kg every 2 weeks. Safety MRI of the 
brain, which has been an important component of the trial, is done at 4 weeks and complete 
staging studies are conducted every 8 weeks. Prior trials using bevacizumab every 2 weeks 
for treating perilesional CNS edema have determined the safety and efficacy of a regimen of 
7.5mg/kg of bevacizumab every 2 weeks 50. For simplicity and convenience, we will 
administer both drugs every 3 weeks for the first four doses (on Day 1 of cycles 1, 2, 3 and 
4), while continuing pembrolizumab every 3 weeks. 
 
4.2.4. Rationale for Endpoints 
 
Efficacy Endpoints 
 
The primary purpose of this trial is to determine the activity of pembrolizumab and 
bevacizumab in combination in patients with untreated brain metastases from melanoma or 
NSCLC. The primary endpoint is therefore brain metastasis response rate. In our previous 
experience there is a small number of patients that have discordant responses in the brain and 
the body, and extra-cerebral response as well as overall response are therefore secondary 
efficacy endpoints. PFS and OS is expected to be shorter in this patient population with very 
advanced disease than in stage IV patients with melanoma or NSCLC without brain 
metastases, and determination of OS and PFS are secondary endpoints. We note that patients 
might receive additional active antineoplastic agents after progression on these drugs, 
resulting in more prolonged OS than expected for an untreated population of patients with 
brain metastases. 
 
Safety Endpoints 
 
One of the secondary endpoints is to determine the safety of pembrolizumab in combination 
with bevacizumab. A previous trial with pembrolizumab monotherapy in this population 
showed that many of these patients develop peri-lesional edema, and we expect that the 
combination will be better tolerated and result in a decrease in steroid use. 
 
Biomarker Research 
 
Biomarker studies (Section 11) will be conducted retrospectively with the goal of improving 
patient selection for this regimen. If predictive biomarkers or a predictive biomarker panel is 
identified, it  will  be  further  studied  prospectively  in  future  trials.  These  studies  are 
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considered exploratory at this juncture, and we note that the panel of biomarkers studied 
might change over time as the scientific field evolves. 
 
5.0 
METHODOLOGY 
 
5.1 Entry Criteria 
 
5.1.1. Diagnosis/Condition for Entry into the Trial 
 
Metastatic melanoma or non-squamous NSCLC with untreated brain metastases and/or post- 
treatment progressing brain metastases. 
 
5.1.2 Subject Inclusion Criteria 
 
1. Biopsy proven metastatic melanoma or non-squamous NSCLC with at least one untreated 
cerebral metastasis that is at least 5 mm AND twice the MRI slice thickness, but less than 
20 mm, that is asymptomatic and does not require local therapy at the time of enrollment 
(“clinically evaluable lesion(s)”). An untreated brain metastasis is defined as a lesion not 
present at the time of whole brain radiation therapy or included in a stereotactic 
radiotherapy field (or within 2mm of a treated lesion), or any lesion that is new or 
unequivocally progressing since prior radiation therapy. All MRIs at screening will be 
reviewed centrally at Yale for sign off of eligibility. 
2. Age ≥18 
3. ECOG performance status < 2 
4. Any number of previous treatments with the exception of previous inhibitors of PD-1, 
PD-L1, or PD-L2. Other prior systemic therapies must have been administered at least 2 
weeks before administration of pembrolizumab; the exception to this  is  ipilimumab which 
must have been administered at least 4 weeks prior to the start of pembrolizumab. Patients 
are not required to have had prior systemic therapy. 
5. Life expectancy of at least 3 months 
6. A history of previously treated brain metastases is allowed, provided that at least 7 days 
have lapsed between radiation and initiation of pembrolizumab.   Any brain metastasis 
≥20mm or causing symptoms must be treated with local therapy (i.e. radiation or surgical 
resection, as clinically appropriate) prior to study enrollment. Any lesion present at the 
time of WBRT or included in the stereotactic radiotherapy field (or within 2mm of the 
treated lesion) will NOT be considered evaluable unless it is new or documented to have 
progressed since treatment. 
7. PD-L1 expression >1% in tumor tissue from any site is required for patients with NSCLC. 
Tumor tissue can be archival if no intercurrent systemic therapy was administered, 
however if no archival tissue is available or if intercurrent systemic therapy was 
administered, then a biopsy must be obtained for PD-L1 testing. PD-L1 expression must 
be obtained via central and/or local testing of PD-L1 IHC by any FDA-approved assay or 
an assay performed in a CLIA-certified laboratory. PD-L1 expression is not required for 
patients with melanoma. 
8. All patients are required to submit a tumor specimen for analysis (brain or extra- cerebral). 
A formalin-fixed paraffin-embedded (FFPE) tissue block, or a 4mm punch from an 
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FFPE block must be submitted.  If it is not possible to safely obtain a biopsy due 
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to anatomic location of tumors, and no prior tissue is available, this requirement may be 
waived upon discussion with the study PI or co-PI. 
 
9. Patients must have normal organ and marrow function as defined below: 
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 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
Prothrombin Time (PT) 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
Activated Partial Thromboplastin Time 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
(aPTT) or Partial Thromboplastin Time 
as long as PT or PTT is within therapeutic range of intended use 
(PTT) 
of anticoagulants 
aCreatinine clearance should be calculated per institutional standard. 
 
10. 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. If the urine test is 
positive or cannot be confirmed as negative, a serum pregnancy test will be required. 
 
11. Female subjects of childbearing potential should be willing to use 2 methods of birth 
control or be surgically sterile, or abstain from heterosexual activity for the course of the 
study through 120 days after the last dose of study medication (Reference Section 5.6.2— 
Contraception). Subjects of childbearing potential are those who have not been surgically 
sterilized or have not been free from menses for > 1 year. 
 
12. Male subjects should agree to use an adequate method of contraception starting with the 
first dose of study therapy through 120 days after the last dose of study therapy. 
 
5.1.3 Subject Exclusion Criteria 
 
1. Symptomatic brain metastases. Any neurologic symptoms present must have resolved 
with local therapy by the time of administration of study drug. 
2. Patients with brain metastases for whom complete surgical resection is clinically 
appropriate. 
3. Patients with lung cancer with squamous histology.
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4. Has had prior chemotherapy or targeted small molecule therapy within 2 weeks prior to 
start of treatment or has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events 
due to a previously administered agent. Previous radiation to extracranial sites may be 
completed at any time prior to initiation of pembrolizumab. 
a. Note: If subject received major surgery, they must have recovered adequately 
from the toxicity and/or complications from the intervention prior to starting 
therapy. 
b. Note: Toxicity that has not recovered to ≤ Grade 1 is allowed if it meets the 
inclusion requirements for laboratory parameters. 
5. Has had prior treatment with any other anti-PD-1 or PD-L1 or PD-L2 agent. 
6. The use of corticosteroids to control cerebral edema or treat neurologic symptoms will 
not be allowed, and patients who previously required corticosteroids for symptom control 
must be off steroids for at least 1 week prior to treatment on day 1 of cycle 1. Low-dose 
steroid use (≤10 mg of prednisone or equivalent) as corticosteroid replacement therapy is 
allowed 
7. Has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents 
administered more than 4 weeks earlier. 
8. Presence of leptomeningeal disease 
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 (e.g. thyroxine, insulin, or physiologic corticosteroid replacement 
therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic 
treatment. 
10. Pregnancy or breast feeding. Should a woman become pregnant or suspect  she  is pregnant 
while participating in this study, she should inform her treating physician immediately. 
Because there is an unknown but potential risk for adverse events in nursing infants 
secondary to treatment of the mother with pembrolizumab, breastfeeding must be 
discontinued if the mother is treated with pembrolizumab. 
11. Patients may not be receiving any other investigational agents and may not have 
participated in a study of an investigational agent or using an investigational device 
within 4 weeks of the first dose of treatment. 
12. Either a concurrent condition (including medical illness, such as active infection 
requiring treatment with intravenous antibiotics or the presence of laboratory 
abnormalities) or history of a prior condition that places the patient at unacceptable risk if 
he/she were treated with the study drug or a medical condition that confounds the ability 
to interpret data from the study. 
13. Concurrent, active malignancies in addition to those being studied (other than cutaneous 
squamous cell carcinoma or basal cell carcinoma) 
14. Patients with active hemoptysis. 
15. Any contraindication to MRI (i.e. patients with pacemakers or other metal implanted 
medical devices).  An MRI safety questionnaire is required prior to MR imaging. 
16. Has a history of (non-infectious) pneumonitis that required steroids or current 
pneumonitis. 
17. Has a known Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), or Hepatitis C 
(HCV) infection. 
18. Has received a live vaccine within 30 days prior to the first dose of trial treatment. 
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19. Inadequately controlled hypertension (defined as systolic blood pressure > 150 mmHg 
and/or diastolic blood pressure > 100 mmHg). Anti-hypertensive therapy to achieve 
these parameters is allowable. 
20. History  of  myocardial  infarction  or  unstable  angina  within  3 months   prior   to Cycle 
1, Day 1 
21. History of stroke or transient ischemic attack within 3 months prior to Cycle 1, Day 1 
22. Significant vascular disease (e.g., aortic aneurysm requiring surgical repair or recent 
peripheral arterial thrombosis) within 6 months prior to Cycle 1, Day 1 
23. Evidence of bleeding diathesis or clinically significant coagulopathy (in the absence of 
therapeutic anticoagulation). Any history of significant bleeding or thrombosis should be 
discussed with the study PIs. 
24. Current or recent (within 10 calendar days prior to Cycle 1, Day 1) use of dipyramidole, 
ticlopidine, clopidogrel, or cilostazol 
25. Warfarin is not permitted. Prophylactic or therapeutic use of low molecular-weight 
heparin (e.g., enoxaparin), direct thrombin inhibitors or Factor Xa inhibitors (Direct or 
Indirect) are permitted. 
26. History of abdominal or tracheoesophageal fistula or gastrointestinal perforation within 
6 months prior to Cycle 1, Day 1 
27. Serious, non-healing or dehiscing wound 
28. Proteinuria > 2.0 g of protein in a 24-hour urine collection. All patients with 2 protein on 
dipstick urinalysis at baseline must undergo a 24-hour urine collection for protein. 
29. Has a history of (non-infectious) pneumonitis that required steroids, current pneumonitis 
or evidence of interstitial lung disease. 
 
 
5.2 Trial Treatments 
 
The treatments to be used in this trial are pembrolizumab 200mg every 3 weeks and 
bevacizumab 7.5mg/kg on day 1 of cycle 1, 2, 3, and 4 (or alternative cycles if bevacizumab 
is held during these cycles). Each cycle is 3 weeks. Our intent is to treat with the combination 
of pembrolizumab and bevacizumab for four cycles and pembrolizumab monotherapy for up 
to 2 years. 
 
5.2.1 Dose Selection/Modification 
 
 Dose Selection 
 
The rationale for selection of doses to be used in this trial is provided in Section 4.0— 
Background and Rationale. 
 
Details on preparation and administration of pembrolizumab (MK-3475) are provided in the 
Pharmacy Manual. 
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Dose Modification and toxicity management for immune-related AEs associated with 
pembrolizumab and combination therapy 
 
AEs associated with pembrolizumab exposure, including coadministration with additional compounds, 
may represent an immunologic aetiology. These immune-related AEs (irAEs) may occur shortly after the 
first dose or several months after the last dose of pembrolizumab/combination treatment and may affect 
more than one body system simultaneously. Therefore, early recognition and initiation of treatment is 
critical to reduce complications.  Based on existing clinical study data, most irAEs were reversible and 
could be managed with interruptions of pembrolizumab/combination treatment, administration of 
corticosteroids and/or other supportive care. For suspected irAEs, ensure adequate evaluation to confirm 
etiology or exclude other causes. Additional procedures or tests such as bronchoscopy, endoscopy, skin 
biopsy may be included as part of the evaluation. Dose modification and toxicity management guidelines 
for irAEs associated with pembrolizumab/combination treatment are provided in Table 1. 
 
Attribution of Toxicity: 
When study interventions are administered in combination, attribution of an adverse event to a single 
component is likely to be difficult.  Therefore, while the investigator may attribute a toxicity event to the 
combination, to bevacizumab alone or to pembrolizumab alone, for adverse events listed in Table 1, both 
interventions must be held according to the criteria in Table 1 Dose Modification and Toxicity 
Management Guidelines for Immune-Related Adverse Events Associated with Pembrolizumab. 
Holding Study Interventions: 
When study interventions are administered in combination, if the AE is considered immune-related, both 
interventions should be held according to recommended dose modifications. 
Restarting Study Interventions: 
Participants may not have any dose modifications (no change in dose or schedule) of pembrolizumab in 
this study, as described in Table 1. 
• If the toxicity does not resolve or the criteria for resuming treatment are not met, the participant must be 
discontinued from all study interventions. 
• If the toxicities do resolve and conditions are aligned with what is defined in Table 1, the combination 
of Bevacizumab and pembrolizumab may be restarted at the discretion of the investigator. In these cases 
where the toxicity is attributed to the combination or to Bevacizumab alone, re-initiation of 
pembrolizumab as a monotherapy may be considered at the principal investigator’s discretion. 
 
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 PIs. The reason for interruption should be documented in the patient's study 
record. 
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Table 1: Dose Modification Guidelines for Drug-Related Adverse Events for 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 
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/Colitis  
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 
Recurrent 
Grade 3 or 
Grade 4 
Permanently 
discontinue 

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irAEs 
Toxicity 
Grade 
(CTCAE v5.0) 
Action With 
Pembrolizumab 
Corticosteroid and/or Other 
Therapies 
Monitoring and Follow-up 
•  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 
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 prednisone or equivalent) 
followed by taper 
T1DM or 
Hyperglycemia 
New onset 
T1DM or  
Grade 3 or 4 
hyperglycemia 
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 
Hyperthyroidism 
Grade 2 
Continue 

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irAEs 
Toxicity 
Grade 
(CTCAE v5.0) 
Action With 
Pembrolizumab 
Corticosteroid and/or Other 
Therapies 
Monitoring and Follow-up 
Grade 3 or 4 
Withhold or 
permanently 
discontinue d 
•  Treat with nonselective beta-blockers 
(eg, propranolol) or thionamides as 
appropriate 
•  Monitor for signs and symptoms of thyroid 
disorders 
Hypothyroidism 
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 
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 
Confirmed SJS, 
TEN, or 
DRESS 
Permanently 
discontinue 
All Other irAEs 
Persistent Grade 2 Withhold 

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irAEs 
Toxicity 
Grade 
(CTCAE v5.0) 
Action With 
Pembrolizumab 
Corticosteroid and/or Other 
Therapies 
Monitoring and Follow-up 
Grade 3 
Withhold or 
discontinue based 
on the event e  
•  Based on severity of AE administer 
corticosteroids 
•  Ensure adequate evaluation to confirm etiology 
or exclude other causes 
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). 
 
 

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Dose Selection/Modification of Bevacizumab 
 
No reductions in bevacizumab dose are allowed in this study.  Modification to 
bevacizumab administration should be done according to the label and per 
institutional guidelines. If adverse events occur that necessitate holding 
bevacizumab, the weight-based dose in mg/kg will remain unchanged after 
treatment resumes. 
 
Patients who discontinue bevacizumab transiently or permanently for adverse 
events may continue on single-agent pembrolizumab until disease progression. 
 
For non irAEs, temporary suspension of bevacizumab must occur if a patient 
experiences a serious adverse event or a Grade 3 or 4 non-serious adverse event 
assessed by the investigator as related to bevacizumab.  If the event resolves to 
Grade ≤ 1, bevacizumab may be restarted at the same dose level. 
 
The appropriate interval between the last dose of bevacizumab and major surgery 
is unknown.  Because bevacizumab has a half-life of approximately 21 days, 
elective surgery should be delayed whenever possible. Re-initiation of 
bevacizumab should occur after wounds have healed.  Re-initiation of 
bevacizumab after surgery requires approval of the principal investigators. 
 
Infusion of bevacizumab should be interrupted in patients who develop dyspnea or 
clinically significant hypotension. Patients who experience an NCI CTCAE Grade 3 or 
4 allergic reaction/hypersensitivity, adult respiratory distress syndrome, or 
bronchospasm (regardless of grade) will be discontinued from bevacizumab treatment.  
If possible, a sample for ATA assessment will be collected at the time of 
discontinuation. 
 
Bevacizumab infusion should be slowed to ≤ 50% or interrupted for patients who 
experience any infusion-associated symptoms not specified above.  If the 
infusion is interrupted, it may be resumed at ≤ 50% of the rate prior to the 
reaction after the patient’s symptoms have adequately resolved and increased in 
50% increments up to the full rate if well tolerated. Infusions may be restarted at 
the full rate during the next cycle. 
 
Patients who develop Grade 4 toxicities (not immune related) related to bevacizumab for 
> 21 days should permanently discontinue bevacizumab. 
 
If bevacizumab is held due to toxicity that resolves, it can be initiated during any subsequent 
cycle for a total number of four cycles of bevacizumab per patient. 
 
 
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Table 2: Dose Modification Guidelines for Non Immune related Drug‐Related Adverse 
Events for Bevacizumab 
 
 
Event 
Action to Be Taken 
Hypertension 
Grade 1 (asymptomatic, transient [< 24 hr] 
blood pressure increase by > 20 mmHg 
(diastolic) or to > 150/100 mmHg if previously 
within normal limits) 
No bevacizumab dose modifications. 
Grade 2 (recurrent or persistent [> 24 hr] or 
symptomatic increase by > 20 mmHg (diastolic) 
or to > 150/100 mmHg if previously within 
normal limits) 
Hold bevacizumab. Start antihypertensive 
therapy per institutional guidelines. After blood 
pressure is < 150/100 mmHg, patient may 
continue bevacizumab therapy. 
Grade 3 
Requires more than one antihypertensive drug 
or more intensive therapy than previously: If 
not controlled to 150/100 mmHg with 
medication, discontinue bevacizumab. 
Grade 4 (including hypertensive 
encephalopathy) 
Discontinue bevacizumab. 
Hemorrhage 
Grade 1 or 2 non-pulmonary or non-CNS 
events 
No bevacizumab modifications. 
Grade 3 non-pulmonary or non--brain or 
non-spinal cord hemorrhage 
Hold bevacizumab until all of the following 
criteria are met: 
• 
The bleeding has resolved and 
hemoglobin is stable. 
• 
There is no bleeding diathesis that would 
increase the risk of therapy. 
• 
There is no anatomic or pathologic 
condition that significantly increases the 
risk of hemorrhage recurrence. 
Patients who experience a repeat Grade 3 
hemorrhagic event will be discontinued from 
bevacizumab. 
Grade 4 non-pulmonary or non-brain or 
non-spinal cord hemorrhage 
Discontinue bevacizumab. 
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Event 
Action to Be Taken 
Grade 1 pulmonary or brain or spinal cord 
hemorrhage 
Hold bevacizumab until all of the following 
criteria are met: 
• 
The bleeding has resolved and hemoglobin 
is stable. 
• 
There is no bleeding diathesis that would 
increase the risk of therapy. 
• 
There is no anatomic or pathologic 
condition that significantly increases the 
risk of hemorrhage recurrence. 
Grade 2, 3, or 4 pulmonary hemorrhage 
Grade 2, 3 or 4 brain hemorrhage 
Discontinue bevacizumab. 
Discontinue bevacizumab until all hemorrhagic 
lesions have undergone local therapy and upon 
discussion with the study PIs 
Venous thromboembolic event 
Grade 1 or 2 
No bevacizumab modifications. 
Grade 3 or 
asymptomatic Grade 4 
If the planned duration of full-dose 
anticoagulation is < 2 weeks, bevacizumab 
should be held until the full-dose 
anticoagulation period is over. If the planned 
duration of full-dose anticoagulation is > 2 
weeks, bevacizumab may be resumed after 
2 weeks of full-dose anticoagulation if all of the 
following criteria are met: 
• 
The patient must have an in-range INR 
(usually between 2 and 3) if on warfarin; 
LMWH, warfarin, or other anticoagulant 
dosing must be stable prior to restarting 
study treatment. 
• 
The patient must not have had a Grade 3 
or 4 hemorrhagic event while on 
anticoagulation. 
Symptomatic Grade 4 
Discontinue bevacizumab. 
Arterial thromboembolic event 
(new onset, worsening, or unstable angina, 
myocardial infarction, transient ischemic attack, 
cerebrovascular accident, and any other arterial 
thromboembolic event) 
Any grade 
Discontinue bevacizumab. 
Congestive heart failure 
(left ventricular systolic dysfunction) 
Grade 1 or 2 
No bevacizumab modifications. 
Grade 3 
Hold bevacizumab until resolution to Grade ≤ 1. 
Grade 4 
Discontinue bevacizumab. 
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Event 
Action to Be Taken 
Proteinuria 
Grade 1 (urine dipstick 1 + or urine collection 
0.15 to 1.0 g/24 hr) 
No bevacizumab modifications. 
Grade 2 (urine dipstick 2 + to 3 + or urine 
collection > 1.0 to 3.5 g/ 
24 hr) 
For 2 + dipstick, may administer bevacizumab 
and obtain 24-hour urine prior to next dose. 
For 3 + dipstick, obtain 24-hour urine prior to 
administration of bevacizumab. 
Hold bevacizumab for proteinuria >2 g/24 hr and 
resume when proteinuria is ≤ 2 g/24 hr.a 
Grade 3 
(urine dipstick 4 + or urine collection > 3.5 g/24 
hr) 
Hold bevacizumab. Resume when proteinuria 
is ≤ 2 g/24 hr.a 
Grade 4 
(nephrotic syndrome) 
Discontinue bevacizumab. 
GI perforation 
Any grade 
Discontinue bevacizumab. 
Fistula 
Any grade tracheoesophageal fistula 
Discontinue bevacizumab. 
Grade 4 fistula (other than tracheoesophageal) 
Discontinue bevacizumab. 
Bowel obstruction 
Grade 1 
Continue patient on study for partial obstruction 
not requiring medical intervention. 
Grade ≥ 2 
Discontinue bevacizumab. 
Wound dehiscence 
Any grade 
(requiring medical or surgical therapy) 
Discontinue bevacizumab. 
Reversible posterior leukoencephalopathy 
Any grade 
(confirmed by MRI) 
Discontinue bevacizumab. 
CNS = central nervous system; GI = gastrointestinal; LMWH = low molecular-weight heparin. 
a   All proteinuria values are from 24-hour urine collection. 
 
 
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5.2.2 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. 
 
Pembrolizumab 200 mg will be administered as a 30 minute IV infusion every 3 weeks. 
Sites should make every effort to target infusion timing to be as close to 30 minutes as 
possible. However, given the variability of infusion pumps from site to site, a window of -5 
minutes and +10 minutes is permitted (i.e., infusion time is 30 minutes: -5 min/+10 min). 
 
The Pharmacy Manual contains specific instructions for the preparation of the 
pembrolizumab infusion fluid and administration of infusion solution. 
 
5.2.3 Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue for up to 
2 years or until one of the following criteria applies: 
 
1 
Disease progression and absence of clinical benefit 
2 
Symptomatic deterioration of health status without objective evidence of disease 
progression. Every effort should be made to document objective progression of 
disease in such cases. 
3 
Imminent risk in the case of progressing lesion or new/worsening edema seen on 
brain MRI 
4 
Unmanageable toxicity most probably attributed to pembrolizumab 
5 
Development of intercurrent illness limiting the ability to comply with study or the 
development of uncontrolled concurrent illness that prevents further administration 
of treatment or confound the ability to interpret data 
6 
General or specific  changes  in  the  patient’s  condition  rendering  the  patient 
unacceptable for further treatment in the judgment of the investigator 
7 
Patient request for discontinuation, patient withdrawal from study, or patient lost to 
follow up 
8 
Development of neurologic or systemic complications following local therapy to any 
lesion 
9 
Death 
10 
Study termination by sponsor 
 
 
 
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5.2.4 Treatment Beyond Progression 
 
If radiologic imaging shows PD, tumor assessment should 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 tumor burden compared 
to the initial scan demonstrating PD, treatment may be continued as per treatment calendar. 
If repeat imaging confirms progressive disease, subject will be discontinued from study 
therapy unless the investigator believes that the patient is deriving benefit. Patients may 
continue treatment with pembrolizumab and/or bevacizumab beyond PD by RECIST 1.1 (in 
the body) or mRECIST in the brain, if they are determined by the investigator to be deriving 
clinical benefit from treatment and they continue to meet all other criteria for treatment. 
Patients who have rapid progression of disease or clinical deterioration will be removed from 
study. The decision to continue treatment beyond initial progression should be discussed 
with the study PIs. 
 
Additionally, in cases where the majority of the disease is stable or responding, and 
progressing lesions can be controlled with local therapy (i.e. resection or radiotherapy), the 
patient may be continued on trial following local therapy. 
 
5.2.5 Duration of Follow-up 
 
Patients who discontinue early or who complete the study treatment period in full will be 
followed for survival after removal from study until death. See Trial Flow Chart (Section 6.0) 
for more details. 
 
5.3 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 Principal Investigator. The final decision on any supportive therapy or vaccination 
rests with the investigator and/or the subject's primary physician. 
 
5.3.1 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 
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medications administered after 30  days  after  the  last  dose  of  trial  treatment  should  be 
recorded for SAEs and ECIs as defined in Section 7.6.3.1. 
 
5.3.2 Prohibited Concomitant Medications 
 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase of this trial as listed below: 
 
• Antineoplastic systemic chemotherapy or biological therapy < 2 weeks prior to 
treatment Day 1 
• Immunotherapy not specified in this protocol < 2 weeks prior to treatment Day 1 
• Investigational agents other than pembrolizumab or bevacizumab < 2 weeks prior to 
treatment Day 1 
• Radiation therapy 
o Note: Radiation therapy to individual symptomatic solitary extra-cerebral 
lesions or to the brain may be allowed at the investigator’s discretion. This 
should be discussed with the study PIs. 
• 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 PI. 
• Anticoagulation other than low molecular weight heparin, direct thrombin inhibitors, 
or Factor Xa inhibitors (Direct or Indirect). 
Subjects who, in the assessment by the investigator, require the use of any of the 
aforementioned treatments for clinical management 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. 
5.4 Local Therapy 
 
Local therapy for brain metastases: 
 
Local surgical therapy in the form of craniotomy or LITT (laser interstitial thermacoagulation 
therapy) will be performed when clinically appropriate prior to initiating systemic therapy. 
Patients will be required to provide tissue for research when available. At any time point
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throughout the study, local therapy (surgery, radiotherapy or LITT) will be administered to a 
lesion that becomes clinically concerning if deemed necessary by the investigators. This can 
be followed by continuation on treatment, provided that the patient is otherwise benefiting 
from therapy. Approval from the study PI or co-PIs is required to continue treating the 
patient on pembrolizumab and bevacizumab. A brain metastasis that has been treated locally 
will not be considered evaluable for response and will not be included when calculating the 
sum of largest dimensions. If the treated lesion constitutes > 25% of the target lesions (for 
example, if one of three target lesions is treated locally), this will be considered progressive 
disease. If >75% of the baseline lesions are not treated with local therapy and evaluable by 
imaging, the patient will be considered evaluable, and response for the primary endpoint 
analysis will be assessed based on the remaining lesions. Additional response evaluation will 
be performed; those patients who require local therapy due to unequivocal growth while on 
study will be considered as having PD at the time of local therapy. Lesions requiring local 
therapy due to hemorrhage or edema will be considered unevaluable. 
 
Local therapy for extra-cerebral metastases: 
 
Local surgery or radiation therapy (if indicated for palliative measures only after discussion 
with the study PI or co-PIs) may be permitted and the patient can continue to receive 
pembrolizumab provided there is otherwise evidence of clinical benefit from treatment (i.e. 
stable disease or response in measurable lesions). The criteria applied for assessing brain 
metastasis response will be applied to extra-cerebral metastases as well. 
 
5.5 Rescue Medications & Supportive Care 
 
5.5.1 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 along with the dose modification 
guidelines in Table 1. 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 is 
instructed to follow the ECI reporting guidance but does not need to follow the treatment 
guidance.). 
 
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or 
skin photography as part of evaluation of the event. 
 
 
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Dose modification and toxicity management of infusion-reactions related to 
pembrolizumab 
 
Pembrolizumab may cause severe or life-threatening infusion-reactions including severe 
hypersensitivity or anaphylaxis. Signs and symptoms usually develop during or shortly after 
drug infusion and generally resolve completely within 24 hours of completion of infusion. 
Dose modification and toxicity management guidelines on pembrolizumab associated 
infusion reaction are provided in Table 3. 
 
Table 3: 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 therapy or 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 
(e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or ventilatory 
support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued from 
further trial treatment administration. 
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period of drug 
administration. For further information, please refer to the Common Terminology Criteria for Adverse Events v4.0 
(CTCAE) at http://ctep.cancer.gov 
 
 
 
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5.5.2 Supportive Care Guidelines for Events of Clinical Interest (ECIs) and Immune- 
related Adverse Events (irAEs) 
 
Events of clinical interest of a potential immunologic etiology (irAEs) may be defined as an 
adverse event of unknown etiology, associated with drug exposure and is consistent with an 
immune phenomenon. irAEs may be predicted based on the nature of the pembrolizumab, its 
mechanism of action, and reported experience with immunotherapies that have a similar 
mechanism of action. Special attention should be paid to AEs that may be suggestive of 
potential irAEs. An irAE can occur shortly after the first dose or several months after the last 
dose of treatment. 
 
If an irAE is suspected, efforts should be made to rule out neoplastic, infectious, metabolic, 
toxin or other etiologic causes prior to labeling an adverse event as an irAEs. Subjects 
who develop a Grade 2 or higher irAEs should be discussed immediately with the Merck 
Clinical Monitor. 
 
Recommendations to managing irAEs not detailed elsewhere in the protocol are detailed in 
Table 4. 
 
Table 4 General Approach to Handling irAEs 
 
irAEs 
Withhold/Discontinue 
    pembrolizumab? 
Supportive Care 
Grade 1 
No action 
Provide symptomatic 
treatment 
Grade 2 
May withhold 
pembrolizumab 
Consider systemic corticosteroids in 
addition to appropriate symptomatic 
treatment 
Grade 3  
and Grade 4 
 Withhold pembrolizumab 
   
Discontinue if unable to 
reduce corticosteroid dose to 
< 10 mg per day prednisone 
equivalent within 12 weeks of 
toxicity 
Systemic corticosteroids are indicated 
in addition to appropriate 
symptomatic treatment. May utilize 1 
to 2 mg/kg prednisone or equivalent 
per day. 
Steroid taper should be considered 
once symptoms improve to Grade 1 
or less and tapered over at least 4 
weeks. 
 
 
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5.5.3. Supportive Care Guidelines for Pneumonitis 
 
Subjects with grade 2 pneumonitis (symptomatic pneumonitis requiring medical 
intervention) should immediately stop receiving pembrolizumab and have an evaluation. 
The evaluation may include bronchoscopy and pulmonary function tests to rule out other 
causes such as infection. If the subject is determined to have study drug associated 
pneumonitis, the suggested treatment plan is detailed in Table 5 and follow-up will be as 
routine for AEs associated with study drug including monitoring until full resolution of the 
AEs/pneumonitis. 
 
Table 5. Recommended Approach to Handling Pneumonitis 
 
Study drug 
associated 
pneumonitis 
Withhold/Discontinue 
pembrolizumab? 
Supportive 
Care 
Grade 1 
(asymptomatic) 
No action 
Intervention not indicated 
Grade 2 
Withhold 
pembrolizumab, 
may return to 
treatment if 
improves to Grade 1 
or resolves within 
12 weeks 
Systemic corticosteroids are indicated. 
Taper as indicated. 
Grade 3 and Grade 4 Discontinue 
pembrolizumab 
Systemic corticosteroids are indicated. 
 
For Grade 2 pneumonitis that improves to ≤ Grade 1 within 12 weeks, the following rules 
should apply: 
 
• First episode of pneumonitis 
o May increase dosing interval by one week in subsequent cycles 
• Second episode of pneumonitis – permanently discontinue pembrolizumab if upon 
rechallenge subject develops pneumonitis ≥ Grade 2 
 
5.6 Diet/Activity/Other Considerations 
 
5.6.1 Diet 
 
Subjects should maintain a normal diet unless modifications are required to manage an AE 
such as diarrhea, nausea or vomiting. 
 
 
 
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5.6.2 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. Non-pregnant, 
non-breast-feeding women may be enrolled if they are willing to use 2 methods of birth 
control or are considered highly unlikely to conceive. Highly unlikely to conceive is defined 
as 1) surgically sterilized, or 2) postmenopausal (a woman who is ≥45 years of age and has 
not had menses for greater than 1 year will be considered postmenopausal), or 3) not 
heterosexually active for the duration of the study.  The two birth control methods can be 
either two barrier methods or a barrier method plus a hormonal method to prevent pregnancy. 
Subjects should start using birth control from study Visit 1 throughout the study period up to 
120 days after the last dose of study therapy. 
 
The following are considered adequate barrier methods of contraception: diaphragm, condom 
(by the partner), copper intrauterine device, sponge, or spermicide. Appropriate hormonal 
contraceptives will include any registered and marketed contraceptive agent that contains an 
estrogen and/or a progestational agent (including oral, subcutaneous, intrauterine, or 
intramuscular agents). 
 
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, they must adhere to the contraception requirement (described above) for the 
duration of the study and during the follow-up period defined in section 7.6.2—Reporting of 
Pregnancy and Lactation to the Sponsor and to Merck. If there is any question that a subject 
will not reliably comply with the requirements for contraception, that subject should not be 
entered into the study. 
 
5.6.3 Use in Pregnancy 
 
If a subject inadvertently becomes pregnant while on treatment with bevacizumab and/ or 
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 7.6.2—Reporting of Pregnancy and Lactation to the Sponsor 
and to Merck. 
 
 
 
 
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5.6.4 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. 
 
5.7 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 7.4—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: For unconfirmed radiographic disease progression, please see Section 
5.2.3—Duration of Therapy 
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 5.2.4—Treatment Beyond Progression 
• Unacceptable 
adverse 
experiences 
as 
described 
in 
Section 
5.2.1—Dose 
Selection/Modification 
• 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 5.7.1—Discontinuation of Study 
Therapy after CR 
• Administrative reasons 
 
The End of Treatment and Follow-up visit procedures are listed in Section 6 (Trial Flow 
Chart) and Section 7.5 (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 7.6.3.1). Subjects who 
discontinue for reasons other than progressive disease will have post-treatment follow-up for 
disease status until disease progression, initiating a non-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 
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end of the study, whichever occurs first. 
 
5.7.1 Discontinuation of Study Therapy after CR 
 
Discontinuation of treatment may be considered for subjects who have attained a confirmed 
CR that have been treated for at least 24 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 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
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6.0 TRIAL FLOW CHART 
 
6.1  Study Flow Chart 
 
Screening evaluations are to be conducted within 28 days prior to start of systemic therapy. 
Scans must be done within 28 days prior to the start of systemic therapy and after other 
therapy not specified in this protocol is stopped. Screening labs must be done within 10 days 
of Cycle 1 Day 1. In the event that the participant’s condition is deteriorating, laboratory 
evaluations should be repeated within 48 hours prior to initiation of the next cycle of therapy. 
 
All assessments must be performed prior to administration of any study medication. All study 
assessments and medications should be administered within ± 3 days of the protocol- 
specified date, unless otherwise noted. 
 
 
Screening 
Visit 
On‐Study Visits 
Follow‐up 
Visit 
Long Term 
Follow‐up 
Day ‐28 
to ‐1 
Day 1 of 
each 
Cycle 
Day 1 of 
Cycles 1, 
2, 3, and 
4 
Day 1 
Cycles 3 
and 5 
Day 1 
Cycle 8, 
and every 
9 weeks 
thereafter 
Day 28 +/‐ 
7 days 
from last 
study 
treatmenti 
Every 3 
months +/‐ 
14 days 
after the 
follow‐up 
visit 
Informed Consent 
X 
History/Full Physical 
Exam 
X 
X 
X 
Height/Weight/Vital 
SignsA 
X 
X 
X 
Performance Status 
X 
X 
X 
CBC, serum 
chemistry, liver 
function tests, LDHB 
X 
X 
X 
INR or PT & aPTT or 
PTT 
X 
Urinalysis 
X 
X 
X 
TSH, free T3, free T4 
X 
X 
NSCLC patients: 
Determination of 
PD‐L1 expression in 
tumorN 
X 
 
 
 
 
 
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Screening 
Visit 
On‐Study Visits 
Follow‐up 
Visit 
Long Term 
Follow‐up 
Day ‐28 
to ‐1 
Day 1 of 
each 
Cycle 
Day 1 of 
Cycles 1, 
2, 3, and 
4 
Day 1 
Cycles 3 
and 5 
Day 1 
Cycle 8, 
and every 
9 weeks 
thereafter 
Day 28 +/‐ 
7 days 
from last 
study 
treatmenti 
Every 3 
months +/‐ 
14 days 
after the 
follow‐up 
visit 
Plasma and PBMCs 
for correlative 
studies 
XH 
X 
XO 
Obtain tumor 
specimen for 
correlative studies 
(Refer to Section 
11.1)J,M 
X 
Pregnancy TestC 
X 
X 
CT chest/abdomen 
(plus pelvis if 
disease is present) 
X 
XD 
XD 
X E 
Brain MRI 
X F 
XG 
XG 
X E 
Selection of 
“clinically evaluable 
lesion(s)” 
X 
Review concomitant 
medicationsL 
X 
X 
X 
Smoking Status 
X 
Adverse events 
assessment 
X 
X 
Administration of 
pembrolizumab 
X 
Administration of 
bevacizumabK 
X 
Survival Follow‐up 
X 
AIncludes blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. Height at 
screening only. 
BIncludes CBC with differential, serum chemistry (Na, K, Cl, CO2, BUN, creatinine, glucose, calcium), 
magnesium, phosphate, liver function tests (albumin, total protein, alkaline phosphatase, total bilirubin, 
ALT, AST), LDH 
CPregnancy test (serum or urine) is required for women of childbearing potential only on Day 1 of each cycle 
prior to treatment administration. 
DCT scan of the chest/abdomen/pelvis can be performed +/‐ 5 days. Response evaluation is performed using 
RECIST 1.1 
ECT scan of the chest/abdomen/pelvis and brain MRI should continue every 9 weeks (+/‐ 5 days) until 
progression, withdrawal of consent, death, lost to follow‐up, or start of a subsequent anti‐cancer therapy 
 
FAll MRIs will be reviewed centrally by the investigators at Yale prior to confirmation of eligibility. For patients 
who will undergo local therapy on trial, investigators must identify a “clinically evaluable lesion(s)”. Brain MRI 
must be done within 28 days of intervention and should be repeated if more than 28 days will have lapsed by 
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the start of systemic therapy. For patients who previously underwent local therapy to a brain lesion and have 
tumor tissue available for analysis, only identification of “clinically evaluable lesion(s)” is necessary. 
GBrain MRI can be performed +/‐ 5 days. CNS response evaluation is performed using mRECIST criteria. MRIs 
should be done with perfusion, if possible. 
H Can be done at screening or any time prior to Cycle 1 Day 1 dosing 
iFollow‐up Visit should be 28 days after the last dose of trial treatment or before the initiation of a new anti‐ 
cancer treatment, whichever comes first. 
JIf a biopsy is done at any point during the subject’s participation in the trial, a sample of the tumor tissue will 
be taken for research. 
K If bevacizumab is held at any point it can be reinitiated when deemed safe for a total of four doses per 
patient 
L At screening, medications taken in the past 28 days need to be recorded, including over‐the‐counter 
medications and herbal supplements. Information on concomitant therapy including radiation therapy should 
be collected as well. 
M For all patients, archival tumor tissue will be requested. If archival tissue is not available patients on the 
NSCLC arm, or if intercurrent systemic therapy has been administered since the archival tissue was obtained, 
patients will need to have a fresh biopsy. 
N Subjects with PD‐L1 test results from outside the study are not required to undergo repeat testing for 
determination of eligibility as long as no systemic therapy was administered after the test results were 
obtained. Central and/or local testing of PD-L1 IHC by any FDA-approved assay or an assay performed in a CLIA 
laboratory is acceptable. If patients do not undergo PD‐L1 testing to determine eligibility, fresh or archival tissue 
is still required at study entry for correlative studies. 
O Plasma and PBMC are to be collected during the participant’s end of treatment visit in addition to those 
previously outlined. 
 
 
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7.0 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. 
 
7.1 Administrative Procedures 
 
7.1.1  Informed Consent 
 
The Investigator must obtain documented consent from each potential subject prior to 
participating in a clinical trial. 
 
7.1.1.2 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. 
 
7.1.2 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. 
 
7.1.3 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 
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for which the subject has enrolled in this study will be recorded separately and not listed as 
medical history. 
 
7.1.4 Prior and Concomitant Medications Review 
 
 
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. 
 
 
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 7.6.3.1—Serious Adverse Events. 
 
7.1.5  Disease Details and Treatments 
 
Disease Details 
 
The investigator or qualified designee will obtain prior and current details regarding disease 
status. 
 
Prior Treatment Details 
 
The investigator or qualified designee will review all prior cancer treatments including 
systemic treatments, radiation and surgeries. 
 
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. 
 
 
7.2 Clinical Procedures/Assessments 
 
7.2.1 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 5.0 (see Section 13.2). Toxicities 
will be characterized in terms regarding seriousness, causality, toxicity grading, and action 
taken with regard to trial treatment. 
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Please refer to section 7.6 for detailed information regarding the assessment and recording of 
AEs. 
 
7.2.2 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, on day 1 of each cycle, 
and at the follow-up visit. 
 
7.2.3 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. 
 
7.2.4 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, oxygen saturation, weight and blood pressure. Height will be measured at screening 
only. 
 
7.2.5 Eastern Cooperative Oncology Group (ECOG) Performance Scale 
 
The investigator or qualified designee will assess ECOG status (see Section 13.1) at 
screening, prior to the administration of each dose of trial treatment and discontinuation of 
trial treatment as specified in the Trial Flow Chart. 
 
7.2.6 Tumor Imaging and Assessment of Disease 
 
Tumor imaging and assessment of disease will be performed every 6 weeks for the first 3 
months of treatment, and then every 9 weeks thereafter. See section 12.0—Measurement of 
Response—for details. 
 
 
7.2.7 Tumor Tissue Collection and Correlative Studies Blood Sampling 
 
Before initiation of systemic therapy, a core biopsy will be obtained. This can be bypassed if 
there is archival tissue available. For NSCLC patients, it is acceptable to use archived tumor 
tissue rather than obtain a new biopsy to assess for PD-L1 status only if no intercurrent 
therapy was administered. In patients undergoing fresh biopsy, a minimum of two cores is 
required, and these will be formalin fixed and embedded in paraffin. These tissues will be 
stored for correlative studies mentioned below. Please see the Procedures Manual for tissue 
requirements and handling of tissue. 
 
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The stored tissue specimens will be analyzed at Yale University. In the context of a non- 
randomized trial, lack of validated assays and inability to identify and isolate tumor antigen 
specific T-cells, all correlative studies are considered exploratory. These are exploratory 
analyses that will be studying the tumor microenvironment and PBMC. Within the tumor 
microenvironment we will be assessing CD8+/IFNg+, PD-L1 expression, the ratio of 
CD8+/Treg and other assays (please see correlative section below). Within the PBMC, we 
will be studying CD8+/CD127+/PD-1+ (or PD-L1+)/IFNg+ cells, and PD-1/PD-L1 expression 
on central central memory and effector memory CD4+ subsets. Plasma will be stored for 
cytokine analyses. 
 
See section 11.0—Biomarker Studies—for details. 
 
7.3 Laboratory Procedures/Assessments 
 
Details regarding specific laboratory procedures/assessments to be performed in this trial are 
provided below. Laboratory Safety Evaluations (Hematology, Chemistry and Urinalysis) 
 
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 
Total triiodothyronine (T3) 
WBC (total and differential) 
Aspartate aminotransferase (AST) 
Specific gravity 
Free tyroxine (T4) 
Red Blood Cell Count 
Lactate dehydrogenase (LDH) 
Microscopic exam (If abnormal) 
Thyroid stimulating hormone (TSH) 
Absolute Neutrophil Count 
Carbon Dioxide 
results are noted 
Blood for correlative studies 
Absolute Lymphocyte Count 
(CO2 or biocarbonate) 
Urine pregnancy test † 
International Normalized Ratio (INR) or 
Prothrombin Time (PT) 
Uric Acid 
Partial Thromboplastin Time (PTT) or 
Activated Partial Thromboplastin Time 
(aPTT) 
Calcium 
Chloride 
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. 
 
 
 
 
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Laboratory tests for screening 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. 
 
7.4 Other Procedures 
 
7.4.1 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 7.6—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 5.7.1—Discontinuation of Study Therapy 
after CR. After discontinuing treatment following assessment of CR, these subjects 
should return to the site for a Safety Follow-up Visit (described in Section 7.5.1) 
and then proceed to the Follow-Up Period of the study (described in Section 7.5.2). 
 
7.5 Visit Requirements 
 
Visit requirements are outlined in Section 6.0—Trial Flow Chart.   Specific procedure-related 
details are provided above in Section 7.0—Trial Procedures. 
 
7.5.1 Safety Follow-Up Visit 
 
The mandatory Safety Follow-Up Visit should be conducted approximately 28 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. 
 
7.5.2 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 9 weeks (± 7 days) 
by radiologic imaging to monitor disease status. 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. Information regarding post- 
study anti-neoplastic treatment will be collected if new treatment is initiated. 
Survival Follow-up. 
 
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Once a subject experiences confirmed disease progression or starts a new anti- 
cancer therapy, the subject moves into the survival follow-up phase and should be 
contacted by telephone every 12 weeks to assess for survival status until death, 
withdrawal of consent, or the end of the study, whichever occurs first. 
 
7.6 Assessing and Recording Adverse Events 
 
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, 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. 
Examples of this may include, but are not limited to, teething, typical crying in infants and 
children and onset of menses or menopause occurring at a physiologically appropriate time. 
 
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 
within the follow-up period specified by the protocol, or prescribed in clinical practice, from 
overdose (whether accidental or intentional), from abuse and from withdrawal. 
 
Adverse events may also occur in screened subjects during any pre-allocation baseline period 
as a result of a protocol-specified intervention, including washout or discontinuation of usual 
therapy, diet, placebo treatment or a procedure. 
 
Progression of the cancer under study is not considered an adverse event unless it is 
considered to be drug related by the investigator. 
 
All adverse events will be recorded from the time the consent form is signed through 30 days 
following cessation of treatment and 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 7.6.3.1. 
 
 
 
 
 
 
 
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7.6.1 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 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) 
 
7.6.2 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), including the pregnancy of a male subject's female partner 
that occurs during the trial or within 120 days of completing the trial completing the trial, or 
30 days following cessation of treatment if the subject initiates new anticancer therapy, 
whichever is earlier. All subjects and female partners of male subjects who become pregnant 
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) 
 
 
 
 
 
 
 
 
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7.6.3 Immediate Reporting of Adverse Events to the Sponsor and to Merck 
 
Serious Adverse Events 
 
A serious adverse event is any adverse event occurring at any dose or during any 
use of Merck’s product 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 a new cancer (that is not a condition of the study); 
• Is associated with an overdose; 
• Is another important medical event 
 
Refer to Table 7 for additional details regarding each of the above criteria. 
 
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 from the time the consent is signed through 90 days following cessation of 
treatment, or the initiation of new anti-cancer therapy, whichever is earlier, whether 
or not related to Merck product, must be reported within 24 hours to the Sponsor 
and within 2 working days to Merck Global Safety. 
 
Non-serious Events of Interest will be forwarded to Merck GS and will be handled 
in the same manner as SAEs. 
 
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 outside of the time period specified in the previous 
paragraph also must be reported immediately to the Sponsor and to Merck. 
 
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.   
 
All subjects with serious adverse events must be followed up for outcome. 
 
 
 
 
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7.6.4 Reporting to the Food and Drug Administration 
 
This study will be conducted under an IND (Investigational New Drug application) that will 
be held by Harriet Kluger, M.D. The Principal Investigator will report in an expedited 
manner all SAEs meeting the criteria of “serious”, “unexpected” and “related to study 
treatment”.  Written safety reports will use a MedWatch Form 3500A.  A “fillable pdf” 
 
version with instructions is available at: http://www.fda.gov/medwatch/safety/FDA- 
3500A_Fillable_08-16-2006.pdf 
 
There are two types of expedited safety reports to the FDA: 
 
1. 7-Calendar-Day FDA Telephone or Fax Report:  The sponsor-investigator will 
directly notify the FDA, within 7 calendar days after his initial receipt of the 
information, of any adverse event that is ALL of the following: 
Death or immediately life-threatening 
Unexpected 
Associated with the use of study drug 
 
 
Notification to the FDA will be made directly to the new drug review division in the Center 
for Drug Evaluation and Research or in the product review division for the Center for 
Biologics Evaluation and Research, whichever was responsible for the review of the IND. 
[21CFR312.32(c)] A written report of the event is to follow within 15 calendar days. 
 
2. 15-Calendar-Day FDA Written Report:  The sponsor-investigator will directly 
notify the FDA within 15 calendar days of any adverse event that is ALL of the 
following: 
Serious (due to non-fatal and non-life threatening criteria) 
Unexpected 
Associated with the use of study drug 
Note: Serious Adverse Events which do not meet the criteria for expedited reporting will be 
reported to the FDA in the IND Annual Report. 
 
7.6.5 Reporting to the Yale Human Investigation Committee 
 
Sites will report to their IRB per local policy 
 
 
 
 
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7.6.6 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 5.0. 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: 
 
V50 
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 [including hospitalization for an elective procedure] for a preexisting 
condition which has not worsened does not constitute a serious adverse event.); 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) or 
Is an overdose (whether accidental or intentional). Any adverse event associated with an overdose is considered a serious adverse event. 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. 
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 the Merck product to be discontinued? 
Relationship to 
test drug 
Did the Merck product cause the adverse event? The determination of the likelihood that the 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 the Merck product and the AE; the greater the correlation with the components and 
their respective elements (in number and/or intensity), the more likely the Merck product caused the adverse event (AE): 
Exposure 
Is there evidence that the subject was actually exposed to the 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 the 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 
to Merck 
product 
(continued) 
The following components are to be used to assess the relationship between the test drug and the AE: (continued) 
Dechallenge 
Was the 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 Merck product; or (3) the trial is a single-dose drug trial); or (4) Merck product(s) is/are only used one time.) 
Rechallenge 
Was the subject re-exposed to the 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) Merck 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 THE MERCK PRODUCT, OR IF REEXPOSURE TO THE MERCK PRODUCT POSES ADDITIONAL POTENTIAL 
SIGNIFICANT RISK TO THE SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE U.S. CLINICAL 
MONITOR 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 the 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 a Merck product relationship). 
Yes, there is a reasonable 
possibility of Merck product 
relationship. 
There is evidence of exposure to the Merck product.  The temporal sequence of the AE onset relative to the administration of the Merck product 
is reasonable. The AE is more likely explained by the Merck product than by another cause. 
No, there is not a reasonable 
possibility Merck product 
relationship 
Subject did not receive the Merck product OR temporal sequence of the AE onset relative to administration of the Merck product is not 
reasonable OR there is another obvious cause of the AE.  (Also entered for a subject with overdose without an associated AE.) 

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7.6.7 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. 
 
7.6.8 Events of Clinical Interest 
 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest 
(ECI) and must be reported to the Sponsor. 
 
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, any ECI, or follow up to an ECI, that occurs to any subject must be 
reported within 24 hours to the Sponsor if it causes the subject to be excluded from the trial, 
or is the result of a protocol-specified intervention, including but not limited to washout or 
discontinuation of usual therapy, diet, placebo treatment or a procedure. 
For the time period beginning at treatment allocation/randomization through 30 days 
following cessation of treatment, any ECI, or follow up to an ECI, whether or not related to 
the Sponsor’s product, must be reported within 24 hours to the Sponsor, either by electronic 
media or paper. Electronic reporting procedures can be found in the EDC data entry 
guidelines. Paper reporting procedures can be found in the Investigator Trial File Binder (or 
equivalent). 
 
Events of clinical interest for this trial include: 
• an overdose of Merck product, as defined in Section 7.6.1 – 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. 
 
• 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. 
 
8.0 STATISTICAL ANALYSIS PLAN 
 
8.1 Statistical Design 
 
This is a phase II study of patients with melanoma and a pilot study of NSCLC patients who 
have untreated brain metastases. Subjects must have at least 1 brain lesion that does not 
require immediate local therapy and can be assessed for response. Criteria for response are 
defined in Section 12.0. 
 
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The primary goal of this study is to determine the efficacy of pembrolizumab plus 
bevacizumab in patients with untreated brain metastases from melanoma or NSCLC. The 
primary endpoint is the brain metastasis response rate (BMRR). A drug with minimal 
activity would be expected to have a BMRR of 10%. The study was initially designed so that 
pembrolizumab and bevacizumab would be considered worthy of further study in patients 
with untreated brain metastases if its true BMRR is similar to the systemic response rate with 
pembrolizumab, which is 34% for melanoma and 25% for NSCLC. For this to occur, the 
study was originally planned to enroll a total of 53 eligible patients (20 with melanoma, 33 
with NSCLC). In the first stage of a Simon’s optimal two stage design, it was planned that 9 
patients with melanoma and 16 patients with NSCLC would be enrolled. If 2 or more of 9 
evaluable melanoma patients had a response in brain metastases, accrual would continue to 
enroll another 11 patients to that cohort. Similarly, in the NSCLC cohort, if a brain metastases 
response were to be seen in 2 more of the 16 eligible NSCLC patients, another 17 patients were 
planned to be accrued. 
 
Prior to February 2019, 20 patients were accrued to the melanoma cohort of the trial. We 
observed 11 brain metastasis responses in 20 patients (ORR=0.55, 95% CI: 0.32-0.77). For the 
melanoma cohort, we aimed to generate evidence that the true response rate of pembrolizumab 
plus bevacizumab in patients with untreated brain metastases is more than 30% and we 
expanded the cohort by another 20 patients. For the NSCLC cohort, we revised the statistics to 
conduct a pilot study as described below. 
 
In the study of the first 20 melanoma patients, we decided that the combination is not worthy 
of further investigation if the true response rate is <=10%. However, because we observed a 
BMRR of 55% in these patients, we raised this bar from 10% to 30%, which is the lower 
bound of the 95% CI from the first 20 melanoma patients who were enrolled on the study. 
 
For the melanoma cohort, the new null hypothesis that the true response rate is 30%.  was to 
be tested against a one-sided alternative, using Simon’s optimal two stage design, enrolling 
8 patients in the first stage and 12 in the second.  
 
Among the first six patients enrolled in the second melanoma cohort, one had a modified 
RECIST-defined complete response, and two had progression of disease due to initial tumor 
growth at six weeks or appearance of new lesions (one each), with subsequent tumor regression, 
remaining on study beyond progression. Two patients were unevaluable for intra-cranial 
response.  
 
Therefore, we are redesigning the analyses to remove the Simon’s optimal two stage design due 
to the possibility of delayed response and emerging evidence regarding the intra-cranial 
response rate to anti-PD-1 monotherapy (Long et.al, Lancet Oncology, 2018 64, in which 5 of 
25 patients responded and Kluger et al, Journal of Clinical Oncology 2019 65, in which 6 of 23 
patients responded), indicating that the response rate to anti-PD-1 alone is likely between 20-
26%. Long et al also reported a response rate to anti-PD-1 and anti-CTLA-4 combination 
therapy of 46%, and Tawbiet al reported a response rate to anti-PD-1 and anti-CTLA-4 of 56% 
(Tawbi et al, New England Journal of Medicine, 2018) 66.  
 
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The combination of pembrolizumab and bevacizumab, a significantly less toxic regimen, would 
be worthy of further study if the intracranial response rate was 46%. In the first melanoma 
cohort in this trial, the intracranial response rate was 55%, and the purpose of the second cohort 
was to verify this result.  
 
To account for the uncertainty of the historical response rate, we follow the approach proposed 
by Thall and Simon (1994) 63 and approximate the distribution of response rate to anti-PD-1 
monotherapy using a beta distribution with a mean of 23% (95% CI: 0.12-0.36), assuming there 
are 11 responses (5+6) out of 48 (25+23) patients in historical controls. That is, we assume the 
historical response rate 𝜃𝜃𝐻𝐻∼𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵( 𝑛𝑛𝐻𝐻 𝑝𝑝𝐻𝐻,    𝑛𝑛𝐻𝐻(1 − 𝑝𝑝𝐻𝐻), where  𝑛𝑛𝐻𝐻= 48 and  𝑝𝑝𝐻𝐻= 0.23. 
Assume the response rate of the combination has a uniform prior, that is, 𝜃𝜃𝐸𝐸∼𝐵𝐵𝐵𝐵𝐵𝐵𝐵𝐵(1, 1). 
 
After enrolling and evaluating the outcomes of the 20 patients, we conclude the combination 
worthy of further study if 
𝑃𝑃(𝜃𝜃𝐸𝐸> 𝜃𝜃𝐻𝐻|𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑) > 0.936, 
 
i.e., we conclude the treatment is promising if there are at least 8 responses in 20 patients.  
 
The probability of false positive is 0.032, 0.067 and 0.122 if the true probability of response is 
0.20, 0.23 and 0.26, respectively. We achieve 78%, 87% and 94% power if the true probability of 
response is 0.46, 0.50 and 0.55, respectively.  
 
 
 
 
The beta distribution modelling the response rate to monotherapy in historical controls (Left panel) and 
the power function of the design (right panel). 
 
 
 
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For the lung cohort, we will conduct a pilot study which will decrease the number of planned 
enrolled patients from 33 to 13 patients. Under the null hypothesis, the response rate 
corresponding to drug with minimal activity is 10%. We therefore consider a drug is worthy of 
further investigation if the true response rate is at least 25% for NSCLC. 
 
Due to the pilot nature of this study, sample size calculation is not based on formal hypothesis 
testing. We provide the two-sided 90% confidence intervals for observing different number of 
responses. As shown by the table below, we can reject the null hypothesis if at least 4 responses 
are observed. 
 
Number of Responses 
Lower 90% CI 
Upper 90% CI 
3 
0.07 
0.49 
4 
0.11 
0.57 
5 
0.17 
0.65 
6 
0.22 
0.71 
7 
0.29 
0.78 
8 
0.35 
0.83 
 
 
Patients will be considered evaluable if they remain on treatment for the first 6-week scans or 
if they have unequivocal CNS progression prior to that. 
 
8.2 Analytic Plan for Primary Objectives: 
 
We will use mRECIST criteria to determine brain metastasis response rate (BMRR). The 
proportion of patients with a brain metastasis response in the clinically evaluable lesion(s) 
will be calculated along with a 95% confidence interval. 
 
8.3 Analytic Plan for Secondary Objectives: 
 
1) Objective: To determine the incidence of steroid use for control of cerebral 
edema during treatment with pembrolizumab and bevacizumab in combination in 
patients with metastatic melanoma or NSCLC. 
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The percentage of patients requiring corticosteroid use for control of perilesional 
edema will be compared that seen in a previous study with the same patient 
population using pembrolizumab alone. The proportion of patients using steroids 
for > 96 hours will be calculated with a 95% confidence interval. 
 
2) Objective: To determine the best overall response rate (ORR) in patients with 
brain metastases from melanoma or NSCLC treated with combination 
pembrolizumab and bevacizumab. 
 
Best overall response rate (ORR) is defined as the percentage of patients who 
experience a CR or PR in any metastases (clinically evaluable cerebral or 
systemic) as determined by mRECIST criteria in the brain or RECIST criteria in 
the body. The proportion of patients with an ORR will be calculated with a 95% 
confidence interval. A similar analysis will be performed using ir-mRECIST and 
ir-RECIST. 
 
 
3) Objective: To evaluate median progression free survival (PFS) and overall 
survival (OS) in patients with melanoma or NSCLC metastatic to the brain, treated 
with pembrolizumab plus bevacizumab. 
 
Progression-free survival will be calculated as the time from start of study drugs 
to progression (using mRECIST criteria for brain lesions and RECIST criteria for 
systemic disease) or death. Overall survival will be calculated as the time from 
start of pembrolizumab to death. Patients who do not meet the endpoint will be 
censored at the date of last follow-up. PFS and OS will be determined separate 
for each cohort and median survival will be estimated by using Kaplan-Meier 
methodology. 
 
8.4 Exploratory Objective 
 
(1) Objective: To study PD-L1 expression and other potential predictive biomarkers 
in CNS, tumors and blood, and correlate results with response to pembrolizumab 
plus bevacizumab. 
 
PD-L1 expression and other potential biomarkers will be correlated to clinical 
endpoints. Exploratory, hypothesis-generating analyses will be performed. Details of 
the statistical plan for the biomarker studies are provided in Section 11.0. 
 
(2) Objective: To determine the safety and toxicity of pembrolizumab in combination 
with bevacizumab in patients with untreated brain metastases 
 
Safety and toxicity will be assessed using CTC v4.0 criteria. All participants who 
receive any amount of study drug will be evaluable for toxicity. 
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9.0  
LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL 
SUPPLIES 
 
9.1 Investigational Product 
 
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 in accordance with the protocol and any applicable laws and 
regulations. 
 
Clinical 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 
 
 
9.2 Packaging and Labeling Information 
 
Clinical supplies will be affixed with a clinical label in accordance with regulatory 
requirements. 
 
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 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 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. 
 
10.2 Quality Management System 
 
10.2.1 Monitoring 
 
The study principal investigator and YCCI are responsible for monitoring the performance of 
all of the participating sites. This will be performed by conducting a study site initiation 
visit, as well as regularly scheduled monitoring visits and/or remote monitoring throughout 
the life of the protocol. At the end of the trial, the monitor will then perform a study site 
close-out visit at all participating sites. 
 
YCCI will utilize their institution’s initiation, monitoring and close-out visit reports. 
Following each site visit, a visit report will be generated containing information on site 
activities, and a summary of pertinent points and action items together with a copy of the 
follow-up letter will be sent to each investigative site. 
 
During these monitoring visits, some of the items that will be reviewed are the following: 
• Training of the sites 
• Site personnel qualifications to participate in the trial 
• That study related documents are current 
• That regulatory compliance is accomplished 
• That each subject has signed the informed consent 
• That the current and approved protocol is complied with (including reporting and 
logging of all protocol deviations) 
• That all SAEs and AEs have been reported to the local regulatory and Ethics/IRB 
Committees, YCCI, and Merck as appropriate 
• That source documentation matches CRFs 
• That required procedures for study drug accountability, distribution, and storage are 
followed. 
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YCCI will document the required study monitoring activities in a Study Monitoring Plan. 
 
10.2.2 Audit and inspection 
 
To ensure compliance with GCP and regulatory requirements, the YCCI Office of Quality 
Assurance and Training will audit the trial at least annually or as determined by the Yale 
Cancer Center DSMC. The overall principal investigator, study coordinator and/or data 
manager may request access to all source documents and other study documentation for on- 
site or remote monitoring, audit or inspection. 
 
Involvement in this study as a participating investigator implies acceptance of potential 
audits or inspections, including source data verification, by representatives designated by the 
Principal Investigator or Yale. The purpose of these audits or inspections is to examine 
study-related activities and documents to determine whether these activities were conducted 
and data were recorded, analyzed, and accurately reported in accordance with the protocol, 
institutional policy, and any applicable regulatory requirements. 
 
In addition, inspections by regulatory health authority representatives and IEC(s)/IRB(s) are 
possible. The investigator should notify the sponsor immediately of any such inspection. 
The Sponsor-Investigator/institution and participating site investigators/institutions agree to 
allow the auditor or inspector direct access to all relevant documents and allocate their time 
and the time of their staff to the auditor/inspector to discuss findings and any issues. Audits 
and inspections may occur at any time during or after completion of the study. 
 
10.2.3 Data Safety Monitoring Committee (DSMC) 
 
The Yale Cancer Center DSMC will serve at the DSMC of record. The Yale DSMC will 
review and monitor compliance, toxicity and deviations from this study. The committee is 
composed of clinical specialists with experience in oncology and who have no direct 
relationship with the study. Information that raises any questions about participant safety will 
be addressed with the Principal Investigator. 
 
The DSMC will review this protocol at a minimum of once every six months. Information to 
be provided to the committee includes: a study narrative by the PI, a summary DSMC report 
produced by OnCore (which includes participant accrual, response, trial status history, SAEs, 
Adverse Events, Deviations and survival); audit results, and monitoring reports as applicable. 
Other information (e.g. scans, laboratory values) will be provided upon request. 
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11.0 BIOMARKER STUDIES 
 
11.1 Tissue-based correlative studies: 
 
Correlative studies will be conducted on the pre-treatment tissue specimens. When available 
we will include both cerebral and extra-cerebral samples. PD-L1 staining will also be 
determined by c entral and/or local testing of PD-L1 IHC by any FDA-approved assay or an 
assay performed in a CLIA laboratory on FFPE tissue. A number of additional biomarkers 
will be studied for their potential predictive value in pre- treatment specimens. These 
exploratory studies include (but are not limited to): 
 
1) Markers to be studied on tumor cells: PDL1, PDL2, B7-H2, B7-H3, B7-H4, Galactin- 
9, CEACAM-1, CD-70, HVEM, IDO, MHC class I antigens. 
2) Percent of tumor sample that constitutes CD3, CD4 and CD8 cells and macrophages 
(CD68) 
3) Markers  on  immune  infiltrating  cells:  LAG-3  on  CD4  cells,  PD1-H  (PD-1 
homologue), CTLA4, TIM3, PD-1, IDO, BTLA 
4) Vessel density will be determined by the area of CD34 staining in the sample. Tumor 
and vessel VEGF-receptor expression will be determined as previously described 52. 
 
Patients who undergo surgical procedures (either of the CNS or peripheral) while on systemic 
treatment will also be required, when feasible, to provide a research specimen to determine 
changes in the above markers in the context of response or resistance to therapy. 
 
Levels of all of the above markers will be measured by a method of Automated Quantitative 
Analysis (AQUA) of in situ protein levels in Dr. Kluger’s laboratory at Yale University. This 
method has been validated for epithelial cancers and melanoma, and has shown to be more 
precise than pathologist-based scoring of 3,3′-diaminobenzidine stain. AQUA is highly 
reproducible and quantitative, as reviewed 53. Tumors will be stained with a number of 
fluorophores: A tumor mask for melanoma will be made using a cocktail of anti-S100 and 
anti-Melan-A, and for NSCLC the mask will be generated by anti-cytokeratin antibodies. The 
methods for masking tumor have been described in the literature 52,54,55. The mask will by 
conjugated to Cy-2, and will be differentiated from the target antigen, which will be 
conjugated to Cy-5. Lymphocytes will be identified by the appropriate antigen conjugated to 
Cy-7. After fluorescent staining is completed, images are taken at the different wavelengths, 
and the images will be analyzed using algorithms that have been extensively described. A 
monochromatic, high-resolution images of each histospot will be obtained using the 10× 
objective of an Olympus AX-51 epifluorescence microscope (Olympus) with automated 
microscope stage and digital image acquisition driven by a custom program and macrobased 
interfaces with IPLabs software (Scanalytics, Inc.). Tumor will be distinguished from stromal 
elements by the tumor mask signal. The signal intensity of the target biomarker will be 
scored on a scale of 0-255 (the AQUA score). This will provide quantitative results. 
 
Biomarker analysis for individual markers will be conducted using standard statistical 
methods. Associations between continuous AQUA scores and dichotomized outcome 
variables (such as response) will be done by ANOVA. Cox univariate analysis will be used to 
study the associations between the survival endpoints and biomarker expression; Kaplan 
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Meier curves will be generated to depict the association between dichotomized biomarker 
levels and survival endpoints. Multivariable models will be generated to predict response. 
Biomarker selection will be done by determining area under the receiver operating 
characteristic (ROC) curves (AUCROC) at the time of each event in the testing set and we 
average these AUCROCs across all these events; this is a variant of the weighted average of 
time dependent ROC curve approaches 56-59. 
 
11.2 Blood-based studies: 
 
We will collect approximately 10 cc of blood from patients pre-treatment, after 6 weeks of 
therapy, 12 weeks of therapy, and every 9 weeks thereafter while on treatment, and at the 
end of treatment visit (5 cc of plasma and 5 cc of whole blood). We will immunophenotype 
cells from pre- and on- treatment blood samples to determine the array and activation status 
of different immune cell populations. We will do this using polychromatic flow cytometry 
which provides a powerful assessment of immune function based on differences in cell 
numbers, cell types and the expression of cell-associated surface and intracellular 
molecules related to immune perturbation 60. Lyophilized antibody cocktails have been 
developed in the form of lyoplates to improve standardization between different labs and will 
be utilized here, with a different panel to examine multiple immune cells types (see Table 
below for details). Approximately 5ml of blood will be used for this assay. 
 
We also will perform a multiplex cytokine analysis assay to determine the cytokines present 
pre-treatment and after 9 weeks on treatment with pembrolizumab 61. We will use the 
Luminex assay which multiplexes 25 cytokines from plasma. The cytokines in the panel 
include: GM-CSF, IFN-γ, IL-10, IL-12 (p70), IL-13, IL-15, IL-17A, IL-17E/IL-25, IL-17F, 
IL-1β, IL-2, IL-21, IL-22, IL-23,IL-27, IL-28A, IL-31, IL-33, IL-4, IL-5, IL-6, IL-9, MIP- 
3α/CCL20, TNFα, and TNFβ .This assay requires about 100ul of plasma and utilizes a bead 
set coated with a capture antibody specific for each cytokine. A second biotinylated antibody 
and streptavidin-phycoerythrin is used to detect the captured cytokine. The Luminex 200 
analyzer is a dual laser, flow-based, sorting and detection platform which can determine the 
specific cytokines present and the amount of cytokine bound. Both the immunophenotyping 
flow cytometry assay and the multiplex cytokine analysis are available through the Immune 
Monitor Core Facility at Yale under the direction of Dr. Lesley Devine, PhD. 
 
Blood-based immunophenotyping and cytokine assays: 
 
Antibody panels for immunophenotyping 
Lyoplate 
panel # 
FITC 
PE 
PE-Texas 
Red 
PerCP- 
Cy5.5 
PE-Cy7 
APC 
AlexaF- 
700 
APC-H7 
V450 
V500 
Purpose 
1 
CD27 
CCR7 
Viability 
Dye 
CD4 
CD45RA 
CD38 
CD28 
CD8 
CD3 
HLA- 
DR 
T cells 
2 
CXCR5 
CXCR3 
Viability 
Dye 
CCR4 
CCR6 
PD-1 
CD8 
CD3 
CD4 
TH1, TH2, TH17 cells 
3 
CD39 
CD25 
Viability 
Dye 
CD4 
CCR4 
CD127 
FoxP3 
CD45RO 
CD3 
HLA- 
DR 
TReg Cells 
4 
CD21 
CD24 
Viability 
Dye 
CD19 
CD27 
CD38 
CD10 
CD20 
CD3 
IgD 
B-cells 
5 
CD56 
Viability 
Dye 
CD123 
CD11c 
CD16 
CD3+19+20 
CD14 
HLA- 
DR 
DCs, monocytes and 
NK cells 
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Please note that the profile of biomarkers is likely to change as scientific knowledge evolves. 
 
11.3 Collection and Handling of Specimens 
 
Before initiation of systemic therapy, local surgical therapy may be performed when 
clinically appropriate, and samples of brain or extracerebral tumor will be obtained. After 
tissue is obtained, it will be formalin fixed and embedded in paraffin. These tissues will be 
stored for correlative studies mentioned in the biomarker spectrum. If a patient has previously 
undergone local therapy to a brain lesion and tissue is available for analysis, paraffin-
embedded tissue will be obtained from the sample. For patients who do not have tissue 
from a brain lesion available, tissue from a systemic lesion will be used to perform the planned 
studies. This tissue may include a FFPE specimen or SNAP frozen tissue. Please see the 
Procedures Manual for tissue requirements and handling of tissue 
 
12.0  MEASUREMENT OF RESPONSE 
 
Response will be evaluated with a CT chest/abdomen/pelvis and MRI brain every 6 weeks 
for the first 3 months of treatment and then every 9 weeks thereafter. If symptoms develop 
or clinical deterioration occurs, patients may be imaged prior to the pre-specified time 
points for imaging. 
 
12.1 Brain Metastasis Response Assessment 
 
RECIST criteria v1.1 will be modified to account for differences in measuring the response 
of clinically evaluable brain lesions as opposed to systemic lesions (modified RECIST, or 
mRECIST). Size is considered the tumor’s largest diameter. Measurements from multiple 
lesions are summed to calculate the sum of the diameters (SD). The SD calculated on a 
baseline scan performed within 28 days of study drug initiation will be used as a reference to 
determine the objective response of the clinically evaluable lesions. All responses must be 
confirmed at ≥6 weeks with an equivalent or better response. Please refer to the original 
RECIST criteria if further reference is necessary. 
 
 
12.2 Brain Metastasis Measurable disease 
 
Specification of a minimal lesion diameter for measurable lesions reduces the potential for 
variation in the measurement of smaller lesions due to slice selection and volume averaging. 
The minimal lesion diameter should be greater than or equal to 2 times the section thickness 
and a minimum of 5mm. A previously irradiated lesion will not be measured as a target 
lesion unless it is documented to have progressed since treatment. 
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12.3 Brain Metastasis Nonmeasurable disease 
 
Nonmeasurable lesions at baseline are important in clinical trials because tumor progression 
may occur at these sites. Nonmeasurable lesions include enhancing lesions that are less than 
the specified smallest measurable diameter (5mm when slice thickness is 2.5mm or twice the 
slice thickness), hemorrhagic or predominantly cystic or necrotic lesions that are difficult to 
accurately measure and track, and lesions that are indeterminate for metastatic disease. Intrinsic 
T1-hyperintensity is noted within hemorrhagic lesions that may be misinterpreted as enhancing 
tumor, and for this reason, the precontrast T1-weighted image must be examined at baseline 
to prevent this error. Nonmeasurable lesions should be briefly described on the imaging case 
report form for each study.62 
 
RECIST 1.1 limits the number of lesions measured to 5 in total, with 2 per organ. For our 
purposes, if there are multiple measurable lesions in the brain, the sum of diameters of up 
to a maximum of 5 of the largest lesions will be considered for response assessment. 
assessment. 
 
12.4 Modified Response Criteria for Brain Metastases 
Up to 5 CNS lesions can be selected as target lesions for response evaluation 
Complete Response (CR): Disappearance of all target 
lesions. 
 
Partial Response (PR): At least a 30% decrease in the sum of diameters of target lesions, 
taking as reference the baseline sum diameters. 
 
Progressive Disease (PD): At least a 20% increase in the sum of diameters of target 
lesions, taking as reference the smallest sum recorded since the treatment started or the 
appearance of one or more new lesions (new lesions must be greater than slice thickness). 
 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase 
to qualify for PD, taking as reference the smallest sum diameters since the treatment started. 
 
Please refer to RECIST v1.1 for additional details regarding response criteria. 
 
12.5 Systemic Disease Response Assessment 
 
Response of all systemic, non-cerebral metastases will be evaluated in this study using the 
new international criteria proposed by the Response Evaluation Criteria in Solid Tumors 
(RECIST) Committee v1.1. Version 1.1 stipulates that the number of lesions required to 
assess tumor burden for response determination has been reduced to a maximum of five total 
lesions (two lesions maximum per organ). 
 
 
 
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Briefly, measurable lesions must have a minimum size of 10 mm by CT scan (CT scan slice 
thickness no greater than 5 mm) in at least one dimension. Lesions with a longest diameter of 
<10 mm are considered non-measurable lesions and will be tracked as non-target disease. 
Tumor lesions in a previously irradiated area, or in an area subject to other loco-regional 
therapy, are not considered measurable unless there has been demonstrated progression in the 
lesion. For complete definitions of measurable and non-measurable disease, please refer to 
the RECIST v1.1 criteria. 
 
12.6 Evaluation of Best Overall Response 
 
The Best Overall Response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). The patient's best response assignment 
will depend on the achievement of both measurement and confirmation criteria. The best 
response will take into consideration both the clinically evaluable brain metastases and 
systemic metastases, and therefore will include measurements from both mRECIST criteria 
(in the brain) and RECIST criteria (in the body) as follows: 
 
Complete Response (CR): Disappearance of all target lesions in the brain and systemic 
disease. 
Partial Response (PR): Partial response in both the brain and the systemic disease, or if there 
is PR at one site and SD at the other, the sum of diameters from the brain and systemic 
disease will be added and the best overall response will be considered PR if there is at least a 
30% decrease, taking as reference the baseline sum diameters. 
Progressive Disease (PD): Progressive disease in either the brain or the systemic disease will 
qualify as PD as the best overall response. 
 
Stable Disease (SD): Stable disease in both the brain and systemic disease, or if the sum of 
diameters from the brain and systemic disease does not qualify for PR or PD (at least a 20% 
increase in the sum of diameters of target lesions), taking as reference the smallest sum 
diameters since the treatment started. 
 
Duration of overall response: The duration of overall response is measured from the time 
that measurement criteria are met for CR or PR (whichever is first recorded) until the first 
date that recurrent or progressive disease is objectively documented (taking as reference for 
progressive disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met for 
CR until the first date that recurrent disease is objectively documented. Please note that 
objective documentation implies confirmation of response by imaging. 
 
Duration of stable disease: Stable disease is measured from the start of the treatment until 
the criteria for progression are met, taking as reference the smallest measurements recorded 
since the treatment started. 
 
 
 
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Progression-Free Survival (PFS): PFS is defined as the time from initiation of study drug 
until the first documented, confirmed progression of clinically evaluable brain metastases 
based on mRECIST criteria, systemic disease based on RECIST criteria, or death. If there is 
progression of disease that is then confirmed on a follow up scan at least 4 weeks later, the 
initial date of documented progression should be used in the PFS analysis. 
 
 
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13.0 APPENDICES 
 
13.1 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. 
 
 
13.2 Common Terminology Criteria for Adverse Events V5.0 (CTCAE) 
 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version 5.0 will be utilized for adverse event reporting. 
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ENGINEERED PD-L1 ANTIBODY, IN PATIENTS WITH METASTATIC RENAL CELL 
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