A Phase I/II Study Testing the Safety, Toxicities, and Efficacy of MK-3475 in Combination With MRI-guided Laser Ablation in Recurrent Malignant Gliomas
Phase: PHASE1
Conditions: Malignant Glioma
Sponsor: Washington University School of Medicine

Protocol Amendment 16, 10/06/2021 
 
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A Phase I/II Study Testing the Safety, Toxicities, and Efficacy of MK-3475 in Combination 
with MRI-guided Laser Ablation in Recurrent Malignant Gliomas 
 
Washington University School of Medicine, Division of Oncology 
660 South Euclid Avenue, Campus Box 8056, St. Louis, MO  63110 
 
Protocol #: 201501072  
Version Date: 10/06/2021 
 
Coordinating Center: 
 
Washington University School of Medicine 
 
PI and IND Holder:  
 
Milan G. Chheda, M.D. 
Phone: (314) 747-2712 
E-mail: mchheda@wustl.edu  
 
University of Florida PI:  
 
David D. Tran, M.D., Ph.D. 
 
 
 
 
 
E-mail: david.tran@neurosurgery.ufl.edu  
 
Sub-Investigators 
 
 
Institution 
 
 
Modality 
Tanner M. Johanns, M.D., Ph.D. 
Washington University 
Medical Oncology 
Albert Kim, M.D., Ph.D. 
 
Washington University 
Neurosurgery 
Eric Leuthardt, M.D.  
 
Washington University 
Neurosurgery 
Esther Lu, Ph.D. 
 
 
Washington University 
Biostatistics 
Robert D. Schreiber, Ph.D. 
 
Washington University 
Pathology & Immunology 
Maryam Rahman, M.D. 
 
University of Florida  
Neurosurgery 
Duane Mitchell, M.D., Ph.D.  
University of Florida  
Neurosurgery 
Gregory Murad, M.D.  
 
University of Florida  
Neurosurgery 
Ashley Ghiaseddin, M.D. 
 
University of Florida  
Neuro-Oncology 
Steven Roper, M.D.  
 
University of Florida  
Neurosurgery 
 
Study Drug:  
 
MK-3475 (pembrolizumab, Keytruda) 
IND #: 
125099 
Clinical Trials.gov #: 
NCT02311582 
 
CONFIDENTIAL 
The information contained in this document is regarded as confidential and, except to the extent necessary to 
obtain informed consent, may not be disclosed to another party unless law or regulations require such 
disclosure.  Persons to whom the information is disclosed must be informed that the information is 
confidential and may not be further disclosed by them 
 
 
 

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A Phase I/Phase II Study Testing the Safety, Toxicities, and Efficacy of MK-3475 in 
Combination with MRI-guided Laser Ablation in Recurrent Malignant Gliomas 
 
Protocol Revision History 
 
Initial Approval Version 
 
 
 
 
 
 
01/16/2015 
Amendment #1 Version 
 
 
 
 
 
 
04/16/2015 
Amendment #2 Version 
 
 
 
 
 
 
09/16/2015 
Amendment #3 Version (PRMC approved only)  
 
 
02/05/2016 
Amendment #3 Version (HRPO requested changes) 
 
 
03/25/2016 
Amendment #4 Version 
 
 
 
 
 
 
06/15/2016 
Amendment #5 Version 
 
 
 
 
 
 
09/22/2016 
Amendment #6 Version 
 
 
 
 
 
 
01/12/2017 
Amendment #7 Version 
 
 
 
 
 
 
09/20/2017 
Amendment #8 Version 
 
 
 
 
 
 
10/19/2017 
Amendment #9 Version  
 
 
 
 
 
 
12/05/2017 
Amendment #10 Version  
 
 
 
 
 
 
01/18/2017 
Amendment #11 Version 
 
 
 
 
 
 
02/21/2018 
Amendment #12 Version 
 
 
 
 
 
 
06/19/2019 
Amendment #13 Version 
 
 
 
 
 
 
01/06/2021 
Amendment #14 Version 
 
 
 
 
 
 
05/27/2021 
Amendment #15 Version 
 
 
 
 
 
 
08/03/2021 
Amendment #16 Version 
 
 
 
 
 
 
10/06/2021 
 
 
 

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A Phase I/II Study Testing the Safety, Toxicities, and Efficacy of MK-3475 in Combination 
with MRI-guided Laser Ablation in Recurrent Malignant Gliomas 
 
Principal Investigator Signature Page 
 
 
Principal Investigator: 
 
Milan G. Chheda, M.D. 
 
 
 
 
 
Signature of Investigator 
 
Date 
 
 
 
Printed Name of Investigator 
 
 
 
By my signature, I agree to personally supervise the 
conduct of this study and to ensure its conduct in 
compliance with the protocol, informed consent, 
IRB/HRPO procedures, the Declaration of Helsinki, ICH 
Good Clinical Practices guidelines, and the applicable 
parts of the United States Code of Federal Regulations or 
local regulations governing the conduct of clinical 
studies. 
 
 
 

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Unacceptable toxicity
0
weeks
Baseline
MRI
Phase I
Eligible pts 
with 
recurrent 
grade III&IV 
gliomas
MLA
2
4
MRI
6
8
10
12
MRI
MK-3475
MK-3475
MK-3475
MK-3475
Dose level -1
Research 
blood
A Phase I/II Study Testing the Safety, Toxicities, and Efficacy of MK-3475 in Combination 
with MRI-guided Laser Ablation in Recurrent Malignant Gliomas 
 
SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Phase I sample size: maximal 18 
Phase II sample size: 32 evaluable patients with up to 39 enrollments 
 
Dose Escalation Schedule (Phase I portion) 
Dose Level 
MK-3475 Dose 
Level 1 (Starting Dose) 
100 mg IV q3wks 
Level 2 
150 mg IV q3wks 
Level 3 
200 mg IV q3wks 
 
                                                                                                                         
As of Amendment 12, patients will no longer be randomized in the phase II portion of this 
trial. Phase II patients enrolled after the approval of Amendment 12 will participate in a 
single treatment arm with MK-3475 and MLA and follow the schedule of events in Section 
10.2.1 of the protocol.  
 
 
Phase II
Eligible pts 
with 
recurrent 
grade IV GBM
Baseline MRI
Surgery
MK-3475 MK-3475 MK-3475 MK-3475
MRI
MRI
MLA
(optional)

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Glossary of Abbreviations 
 
AE 
Adverse event 
ALT (SGPT) 
Alanine transaminase (serum glutamate pyruvic transaminase) 
ANC 
Absolute neutrophil count 
AST (SGOT) 
Aspartate transaminase (serum glutamic oxaloacetic transaminase) 
BBB 
Blood brain barrier 
B-HCG 
Beta human chorionic gonadotropin  
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 
CNS 
Central nervous system 
CRF 
Case report form 
CT 
Computed tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
DLTs 
Dose Limiting Toxicities 
DSM 
Data and Safety Monitoring  
ECI 
Event of clinical interest 
FDA 
Food and Drug Administration 
FNA 
Fine needle aspiration 
FWA 
Federal wide assurance 
GBM 
Glioblastoma multiforme 
HIV 
Human Immunodeficiency Virus 
HRPO 
Human Research Protection Office (IRB) 
IB 
Investigator’s brochure 
IHC 
Immunohistochemistry 
IND 
Investigational New Drug 
INR 
International normalized ratio 
irAE 
Immune-related adverse event 
IRB 
Institutional Review Board 
IULN 
Institutional upper limit of normal 
IV 
Intravenous (i.v.) 
MLA 
MRI-guided laser ablation 
MRI 
Magnetic resonance imaging 
MTD 
Maximum tolerated dose 
NCI 
National Cancer Institute 
NIH 
National Institutes of Health 
NSCLC 
Non-small cell lung cancer 
OHRP 
Office of Human Research Protections  
OS 
Overall survival 
PFS 
Progression-free survival 
PI 
Principal investigator 

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PK 
Pharmacokinetic 
PT 
Prothrombin time 
PTT 
Partial thromboplastic time 
QASMC 
Quality Assurance and Safety Monitoring Committee 
RANO 
Response Assessment in Neuro-Oncology 
SAE 
Serious adverse event 
SCC 
Siteman Cancer Center 
SUSAR 
Suspected unexpected serious adverse reaction 
TIL 
Tumor-infiltrating lymphocytes 
TSH 
Thyroid stimulating hormone 
UPN 
Unique patient number 
 
 

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Table of Contents 
SCHEMA ........................................................................................................................................ 4 
1.0 
BACKGROUND AND RATIONALE ....................................................................... 9 
1.1 
Glioblastoma Multiforme ............................................................................................ 9 
1.2 
MRI-guided Laser Ablation (MLA) ............................................................................ 9 
1.3 
Immune Dysregulation .............................................................................................. 11 
1.4 
MK-3475 ................................................................................................................... 11 
1.5 
Study Rationale ......................................................................................................... 13 
1.6 
Correlative Studies Background................................................................................ 14 
1.7 
Rationale for Amendment 12 .................................................................................... 14 
2.0 
OBJECTIVES ........................................................................................................... 15 
2.1 
Primary Objectives .................................................................................................... 15 
2.2 
Secondary Objectives ................................................................................................ 15 
3.0 
PATIENT SELECTION ........................................................................................... 15 
3.1 
Inclusion Criteria ....................................................................................................... 15 
3.2 
Exclusion Criteria ...................................................................................................... 17 
3.3 
Inclusion of Women and Minorities .......................................................................... 19 
4.0 
REGISTRATION PROCEDURES ........................................................................... 19 
4.1 
Confirmation of Patient Eligibility ............................................................................ 20 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database ...................... 20 
4.3 
Assignment of UPN .................................................................................................. 20 
4.4 
Phase II Patients ........................................................................................................ 21 
5.0 
TREATMENT PLAN ............................................................................................... 21 
5.1 
Premedication Administration ................................................................................... 22 
5.2 
Agent Administration ................................................................................................ 22 
5.3 
MRI-Guided Laser Ablation ..................................................................................... 22 
5.4 
Phase I Dose Escalation Schema ............................................................................... 23 
5.5 
Definition of MTD, DLT, and Dose Escalation Criteria ........................................... 23 
5.6 
Toxicity, Response, and DLT Evaluations ................................................................ 24 
5.7 
General Concomitant Medication and Supportive Care Guidelines ......................... 25 
5.8 
Women of Childbearing Potential ............................................................................. 26 
5.9 
Duration of Therapy .................................................................................................. 28 
5.10 
Second Course Phase ................................................................................................ 29 
5.11 
Duration of Follow-up ............................................................................................... 30 
6.0 
DOSE DELAYS/DOSE MODIFICATIONS ............................................................ 30 
7.0 
REGULATORY AND REPORTING REQUIREMENTS ....................................... 34 
7.1 
Sponsor-Investigator Reporting Requirements ......................................................... 34 
7.2 
Reporting Requirements for Secondary Sites ........................................................... 38 
7.3 
Exceptions to Expedited Reporting ........................................................................... 39 
8.0 
PHARMACEUTICAL INFORMATION ................................................................. 39 
8.1 
MK-3475 ................................................................................................................... 39 
9.0 
CORRELATIVE STUDIES ...................................................................................... 40 
9.1 
Blood Specimens ....................................................................................................... 40 
9.2 
Cervical Lymph Node Samples - OPTIONAL ......................................................... 41 
9.3 
Tumor Tissue Specimens .......................................................................................... 42 
10.0 
STUDY CALENDAR ............................................................................................... 43 
10.1 
Phase I Study Calendar ............................................................................................. 43 

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10.2 
Phase II Study Calendars........................................................................................... 45 
10.3 
Second Course Phase Calendar ................................................................................. 47 
11.0 
DATA SUBMISSION SCHEDULE ......................................................................... 48 
11.1 
Adverse Event Collection in the Case Report Forms ................................................ 48 
12.0 
MEASUREMENT OF EFFECT ............................................................................... 49 
12.1 
Antitumor Effect – Solid Tumors .............................................................................. 49 
12.2 
Disease Parameters .................................................................................................... 51 
12.3 
Methods for Evaluation of Measurable Disease ....................................................... 51 
13.0 
DATA AND SAFETY MONITORING ................................................................... 54 
14.0 
AUDITING ............................................................................................................... 56 
15.0 
STATISTICAL CONSIDERATIONS ...................................................................... 57 
15.1 
Power Analysis .......................................................................................................... 57 
15.2 
Analysis Plan ............................................................................................................. 58 
15.3 
Phase II Stopping Rules ............................................................................................ 58 
15.4 
Interim Analysis ........................................................................................................ 58 
15.5 
Subgroup analysis ..................................................................................................... 59 
16.0 
MULTICENTER REGULATORY REQUIREMENTS ........................................... 59 
17.0 
REFERENCES .......................................................................................................... 61 
APPENDIX A: Karnofsky Performance Scale ............................................................................. 64 
APPENDIX B: Definitions for Adverse Event Reporting ............................................................ 65 
APPENDIX C: Reporting Timelines ............................................................................................ 67 
APPENDIX D: Washington University Serious Adverse Event Reporting Cover Sheet ............ 70 
 
 

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1.0 
BACKGROUND AND RATIONALE 
 
1.1 
Glioblastoma Multiforme 
 
Glioblastoma multiforme (GBM) is the most common and lethal malignant brain tumor1.  
Despite advanced chemoradiotherapy, median survival is < 15 months, and < 5% of 
patients survive > 5 years1-3.  Several targeted agents including monoclonal antibodies have 
been tested in GBM patients with minimal success4, although these agents have shown 
anti-growth activity in vitro.  This high failure rate is likely due to the redundancy in key 
growth pathways and the molecular and cellular heterogeneity within each tumor.  Another 
explanation is the poor CNS penetration of these drugs due to the blood brain barrier 
(BBB).  As a result, high drug doses were used to achieve therapeutic drug concentrations 
in the CNS, resulting in significant toxicities4.  Thus an outstanding challenge in neuro-
oncology has been to generate drugs that have excellent CNS penetration or methods that 
can compromise the BBB to enhance drug delivery. 
 
1.2 
MRI-guided Laser Ablation (MLA) 
 
MRI-guided laser ablation (MLA) therapy for GBM is a novel minimally invasive surgery 
approved for cytoreductive treatment 
of brain tumors5.  Dr. Eric Leuthardt 
and Dr. Albert Kim performed one of 
the first MLA procedures in the 
country and are experts in this 
technique.  Currently Washington 
University has one of the largest 
clinical experiences using this new 
technology 
(Monteris, 
Winnipeg, 
CA), which has received FDA 
clearance for “use to ablate, necrotize, 
or coagulate soft tissue through 
interstitial irradiation or thermal 
therapy (LITT) in medicine and 
surgery 
in 
the 
discipline 
of 
neurosurgery with 1064 nm lasers,” 
and is marketed under the brand name 
of NeuroBlate.  MLA employs a small 
incision in the scalp and skull, through 
which a thin laser probe is inserted 
and guided by MR imaging to the core 
of a tumor mass where it delivers 
hyperthermic ablation from the core 
to the rim.  The temperature at the 
core can reach 70°C, resulting in 
coagulative necrosis (Fig. 1).  The 

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temperature decrease in the peritumoral region but remains high enough (> 40°C) to induce 
disruption of the BBB as evidenced by new contrast enhancement in this region, while the 
original tumor enhancement is lost due to the heat ablation (Figs. 1 and 2).   
 
General characteristics that 
make the lesion(s) favorable 
to 
treatment 
include 
the 
following: (1) the lesion(s) is 
(are) 
supratentorial 
and 
accessible from a cephalad 
approach (i.e., top one third of 
the head), (2) the lesion(s) is 
(are) 
unilateral, 
(3) 
the 
lesion(s) is (are) relatively 
well circumscribed, (4) the 
volume of lesion(s) can be 
encompassed by two 3-cm 
cylinders (i.e., 2 treatment 
trajectories), 
(5) 
a 
safe 
trajectory can be established 
relative to functional structures (i.e., eloquent cortex and corticospinal tract), and (6) the 
patient’s body habitus can fit into the bore of the MRI. Trajectories are chosen to maximize 
lesion ablation and minimize the number of passes.  MLA will be performed per FDA 
clearance for the NeuroBlate device using 1064nm lasers (for a detailed description of the 
procedure, please refer to these references5-8).  Live intra-procedural treatment monitoring 
is critical for stereotactic LITT in order to assess for real-time tissue temperature and avoid 
treatment beyond the target zone. Fortunately, recent technological advances in 
intraoperative MR imaging when coupled with the NeuroBlate apparatus now enable 
accurate intraoperative thermal monitoring that is necessary for successful and safe 
ablation of intracranial lesions. Intra-procedural repetitive measurements of a T1-weighted 
2-dimensional-FLASH sequence, or similar methods, provide temporally-sensitive 
thermometry measurements necessary to create controlled and conformal lesions (Fig. 1C).   
 
The disrupted BBB may also allow release of tumor antigens into the circulation and influx 
of immune cells into the peritumoral region.  In a series of patients treated with MLA at 
our institution, peritumor enhancement modestly increased 3 days after MLA while FLAIR 
signal changed only minimally, indicating that the post-MLA condition created 
peritumoral BBB disruption but early non-specific inflammatory edema was not a major 
feature.  Interestingly, both peritumoral enhancement and FLAIR signal significantly 
increased 2 weeks after MLA and then persisted for several weeks.  These delayed and 
persistent changes suggest that another effect of the BBB disruption after MLA could be 
the activation of an immune reaction leading to infiltration of tumor-specific lymphocytes 
and the resultant delayed inflammatory reaction. 
 

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1.2.1 Prior Clinical Experience with MLA 
 
We have had one of the largest clinical experiences using MLA in the country.  To 
date we have done more than 80 cases, of which approximately two-thirds are high-
grade glial neoplasms. In regards to adverse events, patients have experienced 
transient aphasia, transient hemiparesis, transient hyponatremia, and a documented 
case of lower extremity deep venous thrombosis. Patients with aphasia or 
hemiparesis improved over time with steroid therapy. Hyponatremia resolved 
spontaneously. One patient experienced fatal meningitis. Subsequent in-depth 
analysis revealed that this patient’s meningitis was due to an operating room 
infrastructure-related contamination and not due to equipment contamination 
related to performance of the MLA procedure. 
 
1.3 
Immune Dysregulation 
 
Recent work has collectively demonstrated striking immune dysregulation in patients with 
GBM, including T cell lymphopenia and anergy, cytokine dysregulation, increased 
regulatory T cell (Treg) populations, and NK cell dysfunction, among others, which reflect 
immunologic compromise and functional impairment9-12.  However, a growing list of 
potential tumor antigens has been identified, suggesting that tumor cell-specific 
recognition by immune cells may be biologically relevant and therapeutically 
exploitable11,13.  Therefore, given the immune dysfunction characterized in GBM patients, 
approaches that potentiate the anti-glioma immune response are particularly exciting.  A 
priori, because the immune system has evolved to recognize a tremendous diversity of 
antigenic epitopes in vertebrates, immune-potentiating efforts may be especially effective 
at targeting the heterogeneity that defines GBM.  Recently, the success of antibody-based 
therapies targeting immune checkpoints14,15 has generated field-wide enthusiasm that 
biological therapies may be broadly effect across many cancer types, including GBM.  Of 
these agents, those targeting the negative regulator proteins CTLA-4 and PD-1/PD-L1 have 
shown clinical efficacy but have not been studied in GBM patients. 
 
1.4 
MK-3475 
 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades16.  Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in 
various malignancies17-21 .  In particular, the presence of CD8+ T-cells and the ratio of 
CD8+ effector T-cells / FoxP3+ regulatory T-cells seems to correlate with improved 
prognosis and long-term survival in many solid tumors. 
 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress 
immune control.  The normal function of PD-1, expressed on the cell surface of activated 
T-cells under healthy conditions, is to down-modulate unwanted or excessive immune 
responses, including autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig 
superfamily member related to CD28 and CTLA-4 which has been shown to negatively 
regulate antigen receptor signaling upon engagement of its ligands (PD-L1 and/or 

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PD-L2)22,23.  The structure of murine PD-1 has been resolved24.  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 22,25-27.  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 proteins28,29.  PD-1 was shown to 
be expressed on activated lymphocytes including peripheral CD4+ and CD8+ T-cells, B-
cells, T regs and Natural Killer cells30,31 .  Expression has also been shown during thymic 
development on CD4-CD8- (double negative) T-cells as well as subsets of macrophages 
and dendritic cells 32 .  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 28,33-35 .  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 28.  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) 36.  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. 
 
Please refer to the IB for preclinical and clinical data. 
 
1.4.1 Rationale for Dosing 
 
An open-label Phase I trial (Protocol 001) is being conducted to evaluate the safety 
and clinical activity of single agent MK-3475.  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 

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were well tolerated and no dose-limiting toxicities were observed.  This first in 
human study of MK-3475 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.  10.0 mg/kg Q2W, the highest dose 
tested in PN001, will be the dose and schedule utilized in Cohorts A, B, C and D 
of this protocol to test for initial tumor activity.  Recent data from other clinical 
studies within the MK-3475 program has shown that a lower dose of MK-3475 and 
a less frequent schedule may be sufficient for target engagement and clinical 
activity. 
 
PK data analysis of MK-3475 administered Q2W and Q3W showed slow systemic 
clearance, limited volume of distribution, and a long half-life (refer to IB).  
Pharmacodynamic data (IL-2 release assay) suggested that peripheral target 
engagement is durable (>21 days).  This early PK and pharmacodynamic data 
provides scientific rationale for testing a Q2W and Q3W dosing schedule.   
 
A population pharmacokinetic analysis has been performed using serum 
concentration time data from 476 patients. Within the resulting population PK 
model, clearance and volume parameters of MK-3475 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.  MK-3475 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 MK-3475 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. the proposed dose regimen 
of 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. 
 
One of the potential immune-related adverse events of a PD-1 inhibitor is increased 
intracranial pressure due to edema resulting from drug-induced tumor-specific 
immune activation.  In addition, mild edema can occasionally occur after MLA.  
Therefore, we have built in a dose escalation plan including a low dose of MK-
3475 of 100 mg Q3W, an intermediate dose of 150 mg Q3W, and a high dose of 
200 mg Q3W in order to determine the safety of this combination. 
 
1.5 
Study Rationale 
 
The BBB is a major obstacle to drug delivery in the treatment of malignant brain tumors 
including GBM. Recent work also detailed immune dysregulation in patients with GBM, 
which is due in part to the BBB limiting tumor antigen presentation and access of immune 

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cells to the tumor.  MLA has been noted to disrupt peritumoral BBB, which could then lead 
to increased access of new tumor antigens to the lymphovascular system and vice versa of 
immune effector cells to the tumor for effective activation of the immune system. 
Therefore, the combination of MK-3475 and MLA as proposed in this protocol is 
hypothesized to create a therapeutic synergy in which MLA increases material access to 
promote immune activation and then MK-3475 maximizes these tumor-specific immune 
reactions to impart effective tumor control. 
 
1.6 
Correlative Studies Background 
 
In both arms of phase II, intratumoral PD-L1 expression will be determined by qRT-PCR 
and/or IHC. TIL profile will be assessed by flow and mass spectrometry or IHC to compare 
to the profile at initial surgery prior to recurrence (when available). Glioma-specific 
immune response will be assessed in cultured TIL, peripheral blood, and sampled cLN 
(where available). Pre- and post-surgery peripheral blood will be assessed by flow 
cytometry through the Center for Human Immunology and Immunotherapy immune 
monitoring core (for Washington University samples) and the Tran lab or the University 
of Florida Brain Tumor Immunotherapy Program (for the UF samples) for markers of T 
cell activation and anergy as well as cytokine profiles. In addition, PD-1-dependent 
signature in glioma cell-specific T cells from the peripheral blood and sampled cLN where 
samples and RNAseq are available can be generated by novel RNAseq methodology 
developed at Washington University and University of Florida in order to characterize the 
PD-1-dependent transcriptional signatures and develop a PD-1 dependent biomarker 
program that will be easily de-convoluted to provide data on serial changes in (a) cell type 
composition and (b) cell type activation programs.  Furthermore, if necessary, serum or 
plasma will be assessed for the presence and level of soluble immune checkpoint 
molecules, cytokines, and chemokines using commercially available multiplex 
immunoassays. 
 
1.7 
Rationale for Amendment 12 
 
Based on recent data44-46, anti-PD1 antibody monotherapy given without or after surgical 
resection showed limited activity and failed to improve PFS or OS in recurrent GBM.  
Although this data was based on early staged small clinical trials, it is emerging knowledge 
in the field that due to the immunosuppressive nature and neoantigen access limitation of 
malignant gliomas that immune checkpoint inhibitors are likely inadequate when used 
alone. As determined during the May 2019 DSMC meeting, this has had an impact on the 
feasibility of completing enrollments in the MK-3475 monotherapy arm.  Therefore, in the 
spirit of minimizing harm, potential or perceived, to subjects and to complete the study in 
a timely manner, patients will no longer be randomized in the phase II portion of this trial. 
After approval of Amendment 12, an additional 20 evaluable patients will be enrolled to 
participate in a single treatment arm with both MLA and MK-3475. Survival endpoints 
will be compared to historical data based on the above existing data. 
 
 

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2.0 
OBJECTIVES 
 
2.1 
Primary Objectives 
 
Phase I: To determine the maximal tolerated dose (MTD) of MK-3475 when combined 
with MLA for the treatment of recurrent malignant gliomas. 
 
Phase II: To determine the progression-free survival (PFS) of patients with recurrent GBM, 
WHO grade IV being treated with MK-3475 plus MLA. 
 
2.2 
Secondary Objectives 
 
1. Phase I: To determine the toxicity profile of MK-3475 in combination with MLA for 
the treatment of recurrent malignant gliomas. 
 
2. Phase II: To determine the overall survival (OS) of patients with recurrent GBM, WHO 
grade IV being treated with MK-3475 plus MLA as compared to historical controls 
treated with MK-3475 alone. 
 
3. Phase II: To assess the anti-glioma immune response before and after MK-3475 with 
MLA. 
 
4. Phase II: To correlate intratumoral expression of PD-L1 and the frequency of glioma 
cell-specific cytotoxic T cells with PFS and OS. 
 
5. Phase II: To identify PD-1-dependent biomarkers in glioma cell-specific T cells that 
negatively correlate with the frequency of glioma cell-specific cytotoxic T cells and 
PFS and OS.  
 
 
3.0 
PATIENT SELECTION 
 
3.1 
Inclusion Criteria 
 
1. Phase I: Histologically confirmed grade III or IV malignant glioma. 
Phase II: Histologically confirmed grade IV malignant glioma (GBM). 
 
Note: GBM variants and secondary GBM, and suspected secondary GBM are allowed 
for both phase I and phase II. 
 
2. Unequivocal evidence of tumor progression as documented by biopsy or brain MRI 
scan per RANO criteria (see Section 12).  
 
3. There must be an interval of at least 12 weeks from the completion of standard frontline 
therapy to study registration unless there is unequivocal evidence for tumor recurrence 
per RANO criteria (see Section 12).  When the interval is less than 12 weeks, the use 

Protocol Amendment 16, 10/06/2021 
 
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of perfusion imaging and/or PET scan is allowed to differentiate between unequivocal 
evidence of tumor recurrence and pseudoprogression.  Standard frontline therapy is as 
described below: 
 
a. For grade IV malignant gliomas (GBM): Standard frontline therapy for newly 
diagnosed GBM must include maximal feasible surgical resection (biopsy alone 
allowed), radiotherapy, and temozolomide chemotherapy.  If the tumor was initially 
diagnosed as either a grade II or III tumor and now has recurred or progressed as a 
grade IV GBM, it will be considered a secondary recurrent grade IV GBM and will 
be eligible for this study as long as prior treatment included maximal feasible 
surgical resection (biopsy alone allowed), radiotherapy, and temozolomide 
chemotherapy. 
 
b. For grade III malignant gliomas with 1p 19q codeletions: Standard frontline therapy 
for newly diagnosed grade III malignant gliomas must include maximal feasible 
surgical resection (biopsy alone allowed), radiotherapy, and chemotherapy (PCV 
or temozolomide).  If the patient did not receive any or all components of the 
standard front line therapy as detailed above for newly diagnosed grade III gliomas 
with 1p 19q codeletions and the tumor then recurred or progressed, s/he must first 
receive at least one prior standard therapy or any appropriate combination of the 
components of standard therapy as detailed above and must experience further 
recurrence or progression before s/he is deemed eligible for this study.  If the tumor 
was initially diagnosed as a grade II glioma with 1p 19q codeletions and now has 
recurred or progressed as a grade III tumor, it will be considered a secondary 
recurrent grade III glioma with 1p 19q codeletions and will be eligible for this study 
as long as prior treatment included maximal feasible surgical resection (biopsy 
alone allowed), radiotherapy, and chemotherapy (PCV or temozolomide). 
 
c. For grade III malignant glioma without 1p 19q codeletions: Standard frontline 
therapy for newly diagnosed grade III malignant gliomas must include maximal 
feasible surgical resection (biopsy alone allowed), radiotherapy, and temozolomide 
chemotherapy.  If the tumor was initially diagnosed as a grade II glioma without 1p 
19q codeletions and now has recurred or progressed as a grade III tumor, it will be 
considered a secondary recurrent grade III glioma without 1p 19q codeletions and 
will be eligible for this study as long as prior treatment included maximal feasible 
surgical resection (biopsy alone allowed), radiotherapy, and temozolomide 
chemotherapy. 
 
4. Candidate for MLA based on the size, location, and shape of the recurrent tumor as 
determined by the performing neurosurgeon. Surgical resection/debulking prior to 
MLA is allowed per standard of care but is not required; if the patient undergoes 
resection or debulking, it must have occurred at least 3 weeks prior to the first dose of 
MK-3475.  
 
For Phase II: if surgical resection/debulking prior to MLA is not indicated, a biopsy of 
the tumor will be done at the same time of MLA to obtain tumor tissue for both 

Protocol Amendment 16, 10/06/2021 
 
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diagnostic purposes and immune monitoring.  
 
5. Patients who have undergone a resection for recurrence will be eligible. In those who 
have undergone a gross total resection, the MLA will be directed at treating a 
peritumoral margin of 0.5-1cm surrounding the resection cavity to disrupt the BBB and 
potentially increase access of MK-3475 to the peritumoral infiltrating glioma cells. 
 
6. At least 18 years of age. 
 
7. Karnofsky ≥ 60% (see Appendix A) 
 
8. Normal bone marrow and organ function as defined below: 
a. ANC ≥ 1,500/mcL 
b. Platelets ≥ 100,000/mcL 
c. Hemoglobin ≥ 9 g/dL or ≥ 5.6 mmol/L 
d. Serum creatinine ≤ 1.5 x IULN OR creatinine clearance by Cockcroft-Gault ≥ 60 
mL/min for patients with serum creatinine > 1.5 x IULN 
e. Serum total bilirubin ≤ 1.5 x IULN OR direct bilirubin ≤ IULN for patients with 
total bilirubin > 1.5 x IULN 
f. AST (SGOT) and ALT (SGPT) ≤ 2.5 x IULN 
g. INR or PT ≤ 1.5 x IULN unless patient is receiving anticoagulant therapy as long 
as PT or PTT is within therapeutic range of intended use of anticoagulants 
h. aPTT ≤ 1.5 x IULN unless patient is receiving anticoagulant therapy as long as PT 
or PTT is within therapeutic range of intended use of anticoagulants 
 
9. Sexually active women of childbearing potential and men must agree to use 
contraceptive methods as described in Section 5.8 prior to study entry, for the duration 
of study participation, and for 120 days after last dose of MK-3475.  Should a woman 
become pregnant or suspect she is pregnant while participating in this study, she must 
inform her treating physician immediately. 
 
10. Patients with the ability to understand and willingness to sign an IRB approved written 
informed consent document will be enrolled into the trial. However, should a patient 
lose their ability to consent while participating in this study and s/he is still receiving 
clinical benefit from participation, s/he may continue on study with the consent of a 
Legally Authorized Representative.  
 
3.2 
Exclusion Criteria 
 
1. Prior treatment with any anti-angiogenic agent (including bevacizumab). 
 
2. Prior treatment with an anti-PD-1, anti-PD-L1, anti-PD-L2, or anti-CD137, or anti-
cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) antibody (including 
ipilimumab or any other antibody or drug specifically targeting T-cell co-stimulation 
or checkpoint pathways). 
 

Protocol Amendment 16, 10/06/2021 
 
page 18 of 70 
3. Prior treatment with a monoclonal antibody within 4 weeks prior to the first dose of 
MK-3475 or has not recovered (i.e. ≤ grade 1 or at baseline) from adverse events due 
to agents administered more than 4 weeks earlier. 
 
4. Prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 
weeks prior to the first dose of MK-3475 or has not recovered (i.e. ≤ grade 1 or at 
baseline) from adverse events due to a previously administered agent. 
 
Note: patients with ≤ grade 2 neuropathy are an exception to this criterion and may 
qualify for the study. 
 
Note: if a patient underwent major surgery, s/he must have recovered adequately from 
the toxicity and/or complications from the intervention prior to starting therapy. 
 
5. Candidate for curative resection or urgent surgical procedure(s) needed. 
 
6. Presence of brainstem lesions or lesions that are less than 5 mm from the hypophysis 
or cranial nerves. 
 
7. Multifocal gliomas that are bilateral. Patients with unilateral multifocal gliomas may 
be eligible if their multifocal disease can be treated effectively and safely in a single 
MLA procedure.  Also note that corpus callosal tumors are eligible even if they are 
bilateral as long as they satisfy the size and shape limits of MLA as determined by the 
performing neurosurgeon. 
 
8. Presence of leptomeningeal metastases. 
 
9. Recent (within 8 weeks) history of CNS hemorrhage unless the hemorrhage is located 
within the tumor that will be removed en total during surgical debulking or ablated 
during MLA. 
 
10. Requires therapeutic doses of anticoagulants unless anticoagulation can be safely 
discontinued before surgery per standard practice (e.g. first DVT for which 
anticoagulation has been at least 3 months and repeat imaging demonstrates resolution 
of DVT) or an IVC filter can be used in place of anticoagulation. Subjects are permitted 
to resume anticoagulation following surgery per discretion of treating physician and/or 
site SOPs. 
 
11. Received prior local therapy (stereotactic radiosurgery, brachytherapy, or carmustine 
wafers) to the proposed area of MLA treatment. 
 
12. Received a live vaccine or live-attenuated vaccine within 30 days prior to the first dose 
of MK-3475.  Administration of killed vaccines is allowed. 
 
13. Currently receiving any other investigational agents or has participated in a study of an 
investigational agent or using an investigational device within 3 weeks of the first dose 

Protocol Amendment 16, 10/06/2021 
 
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of MK-3475. 
 
14. A history of allergic reactions attributed to compounds of similar chemical or biologic 
composition to MK-3475 or other agents used in the study. 
 
15. Dexamethasone > 4 mg at the time of registration. 
 
16. Has a diagnosis of immunodeficiency or is receiving chronic systemic steroid therapy 
(in dosing exceeding 10 mg daily of prednisone equivalent) or any other form of 
immunosuppressive therapy within 7 days prior to the first dose of trial treatment (with 
the exception of daily dexamethasone ≤ 4 mg). 
 
17. Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac 
arrhythmia, uncontrolled hypertension, or psychiatric illness/social situations that 
would limit compliance with study requirements. 
 
18. Has an active autoimmune disease requiring systemic treatment within the past 2 years 
(i.e. with use of disease modifying agents, corticosteroids, or immunosuppressive 
drugs).  Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid 
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form 
of systemic treatment. 
 
19. Has a history of (non-infectious) pneumonitis/interstitial lung disease that required 
steroids or current pneumonitis/interstitial lung disease. 
 
20. Pregnant and/or breastfeeding.  Patient must have a negative serum or urine pregnancy 
test within 2 weeks of study entry. 
 
21. Known history of hepatitis B (defined as hepatitis B surface antigen [HBsAg] reactive) 
or known active hepatitis C virus (defined as HCV RNA [qualitative] is detected) 
infection. 
 
22. Known history of active TB (bacillus tuberculosis). 
 
23. Known history of HIV (HIV 1/2 antibodies). 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial. 
 
 
4.0 
REGISTRATION PROCEDURES 
 
Patients must not start any protocol intervention prior to registration through the Siteman 
Cancer Center. 

Protocol Amendment 16, 10/06/2021 
 
page 20 of 70 
 
The following steps must be taken before registering patients to this study: 
 
1. Confirmation of patient eligibility by Washington University 
2. Registration of patient in the Siteman Cancer Center OnCore database 
3. Assignment of unique patient number (UPN) 
 
Once the patient has been entered in the Siteman Cancer Center OnCore database, the WUSM 
coordinator will forward verification of enrollment and the UPN via email. 
 
4.1 
Confirmation of Patient Eligibility 
 
Confirm patient eligibility by collecting the information listed below and scanning and 
emailing it to the research coordinator listed in the Siteman Cancer Center Clinical Trials 
Core Protocol Procedures for Secondary Sites packet at least one business day prior to 
registering patient: 
 
1. Your name and contact information (telephone number, fax number, and email 
address) 
2. Your site PI’s name, the registering MD’s name, and your institution name 
3. Patient’s race, sex, and DOB 
4. Three letters (or two letters and a dash) for the patient’s initials 
5. Currently approved protocol version date 
6. Copy of signed consent form (patient name may be blacked out) 
7. Planned date of enrollment 
8. Completed eligibility checklist, signed and dated by a member of the study team 
9. Copy of appropriate source documentation confirming patient eligibility 
 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database 
 
Registrations may be submitted Monday through Friday between 8am and 5pm CT. Urgent 
late afternoon or early morning enrollments should be planned in advance and coordinated 
with the Washington University research coordinator.  Registration will be confirmed by 
the research coordinator or his/her delegate by email within one business day. Verification 
of eligibility and registration should be kept in the patient chart. 
 
All patients at all sites must be registered through the Siteman Cancer Center OnCore 
database at Washington University. 
 
4.3 
Assignment of UPN 
 
Each patient will be identified with a unique patient number (UPN) for this study.  All data 
will be recorded with this identification number on the appropriate CRFs. 
 

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4.4 
Phase II Patients  
 
As of Amendment 12, patients enrolled in the phase II portion of this trial will no longer 
be randomized. After registration and surgery (if applicable), these patients will undergo 
MLA followed by MK-3475 treatment.  
 
 
5.0 
TREATMENT PLAN 
 
Patients enrolling in phase I will receive the first dose of MK-3475 will be given not more than 1 
week after MLA, and it will be administered every 3 weeks +/- 4 days thereafter until progression 
or unacceptable toxicity. 
 
The phase II dose will be determined during the phase I portion of this study.  Patients enrolling 
in phase II will need to have tissue available for diagnostic purpose and for immunological 
monitoring. Surgical resection/debulking is per standard of care and optional for the purpose of 
this study and the performing neurosurgeon will determine whether each patient will undergo 
surgery.  
 
All phase II patients will undergo MLA followed by MK-3475.  Patients who are planning to have 
surgical resection/debulking will have MLA performed at least 3 weeks but not more than 6 weeks 
after surgical resection/debulking.   
 
Patients who are not planning to have surgical resection/debulking will have a biopsy for tissue 
diagnosis and immune monitoring during MLA. If there is a patient with suspected GBM and the 
pathology results are not available by the time the patient is scheduled to start treatment with MK-
3475, s/he will not be treated and will be removed from study. “Determined to be ineligible” will 
be listed as the “Reason Off Therapy” in the OnCore database. The date pathology results were 
reviewed and/or the date the final determination about eligibility was made will be used as the 
“Date Off Therapy.” Patients removed from study due to suspected GBM not being confirmed 
through pathology will not be included in the patient total enrolled and will be replaced. 
 
All patients will receive their first dose of MK-3475 not more than 1 week after MLA (if 
applicable) or biopsy, and then every 3 weeks +/- 4 days thereafter.  For patients who had surgical 
debulking but did not undergo MLA, MK-3475 will be started at least 3 weeks but not more than 
6 weeks after surgical debulking, and then every 3 weeks +/- 4 days thereafter.  Dosing of MK-
3475 will continue at the dose determined by phase I until progression or unacceptable toxicity. 
 
For all phase II patients, research blood will be drawn prior to MLA and immediately prior to the 
first dose of MK-3475.  Subsequently, research blood will be drawn at doses 2, 4, 6, 9, 18, 36, and 
at the end of treatment.  In addition, an optional ipsilateral cervical lymph node may be sampled 
by FNA prior to or at the time of surgical procedure (including surgical debulking, MLA, or 
biopsy) and again 6 weeks after surgery. Those patients who, in the event of surgical intervention 
for clinical reasons of a radiographically progressing tumor, undergo a subsequent surgical 
procedure (whether biopsy or resection) will have tissue collected for correlative analysis after 
histopathologic diagnosis of recurrent GBM.  

Protocol Amendment 16, 10/06/2021 
 
page 22 of 70 
 
Additionally, for patients enrolled to phase II who have surgical intervention for a radiographically 
progressing tumor but subsequent surgical pathology demonstrating a predominant immune-
mediated reaction with no obvious progression of tumor, such subjects will be deemed not to 
have progressed and be allowed to resume assigned study treatment at a time deemed safe by the 
treating physician, but no later than 8 weeks from the surgery. 
  
5.1 
Premedication Administration 
 
No premedications are required, but antiemetics may be given as per institutional practice 
if needed. 
 
5.2 
Agent Administration 
 
MK-3475 will be given intravenously over the course of 30 minutes (-5 min/+10 min) on 
an outpatient basis.  The starting dose for the phase I portion of the study is 100 mg every 
3 weeks; please refer to the dose escalation schema in Section 5.4 for dosing during phase 
I.  As determined during the phase I portion of the study, the phase II dose of MK-3475 for 
all patients is 200 mg.  In the phase I portion of this study, MK-3475 will be given every 3 
weeks starting no more than 1 week after MLA.  In the phase II portion of this study, MK-
3475 will be given every 3 weeks beginning no more than 1 week (+/- 3 days) after MLA. 
 
5.3 
MRI-Guided Laser Ablation 
 
MLA is a minimally invasive laser surgery, which employs a small incision in the scalp 
and skull, through which a thin laser probe is inserted and guided by MR imaging to the 
core of the tumor mass where it delivers hyperthermic ablation from the core to the rim.  
The maximal temperature in the core can reach 70°C, resulting in coagulative necrosis.  
MLA will be performed as per standard of care. In those who have undergone a gross total 
resection, the MLA will be directed at treating a peritumoral margin of 0.5-1cm 
surrounding the resection cavity to disrupt the BBB and potentially increase access of MK-
3475 to the peritumoral infiltrating glioma cells. 
 
After initiation of anesthesia and placement of an MRI-compatible head holder, a MRI-
guided navigation system is registered using preoperative MRI to define the centroid of the 
target lesion. After inserting the probe in the lesion and positioning the patient in the MRI 
scanner, the laser (1064 nm wavelength, 10-14 Watts power, pulse duration 2.2 seconds 
on, 1.7 seconds off) is activated and real-time thermal isodose MRI is monitored to achieve 
sufficient treatment (no limit to exposure duration). The NeuroBlate software provides 
predictive thermal dosage lines.  Yellow lines for 43 °C are set for 2 min and blue lines for 
43°C for 10 min to estimate ablation volume. These thermal dosage lines will be used to 
establish treatment duration, movement of the probe, and additional trajectories depending 
on the location, shape and size of the target lesion. For some patients, additional trajectories 
are chosen preoperatively; for other patients, additional trajectories are chosen based on 
thermal dosage lines of the initial trajectory. After successful ablation, the probe is removed 
and the wound is closed in routine fashion.  Patients are generally hospitalized for one or 

Protocol Amendment 16, 10/06/2021 
 
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two days after the procedure, and monitoring will take place as described below. 
 
Perioperative care will be consistent with current standard care for patients undergoing 
craniotomy or biopsy of a brain tumor.  This includes either ICU or step-down unit post-
operative stay. Typically, these patients are placed on perioperative steroids to reduce the 
risk of post-treatment edema. Also, the patients are placed on prophylactic antiepileptics 
(i.e. Keppra) to mitigate perioperative and post-treatment seizures. During post-operative 
recovery, patients have routine neurological exams per the care team.  In the ICU this is on 
an hourly basis; in the stepdown unit this is every two hours. Additionally, post-operative 
labs are obtained immediately after surgery and on the following day to ensure there are 
no metabolic abnormalities. They are also seen in the morning and in the late afternoon by 
the neurosurgical team. 
 
5.4 
Phase I Dose Escalation Schema 
 
Dose Escalation Schedule 
Dose Level 
MK-3475 Dose 
Level 1 (Starting Dose) 
100 mg IV q3wks 
Level 2 
150 mg IV q3wks 
Level 3 
200 mg IV q3wks 
 
A decision regarding dose escalation will not take place until all patients in the Level 1 
cohort have received the post-MLA dose of MK-3475 and the Principal Investigator has 
been able to review all toxicities for 3 weeks after that dose. 
 
NOTE: No later than two weeks following the completion of the first two months of 
treatment for the first 3 patients enrolled in this trial, interim safety data must be provided 
to the FDA as a formal IND submission.  This submission should include a listing of all 
AEs of grade 2 or greater severity observed.  For all AEs of grade 3 or greater severity, and 
for all SAEs, a narrative description of the events should be included, along with the timing 
of the event in relationship to study treatment, interventions, duration, and outcome.  
 
5.5 
Definition of MTD, DLT, and Dose Escalation Criteria 
 
5.5.1 Definition of Maximum Tolerated Dose (MTD) 
 
The maximum tolerated dose (MTD) is defined as the dose level immediately 
below the dose level at which 2 patients of a cohort (of 2 to 6 patients) experience 
dose-limiting toxicity during the first cycle.  Dose escalations will proceed until the 
MTD has been reached or, failing that, 200 mg q3wks will be considered the MTD. 
 
5.5.2 Dose Limiting Toxicities (DLTs) 
 
DLT is defined as any of the following that occur during the time frame between 
the first dose of MK-3475 and 3 weeks after the second dose of MK-3475 that are 
attributed as possibly, probably, or definitely related to the study treatment: 

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• Grade 2 or greater diarrhea 
• Autoimmune hypophysitis 
• Grade 3 or greater hepatitis 
• Grade 2 or greater pneumonitis 
• Significant intracranial edema requiring high-dose steroid (defined as > 16 
mg/day and/or inability to taper steroids to ≤ 8 mg/day within 4 weeks due 
to recurrent symptoms attributable to excessive cranial edema) 
• Grade 3 or greater non-hematologic toxicity 
• Grade 3 or greater hematologic toxicity 
 
5.5.3 Dose Escalation Criteria 
 
Dose escalations will proceed as follows after the occurrence of DLT: 
Number of Patients with 
DLT at a Given Dose Level 
Escalation Decision Rule 
0 out of 3 
Enter 3 patients at the next dose level 
2 or 3 out of 3 
Dose escalation will be stopped and 3 patients will be entered 
at the next lowest dose level if only 3 patients were treated 
previously at that dose. 
1 out of 3 
• Enter at least 3 more patients at this dose level. 
• If 0 of these 3 patients experience DLT, proceed to the next 
dose level. 
• If 1 or more of this group suffer DLT, then dose escalation is 
stopped and 3 additional patients will be entered at the next 
lowest dose level if only 3 patients were treated previously at 
that dose. 
≤ 1 out of 6 at highest dose 
level below the maximally 
administered dose 
This is generally the recommended phase II dose.  At least 6 
patients must be entered at the recommended phase II dose. 
 
5.6 
Toxicity, Response, and DLT Evaluations 
 
All patients who receive any treatment with MK-3475 are evaluable for toxicity.  Patients 
are evaluated from first receiving study treatment until a 30-day follow-up after the 
conclusion of treatment or death. 
 
All phase II patients are evaluable for disease response unless they come off study before 
any disease assessment. 
 
A phase I patient is evaluable for DLT assessment from the time of the first dose of MK-
3475 through 3 weeks following the second dose of MK-3475.  Once the patient has 
received his/her third dose of MK-3475, s/he will no longer be evaluated for DLTs.  
Patients who do not incur a DLT and who receive only a single dose of MK-3475 or who 
do not undergo MLA should be considered not evaluable for DLT and should be replaced. 
 

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5.7 
General Concomitant Medication and Supportive Care Guidelines 
 
All treatments that the investigator considers necessary for a patient’s welfare may be 
administered at the discretion of the investigator in keeping with the community standards 
of medical care. 
 
Patients are prohibited from receiving the following therapies while in screening for and 
enrolled in this trial: 
• Anti-cancer systemic chemotherapy or biological therapy.  Treatment with 
bevacizumab as a steroid-sparing agent is allowed on trial. 
• Immunotherapy not specified in this protocol 
• Chemotherapy not specified in this protocol 
• Investigational agents other than MK-3475 
• Radiation therapy 
• Live vaccines within 30 days prior to the first dose of 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. 
 
5.7.1 Supportive Care Guidelines for Infusion Reactions 
 
Pembrolizumab may cause severe or life-threatening reactions including severe 
hypersensitivity or anaphylaxis.  Signs and symptoms usually develop during or 
shortly after drug infusion and generally resolve completely within 24 hours of 
completion of infusion.  
 
The table below shows treatment guidelines for patients who experience an infusion 
reaction associated with administration of MK-3475. 
 
NCI CTCAE Grade 
Treatment 
Premedication at 
subsequent dosing 
Grade 1 
Mild reaction; infusion interruption not 
indicated; intervention not indicated 
Increase monitoring of vital signs as medically indicated until 
the subject is deemed medically stable in the opinion of the 
investigator. 
None 
Grade 2 
Requires infusion interruption but responds 
promptly to symptomatic treatment (e.g., 
antihistamines, NSAIDS, narcotics, IV 
fluids); prophylactic medications indicated 
for < =24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may include but is 
not limited to: IV fluids, antihistamines, NSAIDS, 
acetaminophen, Narcotics 
 
Increase monitoring of vital signs as medically indicated until 
the subject is deemed medically stable in the opinion of the 
investigator. 
If symptoms resolve within one hour of stopping drug 
infusion, the infusion may be restarted at 50% of the original 
infusion rate (e.g. from 100 mL/hr to 50 mL/hr).  Otherwise 
dosing will be held until symptoms resolve and the subject 
should be premedicated for the next scheduled dose. 
 
Subjects who develop Grade 2 toxicity despite adequate 
premedication should be permanently discontinued from 
further trial treatment administration. 
Subject may be 
premedicated 1.5h 
(± 30 minutes) prior 
to infusion of MK-
3475 with: 
 
Diphenhydramine 
50 mg po (or 
equivalent dose of 
antihistamine). 
 
Acetaminophen 
500-1000 mg po (or 
equivalent dose of 
antipyretic). 

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NCI CTCAE Grade 
Treatment 
Premedication at 
subsequent dosing 
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. 
 
5.8 
Women of Childbearing Potential 
 
Women of childbearing potential (defined as women with regular menses, women with 
amenorrhea, women with irregular cycles, women using a contraceptive method that 
precludes withdrawal bleeding, and women who have had a tubal ligation) are required to 
have a negative serum or urine pregnancy test within 72 hours prior to the first dose of 
MK-3475.   
 
Pembrolizumab may have adverse effects on a fetus in utero. 
 
For this trial, male subjects will be considered to be of non-reproductive potential if they 
have azoospermia (whether due to having had a vasectomy or due to an underlying medical 
condition).   
 
A woman is considered fertile following menarche and until becoming post-menopausal 
unless permanently sterile (see below).  Women in the following categories are not 
considered of childbearing potential: 
 
• Premenarchal 
• Premenopausal female with 1 of the following: 
o Documented hysterectomy 
o Documented bilateral salpingectomy 
o Documented bilateral oophorectomy 
Note:  Documentation can come from the site personnel’s review of the 
participant’s medical records, medical examination, or medical history interview. 
 
• Postmenopausal female 
o A postmenopausal state is defined as no menses for 12 months without an 
alternative medical cause.  
 A high follicle stimulating hormone (FSH) level in the postmenopausal 
range may be used to confirm a postmenopausal state in women not using 
hormonal contraception or hormonal replacement therapy (HRT). However, 

Protocol Amendment 16, 10/06/2021 
 
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in the absence of 12 months of amenorrhea, confirmation with two FSH 
measurements in the postmenopausal range is required.  
o Females on HRT and whose menopausal status is in doubt will be required to use 
one of the non-hormonal highly effective contraception methods if they wish to 
continue their HRT during the study. Otherwise, they must discontinue HRT to 
allow confirmation of postmenopausal status before study enrollment. 
 
Contraception Requirements 
Subjects should be informed that taking the study medication may involve unknown risks 
to the fetus (unborn baby) if pregnancy were to occur during the study.  In order to 
participate in the study subjects of childbearing potential must adhere to the contraception 
requirement (described below) from the day of study medication initiation (or 14 days prior 
to the initiation of study medication for oral contraception) throughout the study period up 
to 120 days after the last dose of trial therapy.  If there is any question that a subject of 
childbearing potential will not reliably comply with the requirements for contraception, 
that subject should not be entered into the study. 
 
Male Participants: 
Male participants with female partners of childbearing potential are eligible to participate 
if they agree to one of the following during the protocol defined timeframe:  
• Be abstinent from penile-vaginal intercourse as their usual and preferred lifestyle 
(abstinent on a long term and persistent basis) and agree to remain abstinent 
• Use a male condom plus partner use of a contraceptive method with a failure rate 
of <1% per year as described in the table below when having penile-vaginal 
intercourse with a woman of childbearing potential who is not currently pregnant. 
o Note: Men with a pregnant or breastfeeding partner must agree to remain 
abstinent from penile-vaginal intercourse or use a male condom during each 
episode of penile penetration. 
 
Female Participants 
Female participants of childbearing potential are eligible to participate if they agree to use 
a highly effective method of contraception consistently and correctly as described in the 
table below during the protocol-defined timeframe.  
 
Highly Effective Contraceptive Methods That Are User Dependent a  
Failure rate of < 1% per year when used consistently and correctly. 
● Combined (estrogen- and progestogen-containing ) hormonal contraception b, c 
○ Oral  
○ Intravaginal  
○ Transdermal  
○ Injectable 
● Progestogen-only hormonal contraception b, c 
○ Oral  
○ Injectable  
Highly Effective Methods That Have Low User Dependency 
Failure rate of <1% per year when used consistently and correctly. 

Protocol Amendment 16, 10/06/2021 
 
page 28 of 70 
● Progestogen- only contraceptive implant b, c  
● Intrauterine hormone-releasing system (IUS) b  
● Intrauterine device (IUD) 
● Bilateral tubal occlusion 
● Vasectomized partner  
A vasectomized partner is a highly effective contraception method provided that the 
partner is the sole male sexual partner of the WOCBP and the absence of sperm has been 
confirmed.  If not, an additional highly effective method of contraception should be used.
● Sexual abstinence  
Sexual abstinence is considered a highly effective method only if defined as refraining 
from heterosexual intercourse during the entire period of risk associated with the study
treatment.  The reliability of sexual abstinence needs to be evaluated in relation to the 
duration of the study and the preferred and usual lifestyle of the participant.)  
Notes:  
Use should be consistent with local regulations regarding the use of contraceptive methods for participants 
of clinical studies.  
 
a) Typical use failure rates are lower than perfect-use failure rates (i.e. when used consistently and 
correctly).  
b) If hormonal contraception efficacy is potentially decreased due to interaction with study treatment, 
condoms must be used in addition to the hormonal contraception during the treatment period and for at 
least [X days, corresponding to time needed to eliminate study treatment plus 30 days for study treatments
with genotoxic potential] after the last dose of study treatment. 
c) If locally required, in accordance with Clinical Trial Facilitation Group (CTFG) guidelines, acceptable 
hormonal contraceptives are limited to those which inhibit ovulation.  
 
Pregnancy Testing 
WOCBP should only be included after a negative highly sensitive urine or serum 
pregnancy test.  
 
Following initiation of treatment, pregnancy testing will be performed whenever an 
expected menstrual cycle is missed or when pregnancy is otherwise suspected, after the 
last dose of study treatment, and as required locally. 
 
Pregnancy testing will be performed whenever an expected menstrual cycle is missed or 
when pregnancy is otherwise suspected. 
 
5.9 
Duration of Therapy 
 
If at any time the constraints of this protocol are considered to be detrimental to the 
patient’s health and/or the patient no longer wishes to continue protocol therapy, the 
protocol therapy should be discontinued and the reason(s) for discontinuation documented 
in the case report forms. 
 
In the absence of treatment delays due to adverse events, treatment may continue for up to 
24 months (35 cycles; the number of treatments is calculated starting with the first dose) 
or until one of the following criteria applies: 
 

Protocol Amendment 16, 10/06/2021 
 
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• Documented and confirmed disease progression 
• Death 
• Adverse event(s) that, in the judgment of the investigator, may cause severe or 
permanent harm or which rule out continuation of study drug 
• General or specific changes in the patient’s condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
• Suspected pregnancy 
• Serious non-compliance with the study protocol 
• Lost to follow-up 
• Patient withdraws consent 
• Investigator removes the patient from study 
• The Siteman Cancer Center decides to close the study 
 
Patients who prematurely discontinue treatment for any reason will be followed as 
indicated in the study calendar.  
 
Patients currently on pembrolizumab beyond the 2 year/35 cycle limit at the time of the 
approval of Amendment 13 may continue to receive pembrolizumab unless there is 
progression, toxicity or agreement by the patient and PI to come off therapy.  
 
Participants who discontinue pembrolizumab after receiving 35 doses are eligible for 
retreatment with pembrolizumab if they progress during follow-up provided they meet the 
requirements detailed in Section 5.10. Participants may receive an additional 17 cycles (12 
months) of pembrolizumab during the Second Course Phase (Retreatment). 
 
5.10 
Second Course Phase 
 
All participants who discontinue treatment with pembrolizumab with at least stable disease 
are eligible for 17 further cycles (approximately 1 year) of pembrolizumab if they progress 
during follow-up.  This retreatment is termed the Second Course Phase of this study and is 
only available if all of the following conditions are satisfied: 
1. The study is open at the time the patient qualifies for retreatment. 
2. The patient experienced investigator-determined radiographic disease progression by 
RANO criteria (see Section 12) during the follow-up period after stopping initial 
treatment with pembrolizumab and: 
a. No new anticancer treatment was administered after the last dose of 
pembrolizumab and 
b. The participant meets all of the inclusion criteria for lab parameters and 
performance status 
3. The patient EITHER: 
a. Had stable disease, partial response, or complete response based on RANO 
criteria and discontinued pembrolizumab after completion of 35 doses 
(approximately 2 years) for reasons other than disease progression or 
intolerability or 
b. Discontinued pembrolizumab after attaining an investigator-determined 

Protocol Amendment 16, 10/06/2021 
 
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confirmed complete response by RANO criteria, received at least 8 cycles of 
pembrolizumab prior to discontinuation, and received at least 2 treatments with 
pembrolizumab beyond the date when initial CR was declared 
An objective response or disease progression that occurs during the Second Course Phase 
for a participant will not be counted as an event for the primary analysis of either endpoint 
in this study. 
 
5.11 
Duration of Follow-up 
 
Patients will have one follow-up visit 4 weeks (+/- 1 week) after stopping treatment.  They 
will then be followed for up to 2 years for survival.  Routine follow-up will be conducted 
as per standard of care but is not mandated by this protocol.  Patients removed from study 
for unacceptable adverse events will be followed until resolution or stabilization of the 
adverse event. 
 
 
6.0 
DOSE DELAYS/DOSE MODIFICATIONS 
 
AEs associated with pembrolizumab exposure may represent an immunologic etiology. These 
immune-related AEs (irAEs) may occur shortly after the first dose or several months after the last 
dose of pembrolizumab treatment and may affect more than on body system simultaneously. 
Therefore, early recognition and initiation of treatment is critical to reduce complications.  
 
Based on existing clinical study data, most irAEs were reversible and could be managed with 
interruptions of pembrolizumab, administration of corticosteroids and/or other supportive care. 
For suspected irAEs, ensure adequate evaluation to confirm etiology or exclude other causes. 
Additional procedures or tests such as bronchoscopy, endoscopy, skin biopsy may be included as 
part of the evaluation. Based on the severity of irAEs, withhold or permanently discontinue 
pembrolizumab and administer corticosteroids. Dose modification and toxicity management 
guidelines for irAEs associated with pembrolizumab are provided in the table below. 

Protocol Amendment 16, 10/06/2021 
 
page 31 of 70 
 
General instructions: 
1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 weeks. 
2. For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to Grade 1 or 0 and corticosteroid has been 
tapered. Pembrolizumab should be permanently discontinued if AE does not resolve within 12 weeks of last dose or corticosteroids cannot be reduced to ≤ 10 mg 
prednisone or equivalent per day within 12 weeks.  
3. For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other immunosuppressive treatment should be initiated if 
irAEs cannot be controlled by corticosteroids. 
 
Immune-related 
AEs 
Toxicity grade or 
conditions 
(CTCAEv4.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies  
Monitor and follow-up  
Pneumonitis  
Grade 2 
Withhold  
• Administer corticosteroids 
(initial dose of 1 to2mg/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 
• 
 
Grade 3 or 4, or 
recurrent grade 2 
Permanently discontinue 
Diarrhea / colitis  
Grade 2 or 3 
Withhold 
• Administer corticosteroids 
(initial dose of 1 to2mg/kg 
prednisone or equivalent) 
followed by taper 
 
• 
Monitor participants for signs and symptoms of 
enterocolitis (i.e. diarrhea, abdominal pain, blood 
or mucus in stool with or without fever) and of 
bowel perforation (i.e. peritoneal signs and ileus). 
• 
Participants with ≥ Grade 2 diarrhea suspecting 
colitis should consider GI consultation and 
performing endoscopy to rule out colitis.  
• 
Participants with diarrhea/colitis should be 
advised to drink liberal quantities of clear fluids.  
If sufficient oral fluid intake is not feasible, fluid 
and electrolytes should be substituted via IV 
infusion. 
Grade 4 or recurrent 
Grade 3 
Permanently discontinue 
AST / ALT 
elevation or 
Increased Bilirubin 
Grade 2a 
Withhold 
• Administer corticosteroids 
(initial dose of 0.5 to1mg/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 3b or 4c  
Permanently discontinue 
• Administer corticosteroids 
(initial dose of 1to 2mg/kg 
prednisone or equivalent) 
followed by taper 

Protocol Amendment 16, 10/06/2021 
 
page 32 of 70 
Type 1 diabetes 
mellitus (T1DM) or 
Hyperglycemia 
 
Newly onset T1DM or  
Grade 3 or 4 
hyperglycemia 
associated with evidence 
of β-cell failure 
Withholdd 
• Initiate insulin replacement therapy for 
participants with T1DM  
• Administer anti-hyperglycemic in 
participants with hyperglycemia  
 
• 
Monitor participants for hyperglycemia 
or other signs and symptoms of 
diabetes. 
Hypophysitis 
Grade 2 
Withhold 
• Administer corticosteroids and initiate 
hormonal replacements as clinically 
indicated.   
 
• 
Monitor for signs and symptoms of 
hypophysitis (including 
hypopituitarism and adrenal 
insufficiency)  
Grade 3 or 4  
Withhold or permanently 
discontinued  
Hyperthyroidism  
Grade 2 
Continue  
• Treat with nonselective beta-blockers 
(e.g. propranolol) or thionamides as 
appropriate  
• 
Monitor for signs and symptoms of 
thyroid disorders.  
 
Grade 3 or 4  
Withhold or  
Permanently discontinued 
Hypothyroidism 
Grade 2, 3, or 4 
Continue  
• Initiate thyroid replacement hormones 
(e.g. levothyroxine or liothyroinine) 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 to2mg/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 
• Based on severity of AE administer 
corticosteroids  
• 
Ensure adequate evaluation to confirm 
etiology or exclude other causes 
 
Grade 3 
Withhold or discontinue 
based on the type of evente   
Grade 4 or recurrent 
Grade 3  
Permanently discontinue 

Protocol Amendment 16, 10/06/2021 
 
page 33 of 70 
aAE(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 to 5.0 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). 
 
For information on the management of adverse events, see Section 5.7. 

Protocol Amendment 16, 10/06/2021 
 
page 34 of 70 
7.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
The entities providing oversight of safety and compliance with the protocol require reporting as 
outlined below.  Please refer to Appendix B for definitions and Appendix C for a grid of reporting 
timelines. 
 
Adverse events will be tracked from start of treatment through 30 days following the last day of 
study treatment.  SAEs will be tracked for 90 days following the last dose of study treatment.  All 
adverse events must be recorded on the toxicity tracking case report form. This includes all adverse 
events: 
• belonging to the category “Nervous System Disorders” in the CTCAE version 4.03, 
regardless of attribution 
• experienced by the patient during the administration of MK-3475, regardless of attribution 
• that are CTCAE version 4.03 gradable laboratory values, regardless of attribution 
 
The only adverse events that will not be recorded are adverse events that are clearly related to 
MLA and/or surgery AND ALSO not related to MK-3475. 
 
Refer to the data submission schedule in Section 11 for instructions on the collection of AEs in the 
EDC. 
 
Reporting requirements for Washington University study team may be found in Section 7.1.  
Reporting requirements for secondary site study teams participating in Washington University-
coordinated research may be found in Section 7.3. 
 
7.1 
Sponsor-Investigator Reporting Requirements 
 
7.1.1 Reporting to the Human Research Protection Office (HRPO) at 
Washington University 
 
Reporting will be conducted in accordance with Washington University IRB 
Policies. 
 
Pre-approval of all protocol exceptions must be obtained prior to implementing the 
change. 
 
7.1.2 Reporting to the Quality Assurance and Safety Monitoring 
Committee (QASMC) at Washington University 
 
The Washington University Sponsor-Investigator (or designee) is required to notify 
the QASMC of any unanticipated problem involving risks to participants or others 
occurring at WU or any BJH or SLCH institution that has been reported to and 
acknowledged by HRPO.  (Unanticipated problems reported to HRPO and 
withdrawn during the review process need not be reported to QASMC.) 
 
QASMC must be notified within 10 days of receipt of IRB acknowledgment via 

Protocol Amendment 16, 10/06/2021 
 
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email to qasmc@wustl.edu.  Submission to QASMC must include the myIRB form 
and any supporting documentation sent with the form. 
 
For events that occur at secondary sites, the Washington University Sponsor 
Investigator (or designee) is required to notify the QASMC within 10 days of 
Washington University notification via email to qasmc@wustl.edu.  Submission to 
QASMC must include either the myIRB form and supporting documentation or (if 
not submitted to myIRB) the date of occurrence, description of the event, whether 
the event is described in the currently IRB approved materials, the event outcome, 
determination of relatedness, whether currently enrolled participants will be 
notified, and whether the informed consent document and/or any study procedures 
will be modified as a result of this event. 
 
7.1.3 Reporting to Secondary Sites 
 
The Washington University Sponsor-Investigator (or designee) will notify the 
research team at each secondary site of all unanticipated problems involving risks 
to participants or others that have occurred at other sites within 10 working days 
of the occurrence of the event or notification of the Sponsor-Investigator (or 
designee) of the event.  This includes events that take place both at Washington 
University and at other secondary sites, if applicable. 
 
7.1.4 Reporting to the FDA 
 
The conduct of the study will comply with all FDA safety reporting requirements.  
PLEASE NOTE THAT REPORTING REQUIREMENTS FOR THE FDA 
DIFFER FROM REPORTING REQUIREMENTS FOR HRPO/QASMC.  It 
is the responsibility of the Washington University principal investigator to report 
any unanticipated problem to the FDA as follows: 
 
• Report any unexpected fatal or life-threatening suspected adverse reaction 
(refer to Appendix B for definitions) no later than 7 calendar days after 
initial receipt of the information.   
• Report a suspected adverse reaction that is both serious and unexpected 
(SUSAR, refer to Appendix B) no later than 15 calendar days after it is 
determined that the information qualifies for reporting.  Report an adverse 
event (refer to Appendix B) as a suspected adverse reaction only if there is 
evidence to suggest a causal relationship between the drug and the adverse 
event, such as: 
o A single occurrence of an event that is uncommon and known to be 
strongly associated with drug exposure 
o One or more occurrences of an event that is not commonly associated 
with drug exposure but is otherwise uncommon in the population 
exposed to the drug 
o An aggregate analysis of specific events observed in a clinical trial that 
indicates those events occur more frequently in the drug treatment group 

Protocol Amendment 16, 10/06/2021 
 
page 36 of 70 
than in a concurrent or historical control group 
• Report any findings from epidemiological studies, pooled analysis of 
multiple studies, or clinical studies that suggest a significant risk in humans 
exposed to the drug no later than 15 calendar days after it is determined that 
the information qualifies for reporting. 
• Report any findings from animal or in vitro testing that suggest significant 
risk in humans exposed to the drug no later than 15 calendar days after it is 
determined that the information qualifies for reporting.  
• Report any clinically important increase in the rate of a serious suspected 
adverse reaction of that listed in the protocol or IB within 15 calendar days 
after it is determined that the information qualifies for reporting. 
 
Submit each report as an IND safety report in a narrative format or on FDA Form 
3500A or in an electronic format that FDA can process, review, and archive.  Study 
teams must notify the Siteman Cancer Center Protocol Development team of each 
potentially reportable event within 1 business day after initial receipt of the 
information, and must bring the signed 1571 and FDA Form 3500A to the Siteman 
Cancer Center Protocol Development team no later than 1 business day prior to the 
due date for reporting to the FDA. 
 
Each notification to FDA must bear prominent identification of its contents (“IND 
Safety Report”) and must be transmitted to the review division in the Center for 
Drug Evaluation and Research (CDER) or in the Center for Biologics Evaluation 
and Research (CBER) that has responsibility for review of the IND.  Relevant 
follow-up information to an IND safety report must be submitted as soon as the 
information is available and must be identified as such (“Follow-up IND Safety 
Report”). 
 
7.1.5 Reporting to Merck & Co., Inc. 
 
The WU PI shall forward to Merck’s Global Safety group (FAX 215-661-6229) 
any SAE and SUSAR information, including, but not limited to, all initial and 
follow-up information involving any study subject in the study within 24 hours 
(whichever comes first) of learning of the SAE or SUSAR. 
 
“Adverse Event” or “AE” shall mean any untoward medical occurrence in a Study 
subject who is administered the Study Drug regardless of whether or not a causal 
relationship with the Study Drug exists.  By way of example and without limitation, 
an AE can be any unfavorable and unintended sign (for example, an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of the 
Study Drug. 
  
“Serious Adverse Event” or “SAE” shall mean any untoward medical occurrence 
in a Study subject who is administered the Study Drug that results in death, a life-
threatening drug experience, requires inpatient hospitalization or prolongation of 
existing hospitalization, results in persistent or significant disability/incapacity, or 

Protocol Amendment 16, 10/06/2021 
 
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is a congenital anomaly/birth defect, cancer, or is a new cancer if the cancer is the 
condition of the study, or overdose.  Other important medical events that may 
jeopardize the patient or may require intervention to prevent one of the outcomes 
listed previously should also be considered “serious.” 
 
“Suspected Unexpected Serious Adverse Reaction” or “SUSAR” shall mean any 
Serious Adverse Event, the nature, severity or frequency of which is not consistent 
with information in the most current investigator’s brochure, or with respect to a 
marketed product the most current Summary of Product Characteristics (SPC) or 
Package Insert. 
 
7.1.5.1 Reporting Overdose 
 
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 to Merck Global 
Safety. (Attn: Worldwide Product Safety; FAX 215 661-6229) 
 
7.1.5.2 Reporting Events of Clinical Interest 
 
Selected non-serious and serious adverse events are also known as Events 
of Clinical Interest (ECI) and must be reported within 2 working days to 
Merck Global Safety by the WU PI. (Attn: Worldwide Product Safety; FAX 
215 661-6229) 
 
Events of clinical interest are defined in Appendix B. 
 

Protocol Amendment 16, 10/06/2021 
 
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7.1.5.3 Reporting Pregnancy and Lactation 
 
Although pregnancy and infant exposure during breastfeeding are not 
considered adverse events, it is the responsibility of investigators or their 
designees to report any pregnancy or lactation in a subject (spontaneously 
reported to them) that occurs during the trial. 
 
Pregnancies and infant exposures during breastfeeding that occur after the 
consent form is signed but before registration must be reported by the 
investigator if they cause the subject to be excluded from the trial, or are the 
result of a protocol-specified intervention, including but not limited to 
washout or discontinuation of usual therapy, diet, placebo treatment or a 
procedure.   
 
Pregnancies and infant exposures during breastfeeding that occur from the 
time of registration through 120 days following cessation of Sponsor’s 
product, or 30 days following cessation of treatment if the subject initiates 
new anticancer therapy, whichever is earlier, must be reported by the 
investigator.  All reported pregnancies must be followed to the 
completion/termination of the pregnancy. Pregnancy outcomes of 
spontaneous abortion, missed abortion, benign hydatidiform mole, blighted 
ovum, fetal death, intrauterine death, miscarriage and stillbirth must be 
reported as serious events (Important Medical Events). If the pregnancy 
continues to term, the outcome (health of infant) must also be reported. 
 
Such events must be reported within 24 hours to the Sponsor and within 2 
working days to Merck Global Safety. (Attn: Worldwide Product Safety; 
FAX 215 661-6229) 
 
7.2 
Reporting Requirements for Secondary Sites 
 
The research team at each secondary site is required to promptly notify the Washington 
University Sponsor-Investigator and Designee of all serious adverse events (Refer to 
Appendix B) within 1 working day of the occurrence of the event or notification of the 
secondary site’s PI of the event.  This notification may take place via email if there is not 
yet enough information for a formal written report using a FDA form 3500a (MedWatch 
form) and Washington University cover sheet (Appendix D).  A formal written report must 
be sent to the Washington University Sponsor-Investigator within 4 calendar days (for 
fatal or life-threatening suspected adverse reactions) or 11 calendar days (for serious 
unexpected adverse reactions) of the occurrence of the event or notification of the 
secondary site’s PI of the event. 
 
The research team at a secondary site is responsible for following its site’s guidelines for 
reporting applicable events to its site’s IRB according to its own institutional guidelines.  
The research team at Washington University is responsible for reporting all applicable 
events to the FDA and Merck & Co. as needed. 

Protocol Amendment 16, 10/06/2021 
 
page 39 of 70 
 
Washington University pre-approval of all protocol exceptions must be obtained prior to 
implementing the change. Local IRB approval must be obtained as per local guidelines. 
Washington University IRB approval is not required for protocol exceptions occurring at 
secondary sites. 
 
7.3 
Exceptions to Expedited Reporting 
 
Events that do not require expedited reporting as described in Section 7.1 include: 
• Planned hospitalizations 
• Hospitalizations < 24 hours 
• Respite care 
• Events related to disease progression 
 
Events that do not require expedited reporting must still be captured in the EDC. 
 
 
8.0 
PHARMACEUTICAL INFORMATION 
 
8.1 
MK-3475 
 
8.1.1 MK-3475 Description 
 
MK-3475 is a potent humanized IgG4 mAb with high specificity of binding to the 
PD-1 receptor, thus inhibiting its interaction with PD-L1 and PD-L2. Based on 
preclinical in vitro data, MK-3475 has high affinity and potent receptor blocking 
activity for PD-1. MK-3475 has an acceptable preclinical safety profile and is being 
advanced for clinical development as an IV immunotherapy for advanced 
malignancies. 
 
8.1.2 Clinical Pharmacology 
 
Refer to Section 5.2 of the IB. 
 
8.1.3 Pharmacokinetics and Drug Metabolism 
 
Refer to Section 5.2 of the IB. 
 
8.1.4 Supplier 
 
MK-3475 will be provided free of charge by Merck & Co., Inc. 
 
8.1.5 Dosage Form and Preparation 
 
Merck will provide MK-3475 as a liquid drug product. 
 

Protocol Amendment 16, 10/06/2021 
 
page 40 of 70 
8.1.6 Storage and Stability 
 
MK-3475 should be stored under refrigerated conditions (2°C - 8°C). 
 
If not used immediately, vials and/or IV bags may be stored at 2-8 °C for up to a 
cumulative time of 20 hours. If refrigerated, the vials and/or IV bags should be 
allowed to equilibrate to room temperature prior to subsequent use. MK-3475 
solutions may be stored at room temperature for a cumulative time of up to 4 hours.  
 
8.1.7 Administration 
 
MK-3475 will be given intravenously over the course of 30 minutes (-5 min/+10 
min) on an outpatient basis.   
 
8.1.8 Special Handling Instructions 
 
No special handling instructions. 
 
 
9.0 
CORRELATIVE STUDIES 
 
The collections for correlative studies are for patients enrolled in phase II only unless otherwise 
indicated. 
 
9.1 
Blood Specimens  
 
9.1.1 Collection of Specimens 
 
Forty mL of blood will be collected into 4 pink top tubes (with EDTA) for isolation 
of PBMCs at the following time points for Phase II patients only: 
• No more than one week prior to surgical procedure (including 
resection/debulking, MLA or biopsy)  
• No more than 3 days prior to the first dose of MK-3475  
• No more than 7 days prior to the second dose of MK-3475 and at doses 4, 
6, 9, 18, and 36 
• At the end of treatment visit 
 
9.1.2 Handling of Specimens 
 
One 10 mL vial will be used for isolation of plasma via centrifugation.  The 
remaining vials will be used for isolation of peripheral blood mononuclear cells 
(PBMCs) using Ficoll per standard protocol37,38.  
 
9.1.3 Shipping of Specimens 
 
Blood samples collected at WUSM should be transported to and stored in Albert 

Protocol Amendment 16, 10/06/2021 
 
page 41 of 70 
Kim’s lab (located at Couch Biomedical Research Building 4515 McKinley Ave, 
Room 6110) or the Siteman Cancer Center’s Tissue Procurement Core (located on 
the 5th floor of the BJCIH) at ambient temperature immediately after collection and 
processed immediately upon arrival. If a delay in transport or processing of greater 
than 1 hour is anticipated, samples must be stored on ice.  All attempts must be used 
to process samples within 4 hours of collection. 
 
Blood samples collected at UF should be transported to Dr. Tran’s lab to be 
processed within their immunophenotyping lab at ambient temperature 
immediately after collection and processed immediately upon arrival. If a delay in 
transport or processing of greater than 1 hour is anticipated, samples must be stored 
on ice.  All attempts must be used to process samples within 4 hours of collection. 
 
Preliminary processing of the scRNAseq samples will be completed by the MGI 
lab locally at WUSM. To ensure data analysis consistency, the resulting data will 
then be stripped of any identifying information and shared with UF, where it will 
be aggregated and analyzed as a cohort. 
 
9.2 
Cervical Lymph Node Samples - OPTIONAL 
 
9.2.1 Collection of Specimens 
 
Ipsilateral cervical lymph nodes of all phase II patients will be sampled by FNA 
(regardless of whether the node is pathologically enlarged) at the following time 
points: 
• Time of surgical resection/debulking or biopsy or MLA/biopsy 
• 6 weeks +/- 1 week after surgical resection/debulking or biopsy or 
MLA/biopsy (if tumor-specific precursor frequency in PBMC is low) 
 
9.2.2 Handling of Specimens 
 
Lymph nodes will be minced and cells isolated using a cell strainer per standard 
protocol (REF). Suspended lymph node lymphocytes will be Ficoll separated and 
the mononuclear cell population (PBMC) isolated per standard protocol37,38 
 
9.2.3 Shipping of Specimens 
 
Lymph node samples collected at WUSM should be placed in a buffered solution 
(e.g. PBS, a tissue culture media), transported to and stored in Albert Kim’s lab 
(located at Couch Biomedical Research Building 4515 McKinley Ave, Room 6110) 
at ambient temperature, and processed immediately upon arrival. If a delay in 
transport or processing of greater than 1 hour is anticipated, samples must be placed 
on ice.  All attempts must be used to process samples within 4 hours of collection. 
 
Lymph node samples collected at UF should be placed a buffered solution (e.g. 
PBS, a tissue culture media), transported to Dr. Tran’s lab in the 

Protocol Amendment 16, 10/06/2021 
 
page 42 of 70 
immunophenotyping lab at ambient temperature, and processed immediately upon 
arrival. If a delay in transport or processing of greater than 1 hour is anticipated, 
samples must be placed on ice.  All attempts must be used to process samples within 
4 hours of collection. 
 
9.3 
Tumor Tissue Specimens 
 
9.3.1 Collection of Specimens 
 
Any tissue (from either surgical debulking or biopsy or MLA/biopsy) available 
after histopathologic diagnosis of GBM will be collected for correlated studies as 
follows: 
• Flash frozen for DNA and RNA isolation and for priming of DC 
• Fixed and embedded in paraffin for IHC 
• Acutely dissociated to generate patients’ primary GBM cell lines and tumor 
infiltrating lymphocyte culture if adequate tissue is available. 
 
Phase II patients will have tissue collected. 
 
Those patients who, in the event of surgical intervention for clinical reasons of a 
radiographically progressing tumor, undergo a subsequent surgical procedure 
(whether biopsy or resection) will be collected after histopathologic diagnosis of 
progressive GBM. 
 
9.3.2 Handling of Specimens 
 
Tissue cryopreservation and paraffin embedding are per standard protocol. One half 
of the tissue will be equally divided into 2 parts: one part will be flash frozen and 
the other part will be fixed and embedded in paraffin (FFPE).  FFPE samples are to 
be batch shipped to a MERCK-designated laboratory for central performance of 
PD-L1 IHC. Five (5) unstained slides may be submitted in lieu of the FFPE tissue 
block. The other half of the tissue will be divided into 2 parts: one part will be 
acutely dissociated by digestion with collagenase and hyaluronidase for patient-
derived glioma cell line generation, and the other part will be minced into 1 mm 
chunks then plated for tumor-infiltrating lymphocyte cultures per standard protocol.  
 
9.3.3 Shipping of Specimens 
 
Brain tumor samples collected at WUSM should be placed in a buffered solution 
(e.g. PBS, a tissue culture media), transported to the laboratory of Albert Kim (3rd 
floor of McMillan building), or Siteman Cancer Center Tissue Procurement Core 
at ambient temperature and processed immediately upon arrival.  From there the 
tissue will be divided. The half that will be used for the flash frozen stock and FFPE 
blocks will be transported and processed in the Siteman Cancer Center’s Tissue 
Procurement Core. The other half that will be used to generate dissociated cells will 
be delivered immediately to Dr. Kim’s lab (contact person: Tanner Johanns, 

Protocol Amendment 16, 10/06/2021 
 
page 43 of 70 
tannerjohanns@wustl.edu).  If a delay in transport or processing of greater than 1 
hour is anticipated, samples must be stored on ice.  All attempts must be used to 
process samples within 4 hours of collection. 
 
Brain tumor samples collected at UF should be placed in a buffered solution (e.g. 
PBS, a tissue culture media), transported to the Florida Center for Brain Tumor 
Research (FCBTR) tumor bank at UF at ambient temperature and processed 
immediately upon arrival.  From there the tissue will be divided. The half that will 
be used for the flash frozen stock and FFPE blocks will be processed in the FCBTR. 
The other half that will be used to generate dissociated cells will be delivered to Dr. 
Tran’s 
lab 
immediately 
(contact 
person: 
Alexandra 
Sherman, 
Alexandra.sherman@neurosurgery.ufl.edu.  If a delay in transport or processing of 
greater than 1 hour is anticipated, samples must be stored on ice.  All attempts must 
be used to process samples within 4 hours of collection. 
 
10.0 
STUDY CALENDAR 
 
10.1 
Phase I Study Calendar 
 
 
Screening Day 1 
Day 2 to Day 8 
Q3W9 EOT 
Follow-Up2 
H&P, KPS 
X 
 
X 
X 
X 
 
Brain MRI 
X 
 
 
X4 
 
 
CBC 
X 
 
X8 
X 
 
 
CMP7 
X 
 
X8 
X 
 
 
INR, PT/PTT 
X 
 
 
 
 
 
βhCG6 
X 
 
X5 
 
 
 
TSH 
X 
 
 
X1 
 
 
MK-3475 
 
 
X 
X3 
 
 
MLA 
 
X8 
 
 
 
 
AE assessment 
X ------------------------------------------------------ X 
 
1. To be checked at every odd-numbered dose of MK-3475 
2. There will be one follow-up visit 4 weeks after EOT, and then patients will be followed for up to 2 years 
for survival 
3. Treatment can continue for a maximum of 2 years/35 cycles after MLA.  Patients currently on MK-3475 
beyond the 2 year/35 cycle limit at the time of Amendment 13 may remain on MK-3475 unless there is 
progression, toxicity, or agreement by the patient and PI to discontinue treatment.  Refer to Section 5.10 
for guidance on whether a patient qualifies for re-treatment in the Second Course Phase and refer to 
Section 10.3 for the Second Course Phase calendar. 
4. Every 9 weeks +/- 1 week 
5. No more than 72 hours prior to the first dose.  If the screening pregnancy test is performed within that 
window, only one pregnancy test is required. 
6. Women of childbearing potential only 
7. CMP consists of albumin, alk phos, ALT, AST, BUN, Ca++, Cl-, CO2, creatinine, glucose, K+, Na+, 
total bili, total protein 
8. Patients will receive peri- and post-operative care as per SOC.  This typically includes treatment with 
steroids and anti-epileptics, repeated neurological exams (approx. hourly in the ICU and approx. every 
2 hours in the step-down unit), and draws for CBC and CMP immediately post-MLA and again the 
following day. 

Protocol Amendment 16, 10/06/2021 
 
page 44 of 70 
9. +/- 4 days 
 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 45 of 70 
10.2 
Phase II Study Calendars 
 
10.2.1 MK-3475 + MLA 
 
 
Screening 
Surgical 
Resection/ 
Debulking 
(OPTIONAL) 
Day 1 (MLA) 
(no surgical 
resection / 
debulking)15 
Day 1 (MLA)  
(3 weeks post-
surgical resection / 
debulking16) 
 
Day 2 to 
Day 9 
Q3W17 
EOT3 
H&P, KPS 
X 
 
 
 
X12 
X 
X 
Brain MRI 
X 
 
 
 
X20 
X9 
 
CBC 
X18 
 
 
 
X 
X 
 
CMP13 
X18 
 
 
 
X 
X 
 
INR, PT/PTT 
X18 
 
 
 
 
 
 
βhCG11 
X18 
 
 
 
X10 
 
 
TSH 
X18 
 
 
 
X2 
X2 
 
MK-3475 
 
 
 
 
X1 
X4 
 
MLA 
 
 
X6, 15 
X6, 16, 19 
 
 
 
Surgical resection (optional) 
 
X 
 
 
 
 
 
Biopsy 
 
  
X14 
 
 
 
 
Research blood 
 
X5,7 
X5, 7 
 
X5 
X5 
X5 
Research lymph nodes 
 
X7 
X7 
 
 
X8 
 
Research tissue 
 
X7 
X7 
 
 
 
 
AE assessment 
 X-----------------------------------------------------------------------------------------------------------X21 
1. To begin no more than 1 week (+/- 3 days) after MLA or 3 weeks after surgery.  
2. To be checked at the first MK-3475 dose and then every other dose thereafter 
3. There will be one follow-up visit 4 weeks after EOT, and then patients will be followed for up to 2 years for survival 
4. Patients currently on MK-3475 beyond the 2 year/35 cycle limit at the time of this amendment may remain on MK-3475 unless there is 
progression, toxicity or agreement by the patient and PI to come off therapy. The number of treatments is calculated starting with the first 
dose.  Participants who stop the combination or MK-3475 after receiving 35 doses may be eligible for retreatment if they progress after 
stopping study intervention provided they meet the requirements detailed in Section 5.10. Participants may be retreated in the Second 
Course Phase (Retreatment) for up to an additional 17 cycles (approximately 1 year). 
5. Refer to Section 9.1 
6. Patients will receive peri- and post-operative care as per SOC.  This typically includes treatment with steroids and anti-epileptics, repeated 
neurological exams (approx. hourly in the ICU and approx. every 2 hours in the step-down unit), and draws for CBC and CMP immediately 
post-MLA and again the following day. 
7. At time of surgery 
8. 6 weeks post-surgery only (+/- 1 week) 
9. Every 9 weeks (+/- 1 week) 
10. No more than 72 hours prior to the first dose only. Additional pregnancy tests are not required.   
11. Women of childbearing potential only 
12. One week +/- 2 days following MLA or on the first dose of MK-3475 (whichever comes first)  
13. CMP consists of albumin, alk phos, ALT, AST, BUN, Ca++, Cl-, CO2, creatinine, glucose, K+, Na+, total bili, total protein. 
14. For tissue diagnosis and immune monitoring. Biopsy is only for patients who did not have surgical resection and will be performed during 
MLA. 
15. Applies only to patients who did not have surgical resection. 
16. Applies only to patients who had surgical resection. 
17. +/- 4 days 
18. Within 2 weeks prior to registration. 
19. MLA will take place at least 3 weeks but not more than 6 weeks after surgical resection/debulking. 
20. An MRI should be collected and evaluated after any surgical procedure (MLA, surgical resection/debulking, or biopsy).   
21. Adverse events will be followed for 30 days following last treatment. SAEs will be tracked for 90 days following the last dose of study 
treatment. 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 46 of 70 
 
10.2.2 MK-3475 – MLA 
 
This arm is not available to newly enrolled patients as of Amendment 12. 
 
 
Screening 
Surgical Resection/ 
Debulking (OPTIONAL)14 
Biopsy Only15 
Cycle 1 Day 111 
Q3W16 
EOT3 
H&P, KPS 
   X 
 
 
   X11 
X 
X 
Brain MRI 
   X 
   
 
X18 
 X8 
 
CBC 
   X17 
 
 
X 
X 
 
CMP12 
   X17 
 
 
X 
X 
 
INR, PT/PTT 
   X17 
 
 
 
 
 
βhCG10 
   X17 
 
 
X9 
 
 
TSH 
   X17 
 
 
X2 
X2 
 
MK-3475 
 
 
 
X1 
X4 
 
Surgical resection (optional) 
 
 X 
 
 
 
 
Biopsy 
 
 
X13 
 
 
 
Research blood 
 
  X5,6 
X5,6 
X5 
X5 
X5 
Research lymph nodes 
 
X6 
X6 
 
X7 
 
Research tissue 
 
X6 
X6 
 
 
 
AE assessment 
X------------------------------------------------------------------------X19 
1. To begin no more than 1 week (+/- 3 days) after biopsy (if applicable) or 3 weeks after surgery. 
2. To be checked at the first MK-3475 dose and then every other dose thereafter 
3. There will be one follow-up visit 4 weeks after EOT, and then patients will be followed for up to 2 years for survival 
4. Treatment can continue for a maximum of 2 years/35 cycles after MLA.  Patients currently on MK-3475 beyond the 2 year/35 cycle limit 
at the time of Amendment 13 may remain on MK-3475 unless there is progression, toxicity, or agreement by the patient and PI to discontinue 
treatment.  Refer to Section 5.10 for guidance on whether a patient qualifies for re-treatment in the Second Course Phase and refer to Section 
10.3 for the Second Course Phase calendar. 
5. Refer to Section 9.1 
6. At time of surgery 
7. 6 weeks post-surgery only (+/- 1 week) 
8. Every 9 weeks (+/- 1 week) 
9. No more than 72 hours prior to the first dose only. Additional pregnancy tests are not required.   
10. Women of childbearing potential only 
11. One week +/- 2 days following biopsy or on the first dose of MK-3475 (whichever comes first).  For patients who underwent surgical 
resection/debulking, MK-3475 will be started at least 3 weeks but not more than 6 weeks after surgery.   
12. CMP consists of albumin, alk phos, ALT, AST, BUN, Ca++, Cl-, CO2, creatinine, glucose, K+, Na+, total bili, total protein. 
13. For tissue diagnosis and immune monitoring. Biopsy is only for patients who did not have surgical resection and for patients in which the 
treating physician deems a biopsy clinically necessary. 
14. Applies only to patients who had surgical resection. 
15. Applies only to patients who did not have surgical resection. 
16. +/- 4 days 
17. Within 2 weeks prior to registration. As of amendment 12, patients will no longer be randomized in the Phase II portion of this trial. 
Phase II patients enrolled after the approval of amendment 12 will participate in a single treatment arm with MK-3475 and MLA and 
follow the schedule of events in section 10.2.1 of the protocol. 
18.  A standard of care MRI after the biopsy procedure is optional at the discretion of the treating neurosurgeon. 
19. Adverse events will be followed for 30 days following last treatment. SAEs will be tracked for 90 days following the last dose of study 
treatment.    
 
 

Protocol Amendment 16, 10/06/2021 
 
page 47 of 70 
10.3 
Second Course Phase Calendar 
 
Day 1 of Second Course must start no more than 4 weeks after disease progression. 
 
 
Screening 
Day 1 
Q3W10 
EOT8 
H&P, KPS 
X 
X 
X 
X 
Brain MRI 
X 
 
X6 
 
CBC 
X3 
X 
X 
 
CMP1 
X3 
X 
X 
 
INR, PT/PTT 
X3 
 
 
 
βhCG2 
X3 
X4 
 
 
TSH 
X3 
X5 
X5 
 
MK-3475 
 
X 
X7 
 
AE assessment 
 X--------------------------------------------X9 
1. CMP consists of albumin, alk phos, ALT, AST, BUN, Ca++, Cl-, CO2, 
creatinine, glucose, K+, Na+, total bili, total protein. 
2. Women of childbearing potential only 
3. Within 4 weeks of progression. 
4. No more than 72 hours prior to the first dose only. Additional pregnancy 
tests are not required.   
5. To be checked at the first MK-3475 dose and then every other dose 
thereafter 
6. Every 9 weeks (+/- 1 week) 
7. Participants may be retreated in the Second Course Phase (Retreatment) for 
up to an additional 17 cycles (approximately 1 year).  
8. There will be one follow-up visit 4 weeks after EOT, and then patients will 
be followed for up to 2 years for survival 
9. Adverse events will be followed for 30 days following last treatment. SAEs 
will be tracked for 90 days following the last dose of study treatment. 
10. +/- 4 days 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 48 of 70 
 
11.0 
DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
schedule listed in this section. 
 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
Registration Form 
Eligibility Form 
Demographics Form 
Medical Record Number Form 
Participant Address Form 
On-Study Form 
On-Study Treatment History Form 
On-Study Surgical History Form 
Prior to starting treatment 
MK-3475 Dosing Form 
With each dose of MK-3475 (during main study 
and second course as applicable) 
MLA Form 
Time of MLA 
Surgery Form 
Treatment Assignment Form 
Time of surgery 
Research Nodes and Tissue Form 
(Phase II only) 
Time of surgical procedure 
6 weeks post-surgical procedure 
Research Blood Form (Phase II only) 
Prior to starting treatment 
Time of MLA 
Time of surgical procedure 
With each dose of MK-3475 (Per section 9.1) 
Retreatment Form 
Time of start of second course 
Adverse Events Form 
Continuous 
Treatment Summary Form 
Completion of treatment 
Follow Up Form 
Per protocol 
Imaging Form 
Baseline, every 9 +/-1 weeks, and end of treatment 
MedWatch Form 
See Section 7.0 for reporting requirements 
 
Any queries generated by Washington University must be responded to within 28 days of receipt 
by the participating site.  The Washington University research team will conduct a regular review 
of data status at all secondary sites, with appropriate corrective action to be requested as needed. 
 
11.1 
Adverse Event Collection in the Case Report Forms 
 
All adverse events that occur beginning with start of treatment (minus exceptions defined 
in Section 1.0) must be captured in the Toxicity Form.  Baseline AEs should be captured 
on the Medical History Form. 
 
Participant death due to disease progression should be reported on the Toxicity Form as 
grade 5 disease progression.  If death is due to an AE (e.g. cardiac disorders: cardiac arrest), 

Protocol Amendment 16, 10/06/2021 
 
page 49 of 70 
report as a grade 5 event under that AE.  Participant death must also be recorded on the 
Death Form. 
 
 
12.0 
MEASUREMENT OF EFFECT 
 
12.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 9 +/- 1 
weeks.  In addition to a baseline scan, confirmatory scans should also be obtained 9 weeks 
(not less than 4) weeks following initial documentation of objective response. 
 
Response and progression will be evaluated in this study using the updated response 
assessment criteria for high-grade gliomas: Response Assessment in Neuro-Oncology 
(RANO) working group guideline [JCO 28(11): 1963-1972, 2010]. 
 
Criteria for Determining First Progression Depending on Time from Initial Chemoradiotherapy 
First Progression 
Definition 
Progressive disease < 12 
weeks after completion of 
chemoradiotherapy 
Progression can only be defined using diagnostic imaging if there is new 
enhancement outside of the radiation field (beyond the high-dose region or 
80% isodose line) or if there is unequivocal evidence of viable tumor on 
histopathologic sampling (eg, solid tumor areas [ie, > 70% tumor cell nuclei 
in areas], high or progressive increase in MIB-1 proliferation index 
compared with prior biopsy, or evidence for histologic progression or 
increased anaplasia in tumor). Note: Given the difficulty of differentiating 
true progression from pseudoprogression, clinical decline alone, in the 
absence of radiographic or histologic confirmation of progression, will not 
be sufficient for definition of progressive disease in the first 12 weeks after 
completion of concurrent chemoradiotherapy.  
Progressive disease ≥ 12 
weeks after 
chemoradiotherapy 
completion 
1. New contrast-enhancing lesion outside of radiation field on 
decreasing, stable, or increasing doses of corticosteroids. 
2. Increase by ≥ 25% in the sum of the products of perpendicular 
diameters between the first postradiotherapy scan, or a subsequent 
scan with smaller tumor size, and the scan at 12 weeks or later on 
stable or increasing doses of corticosteroids.  
3. Clinical deterioration not attributable to concurrent medication or 
comorbid conditions is sufficient to declare progression on current 
treatment but not for entry onto a clinical trial for recurrence.  
4. For patients receiving antiangiogenic therapy, significant increase in 
T2/FLAIR nonenhancing lesion may also be considered progressive 
disease. The increased T2/FLAIR must have occurred with the 
patient on stable or increasing doses of corticosteroids compared 
with baseline scan or best response after initiation of therapy and 
not be a result of comorbid events (eg, effects of radiation therapy, 
demyelination, ischemic injury, infection, seizures, postoperative 
changes, or other treatment effects).  
 

Protocol Amendment 16, 10/06/2021 
 
page 50 of 70 
 
Criteria for Response Assessment Incorporating MRI and Clinical Factors (Adapted from JCO 
2010) 
Response 
Criteria 
Complete 
response 
• Requires all of the following: complete disappearance of all enhancing 
measurable and nonmeasurable disease sustained for at least 4 weeks. 
• No new lesions; stable or improved nonenhancing (T2/FLAIR) lesions. 
• Patients must be off corticosteroids (or on physiologic replacement 
doses only) and stable or improved clinically. Note: Patients with 
nonmeasurable disease only cannot have a complete response; the best 
response possible is stable disease.  
Partial response 
Requires all of the following:  
• ≥ 50% decrease compared with baseline in the sum of products of 
perpendicular diameters of all measurable enhancing lesions sustained 
for at least 4 weeks. 
• No progression of nonmeasurable disease. 
• Stable or improved nonenhancing (T2/FLAIR) lesions on same or lower 
dose of corticosteroids compared with baseline scan; the corticosteroid 
dose at the time of the scan evaluation should be no greater than the dose 
at time of baseline scan. 
• Stable or improved clinically. Note: Patients with nonmeasurable 
disease only cannot have a partial response; the best response possible is 
stable disease.  
Stable disease 
Requires all of the following:  
• Does not qualify for complete response, partial response, or progression. 
• Stable nonenhancing (T2/FLAIR) lesions on same or lower dose of 
corticosteroids compared with baseline scan. In the event that the 
corticosteroid dose was increased for new symptoms and signs without 
confirmation of disease progression on neuroimaging, and subsequent 
follow-up imaging shows that this increase in corticosteroids was 
required because of disease progression, the last scan considered to 
show stable disease will be the scan obtained when the corticosteroid 
dose was equivalent to the baseline dose.  
Progression 
Defined by any of the following:  
• ≥ 25% increase in sum of the products of perpendicular diameters of 
enhancing lesions compared with the smallest tumor measurement 
obtained either at baseline (if no decrease) or best response, on stable or 
increasing doses of corticosteroids*. The absolute increase in any 
dimension must be at least 5mm when calculating the products. 
• Significant increase in T2/FLAIR nonenhancing lesion on stable or 
increasing doses of corticosteroids compared with baseline scan or best 
response after initiation of therapy* not caused by comorbid events (e.g. 
radiation therapy, demyelination, ischemic injury, infection, seizures, 
postoperative changes, or other treatment effects). 

Protocol Amendment 16, 10/06/2021 
 
page 51 of 70 
Response 
Criteria 
• Any new measureable lesion. 
• Clear clinical deterioration not attributable to other causes apart from the 
tumor (e.g. seizures, medication adverse effects, complications of 
therapy, cerebrovascular events, infection, and so on) or changes in 
corticosteroid dose. 
• Failure to return for evaluation as a result of death or deteriorating 
condition; or clear progression of nonmeasurable disease.  
• 
NOTE. All measurable and nonmeasurable lesions must be assessed using the same techniques as at 
baseline. 
• 
Abbreviations: MRI, magnetic resonance imaging; FLAIR, fluid-attenuated inversion recovery. 
• 
Stable doses of corticosteroids include patients not on corticosteroids.  
 
12.2 
Disease Parameters 
 
Measurable disease:  Bi-dimensionally measurable lesions with clearly defined margins 
by MRI scan of ≥ 10 mm.  All tumor measurements must be recorded in millimeters (or 
decimal fractions of centimeters).   
 
Non-measurable or evaluable disease:  Uni-dimensionally measurable lesions or lesions 
with margins not clearly defined such as areas of T2/FLAIR signal abnormality or poorly 
defined enhancing abnormality.  
 
Note: For cystic lesions, the only measurable part is any enhancement area around the cyst 
that is clearly defined and bi-dimensionally measurable. The cyst itself should not be 
considered measurable or non-measureable disease. 
 
Target lesions: All measurable lesions that are seen at baseline MRI. Target lesions should 
be selected on the basis of their size (lesions with the longest diameter), but in addition 
should be those that lend themselves to reproducible repeated measurements.  It may be 
the case that, on occasion, the largest lesion does not lend itself to reproducible 
measurement in which circumstance the next largest lesion, which can be measured 
reproducibly should be selected.  When there are too many measurable lesions, choose the 
largest 3 lesions as target lesions to follow.  The other measurable lesions should be 
considered evaluable for the purpose of objective status determination. 
 
Non-target lesions:  All non-measurable lesions should be identified as non-target lesions 
and should also be recorded at baseline.  Measurements of these lesions are not required, 
but the presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow-up.  
 
12.3 
Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler.  All 
baseline MRI evaluations should be performed prior to MLA. An MRI should be collected 
and evaluated after any surgical procedure (MLA, surgical resection/debulking, or biopsy).  

Protocol Amendment 16, 10/06/2021 
 
page 52 of 70 
MRI should also be collected prior to first dose of MK-3475 for patients not receiving any 
surgical procedure.    
    
Clinical lesions:  Clinical lesions will only be considered measurable on brain MRI when 
they are ≥ 10 mm in bi-dimensional diameters as assessed using a ruler. 
 
Histology:  This technique can be used to differentiate between partial responses (PR) and 
complete responses (CR) in rare cases when biopsy or surgical resection of a measureable 
lesion is clinically indicated.  
 
Perfusion/CBV: This advanced brain MRI technique can be used as an adjunct test to 
determine treatment response or disease status.  However, it should not be used as the 
primary or sole method to determine response or disease status.  
 
Brain FDG-PET coupled with head CT or brain MRI: This advanced metabolic 
imaging technique can be used as an adjunct test to determine response or disease status. 
However it should be used as the primary or sole method of determining response or 
disease status. 
 
12.3.1 Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions. 
 
Partial Response (PR):  ≥ 50% decrease compared with baseline in the sum of 
products of perpendicular diameters of all target lesions sustained for at least 4 
weeks. 
 
Progressive Disease (PD):  At least a 25% increase in the sum of products of 
perpendicular diameters of at least 1 target lesion, taking as reference the smallest 
sum of products of perpendicular diameters on study (this includes the baseline sum 
if that is the smallest on study).  The absolute increase in any dimension must be at 
least 5mm when calculating the products of perpendicular diameters. 
 
In the event of surgical intervention for clinical reasons of a radiographically 
progressing tumor when subsequent surgical pathology demonstrates a 
predominant immune-mediated reaction with no obvious progression of tumor, 
the subject will be deemed not progressed and allowed to resume study treatment 
as assigned prior to the surgery at a time deemed safe by the treating physician, but 
no later than 8 weeks from the surgery. 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum of products of 
perpendicular diameters while on study. 
 

Protocol Amendment 16, 10/06/2021 
 
page 53 of 70 
12.3.2 Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions.  
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s). 
 
Progressive Disease (PD): Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions on stable or increasing doses 
of corticosteroids compared with baseline scan or best response after initiation of 
therapy* not caused by comorbid events (e.g. radiation therapy, demyelination, 
ischemic injury, infection, seizures, postoperative changes, or other treatment 
effects). Unequivocal progression should not normally trump target lesion status.  
It must be representative of overall disease status change, not a single lesion 
increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the 
opinion of the treating physician should prevail in such circumstances, and the 
progression status should be confirmed at a later time by the review panel (or 
Principal Investigator). 
 
12.3.3 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. 
 
Summary of the RANO Response Criteria (Adapted from JCO 2010) 
Criterion 
CR 
PR 
SD 
PD 
T1 gadolinium 
enhancing disease 
None 
≥ 50% ↓ 
< 50% ↓ but < 25% 
↑ 
≥ 25% ↑* 
T2/FLAIR 
Stable or 
↓ 
Stable or 
↓ 
Stable or ↓ 
↑* 
New lesion 
None 
None 
None 
Present* 
Corticosteroids 
None 
Stable or 
↓ 
Stable or ↓ 
NA† 
Clinical status 
Stable or 
↑ 
Stable or 
↑ 
Stable or ↑ 
↓* 
Requirement for 
response 
All 
All 
All 
Any* 
Abbreviations: RANO, Response Assessment in Neuro-Oncology; CR, complete response; PR, 
partial response; SD, stable disease; PD, progressive disease; FLAIR, fluid-attenuated inversion 
recovery; NA, not applicable.  
* Progression occurs when this criterion is present.  

Protocol Amendment 16, 10/06/2021 
 
page 54 of 70 
† Increase in corticosteroids alone will not be taken into account in determining progression in the 
absence of persistent clinical deterioration.  
NOTE: Patients may continue on treatment and remain under close observation and evaluation at 
4-8 week intervals if there is uncertainty regarding whether pseudoprogression may be present as 
determined by the investigators. If subsequent radiographic or clinical assessments suggest that 
the patient is in fact experiencing progression, then the date of progression should be the time point 
at which this issue was first raised.  Similarly, stable disease may be assigned in cases of presumed 
“pseudoprogression” associated with decreased steroid use. 
 
12.3.4 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from 
the time 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 progressive disease is objectively documented.  
 
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, including the baseline 
measurements.  
 
12.3.5 Neurological Exam and Performance Status  
 
Patients will be graded using the Karnofsky Performance Status scale and their 
neurological function evaluated as improved, stable or deteriorated in addition to 
objective measurement of tumor size. These parameters will be used to determine 
the overall response assessment. 
 
12.3.6 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression 
or death, whichever occurs first. 
 
 
13.0 
DATA AND SAFETY MONITORING 
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, an 
independent Data and Safety Monitoring Board (DSMB) will be specifically convened for this 
trial to review toxicity data.  A DSMB will consist of no fewer than 3 members including 2 clinical 
investigators and a biostatistician.  Like investigators, DSMB members are subject to the 
Washington University School of Medicine policies regarding standards of conduct. Individuals 
invited to serve on the DSMB will disclose any potential conflicts of interest to the trial principal 
investigator and/or appropriate university officials, in accordance with institution policies. 

Protocol Amendment 16, 10/06/2021 
 
page 55 of 70 
Potential conflicts that develop during a trial or a member’s tenure on a DSMB must also be 
disclosed.  
 
Until such a time as the first secondary site enrolls its first patient, a semi-annual DSM report to 
be prepared by the study team will be submitted to the Quality Assurance and Safety Monitoring 
Committee (QASMC) semi-annually beginning six months after study activation at Washington 
University (if at least one patient has been enrolled) or one year after study activation (if no patients 
have been enrolled at the six-month mark). 
 
The DSM report will be prepared by the study team with assistance from the study statistician, 
will be reviewed by the DSMB, and will be submitted to the Quality Assurance and Safety 
Monitoring Committee (QASMC).  The DSMB must meet at least every six months beginning six 
months after study activation at Washington University or beginning six months after enrollment 
of the first patient at a secondary site, no more than one month prior to the due date of the DSM 
report to QASMC.   
 
During the phase I dose escalation, the Principal Investigator will review all patient data at least 
monthly (or before each dose escalation if occurring sooner than monthly), and provide a semi-
annual report to the QASMC.  During the phase II, the Principal Investigator/DSMB will review 
all patient data at least every six months, and provide a semi-annual report to the QASMC. This 
report will include: 
• HRPO protocol number, protocol title, Principal Investigator name, data coordinator 
name, regulatory coordinator name, and statistician 
• Date of initial HRPO approval, date of most recent consent HRPO approval/revision, 
date of HRPO expiration, date of most recent QA audit, study status, and phase of study 
• History of study including summary of substantive amendments; summary of accrual 
suspensions including start/stop dates and reason; and summary of protocol exceptions, 
error, or breach of confidentiality including start/stop dates and reason 
• Study-wide target accrual and study-wide actual accrual including numbers from 
participating sites 
• Protocol activation date at each participating site 
• Average rate of accrual observed in year 1, year 2, and subsequent years at each 
participating site 
• Expected accrual end date, accrual by site, and accrual by cohort 
• Objectives of protocol with supporting data and list the number of participants who 
have met each objective 
• Measures of efficacy 
• Early stopping rules with supporting data and list the number of participants who have 
met the early stopping rules 
• Summary of toxicities at all participating sites separated by cohorts with the number of 
dose-limiting toxicities indicated 
• Abstract submissions/publications 
• Summary of any recent literature that may affect the safety or ethics of the study  
 
Further DSMC responsibilities are described in the DSMC charter. 
 

Protocol Amendment 16, 10/06/2021 
 
page 56 of 70 
Until such a time as the first secondary site activates this protocol, a semi-annual Data and Safety 
Monitoring report to be prepared by the study team will be submitted to the QASM Committee 
beginning 6 months after study activation at Washington University. 
 
The study principal investigator and coordinator will monitor for serious toxicities on an ongoing 
basis. Once the principal investigator or coordinator becomes aware of an adverse event, the AE 
will be reported to the HRPO and QASMC according to institutional guidelines (please refer to 
Section 7.0). 
 
Refer to the Washington University Quality Assurance and Data Safety Monitoring Committee 
Policies and Procedures for full details on the responsibilities of the DSMC at 
https://siteman.wustl.edu/research/clinical-research-resources/protocol-office-prmcqasmc/.   
 
 
14.0 
AUDITING 
 
As coordinating center of this trial, Washington University (via the Quality Assurance and Safety 
Monitoring Committee (QASMC) will monitor each participating site to ensure that all protocol 
requirements are being met; that applicable federal regulations are being followed; and that best 
practices for patient safety and data collection are being followed per protocol. Participating sites 
will be asked to send copies of all audit materials, including source documentation.  The audit 
notification will be sent to the Washington University Research Patient Coordinator, who will 
obtain the audit materials from the participating institution. 
 
Notification of an upcoming audit will be sent to the research team one month ahead of the audit. 
Once accrual numbers are confirmed, and approximately 30 days prior to the audit, a list of the 
cases selected for review (up to 10 for each site) will be sent to the research team. However, if 
during the audit the need arises to review cases not initially selected, the research team will be 
asked to provide the additional charts within two working days. 
 
Items to be evaluated include: 
• Subject screening and enrollment 
• Reporting of adverse events 
• Maintenance of HIPAA compliance 
• Completeness of regulatory documentation 
• Completeness of participant documentation 
• Acquisition of informed consent 
• IRB documentation 
• Issues of protocol adherence 
 
Additional details regarding the auditing policies and procedures can be found at 
https://siteman.wustl.edu/wp-content/uploads/2015/10/QASMC-Policies-and-Procedures-
03.31.2015.pdf  
 
 

Protocol Amendment 16, 10/06/2021 
 
page 57 of 70 
15.0 
STATISTICAL CONSIDERATIONS 
 
15.1 
Power Analysis 
 
In the phase I portion of the study, a traditional 3+3 design is used to determine the maximal 
tolerated dose (MTD) of MK-3475 when combined with MLA for the treatment of 
recurrent malignant gliomas. 
 
Power analysis for phase II is based on PFS.  Using a 1-sided alpha of 0.15, with an accrual 
interval of 20 months and additional follow-up of 6 months (study period in Phase II is 26 
months), and assuming a progression free survival probability at 6 month (6-PFS) of 40% 
for the MK-3475 alone group and 65% for MK-3475 + MLA combination group, we will 
need 17 patients per group with probability (power) 0.8. If the 6-PFS of the MK-3475 alone 
group is 45% and 65% for the MK-3475 + MLA combination group, we will need 25 
patients per group.  We are planning to enroll 20 patients per group for the phase II portion 
of trial. 
 
6-PFS in MK-3475 
alone group 
6-PFS in MK-3475 + MLA 
combination group 
Sample per group 
40% 
50% 
108 
55% 
48 
60% 
27 
65% 
17 
45% 
55% 
105 
60% 
46 
65% 
25 
70% 
16 
50% 
60% 
100 
65% 
43 
70% 
24 
75% 
15 
55% 
65% 
93 
70% 
40 
75% 
21 
80% 
13 
60% 
70% 
84 
75% 
35 
80% 
19 
85% 
11 
 
Six-PFS for all current commonly used treatments for recurrent GBM (e.g. bevacizumab, 
temozolomide, carboplatin, carmustine, lomustine, etoposide, irinotecan) ranges from < 
10% to low 30% 39-43. Since historical data on 6-PFS in recurrent GBM for both MK-3475 
and MLA are not available, for the purpose of reasonable estimation of efficacy of the MK-
3475 and MLA combination as compared to MK-3475 alone in recurrent/progressive 

Protocol Amendment 16, 10/06/2021 
 
page 58 of 70 
GBM, we will assume that the 6-PFS of the MK-3475 alone group to be 40-45% to derive 
sample size estimates for both groups as detailed above. 
 
15.2 
Analysis Plan 
 
PFS and OS will be estimated by Kaplan-Meier product limit method and the difference in 
PFS with recurrent GBM being treated with MK-3475 alone vs. those being treated with 
MK-3475 plus MLA will be compared by log-rank test.  
 
Two-group t-test will be used to compare the anti-glioma immune response before and 
after MK-3475 with or without MLA. 
 
Cox proportional hazard model will be used to determine the relationship between 
intratumoral expression of PD-L1, the frequency of glioma cell-specific cytotoxic T cells 
with PFS and OS while proportional hazard assumption will be examined.  
 
Pearson correlation coefficient (r) will be calculated between intratumoral expression of 
PD-L1 and the frequency of glioma cell-specific cytotoxic T cells. Similarly, Cox 
proportional hazard model will be used to investigate the relationship between PD-1-
dependent biomarkers in glioma cell-specific T cells and PFS and OS. 
 
15.3 
Phase II Stopping Rules 
 
Toxicity will be reviewed on a continuous basis. Early stopping of this trial is calculated 
based upon the grade 3 seizure rate. It is assumed that a maximum-tolerated seizure rate is 
50% and a seizure rate of 33% and or less is acceptable. For each treatment arm (n=20), 
based on the repeated significance testing (using R function toxbdry) with 80% power and 
0.05 overall Type I error, the study will be halted if a treatment-related seizure occurs in 
the first patient, or both of the first 2 patients, or 3 of the first 4, or 4 of the first 5, or 5 of 
the first 7, or 6 of the first 9, or 7 of the first 11, or 8 of the first 14, or 9 of the first 16, or 
10 of the first 18, or if the 11th treatment-related seizure is observed before the last (20th) 
patient has completed the trial. 
 
In addition, enrollment will stop and a review will be conducted to determine whether 
modifications to the protocol are warranted or if the trial should be terminated if 2 patients 
in either group die or incur life-threatening (grade 4) adverse reactions that are thought 
to be at least possibly related to study treatment. 
 
15.4 
Interim Analysis 
 
Per DSMC request, an interim analysis was conducted in June 2019.  The MK-3475 + 
MLA group included 2 GBM patients who received 200mg in Phase 1 and 10 patients in 
Phase 2. PFS probability at 6, 9, and 12 months after treatment are 45.0%, 45.0%, and 
33.8%, the median PFS is 5.49 months. Survival probabilities at 6, 9, and 12 months after 
treatment are 75.0%, 62.5%, and 50.0%, and the median OS is not estimable.  For the MK-
3475 monotherapy (no MLA) group, PFS probability at 3 months after treatment is 44.4% 

Protocol Amendment 16, 10/06/2021 
 
page 59 of 70 
and the median PFS is 2.73 months (95% CI: 1.41-3.88). Survival probabilities at 3 and 6 
months after treatment are 83.3%, and 31.3%, and the median OS is 4.77 months (95% CI: 
1.74-8.78).   
 
This analysis showed significant differences in PFS and survival probabilities between the 
MK-3475 + MLA group and the MK-3475 alone group.  Therefore, with Amendment 12, 
we are revising the study to a single arm (MK-3475 + MLA) in the spirit of minimizing 
harm, potential or perceived, to subjects and to complete the study in a timely manner. The 
recent study46 shows median PFS was 2.4 months. To be conservative, we will use the 
shorter mPFS for MK-3475 + MLA group and longer mPFS from historical data. We will 
enroll additional 27 patients and expect 20 GBM patients will be evaluable for this study. 
With an accrual interval of 20 months and additional follow-up of 6 months, a two-sided, 
one-sample logrank test calculated from a sample of 32 subjects achieves 80.9% power at 
a 0.05 significance level to detect a median PFS of 5.1 months in the MK-3475 + MLA 
group when the median PFS of the historical control is 2.9 months.  
 
15.5 
Subgroup analysis 
 
For participants in the Second Course Phase (Retreatment), PFS and OS will be estimated 
by Kaplan-Meier product limit method.  
 
 
16.0 
MULTICENTER REGULATORY REQUIREMENTS 
 
Washington University requires that each participating site sends its informed consent document 
to be reviewed and approved by the Washington University Regulatory Coordinator (or designee) 
prior to IRB/IEC submission.    
 
Site activation is defined as when the secondary site has received official written documentation 
from the coordinating center that the site has been approved to begin enrollment.  At a minimum, 
each participating institution must have the following documents on file at Washington University 
prior to study activation: 
• Documentation of IRB approval of the study in the form of a letter or other official 
document from the participating institution’s IRB.  This documentation must show 
which version of the protocol was approved by the IRB. 
• Documentation of IRB approval of an informed consent form. The consent must 
include a statement that data will be shared with Washington University, including the 
Quality Assurance and Safety Monitoring Committee (QASMC), the DSMC (if 
applicable), and the Washington University study team. 
• Documentation of FWA, signed FDA Form 1572 (if applicable), and the CVs of all 
participating investigators. 
• Protocol signature page signed and dated by the investigator at each participating site. 
 
The coordinating center Principal Investigator (or designee) is responsible for disseminating to the 
participating sites all study updates, amendments, reportable adverse events, etc.  Protocol/consent 
modifications and IB updates will be forwarded electronically to the secondary sites within 4 

Protocol Amendment 16, 10/06/2021 
 
page 60 of 70 
weeks of obtaining Washington University IRB approval.  Activated secondary sites are expected 
to submit protocol/consent/IB modifications to their local IRBs within 4 weeks of receipt unless 
otherwise noted.  Upon the secondary sites obtaining local IRB approval, documentation of such 
shall be sent to the Washington University study team within 2 weeks of receipt of approval. 
 
Documentation of participating sites’ IRB approval of annual continuing reviews, protocol 
amendments or revisions, all SAE reports, and all protocol violations/deviations/exceptions must 
be kept on file at Washington University. 
 
The investigator or a designee from each institution must participate in a regular conference call 
to update and inform regarding the progress of the trial. 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 61 of 70 
 
17.0 
REFERENCES 
 
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Stupp R, Hegi ME, Mason WP, et al. Effects of radiotherapy with concomitant and 
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Adamson C, Kanu OO, Mehta AI, et al. Glioblastoma multiforme: a review of where we 
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Disis ML. Immune regulation of cancer. Journal of clinical oncology : official journal of 
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18. 
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Leffers N, Gooden MJ, de Jong RA, et al. Prognostic significance of tumor-infiltrating T-
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Nishimura H, Honjo T, Minato N. Facilitation of beta selection and modification of 
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36. 
Liotta F, Gacci M, Frosali F, et al. Frequency of regulatory T cells in peripheral blood and 
in tumour-infiltrating lymphocytes correlates with poor prognosis in renal cell carcinoma. BJU 
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patients with recurrent high-grade glioma. British journal of cancer 2004;91:1038-44. 
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Chua SL, Rosenthal MA, Wong SS, et al. Phase 2 study of temozolomide and Caelyx in 
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Reardon DA, Nayak L, Peters KB, et al. Phase II study of pembrolizumab or 
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Cloughesy TF, Mochizuki AY, Orpilla JR, et al. Neoadjuvant anti-PD-1 immunotherapy 
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Protocol Amendment 16, 10/06/2021 
 
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APPENDIX A: Karnofsky Performance Scale 
 
Able to carry on normal activity and to work; no 
special care needed. 
  100   Normal no complaints; no evidence of 
disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
80 
Normal activity with effort; some 
signs or symptoms of disease.  
Unable to work; able to live at home and care for 
most personal needs; varying amount of 
assistance needed. 
70 
Cares for self; unable to carry on 
normal activity or to do active work. 
60 
Requires occasional assistance, but is 
able to care for most of his personal 
needs. 
50 
Requires considerable assistance and 
frequent medical care.  
Unable to care for self; requires equivalent of 
institutional or hospital care; disease may be 
progressing rapidly. 
40 
Disabled; requires special care and 
assistance. 
30 
Severely disabled; hospital admission 
is indicated although death not 
imminent. 
20 
Very sick; hospital admission 
necessary; active supportive treatment 
necessary. 
10 
Moribund; fatal processes progressing 
rapidly. 
0 
Dead 
 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 65 of 70 
APPENDIX B: Definitions for Adverse Event Reporting 
 
A. Adverse Events (AEs) 
 
As defined in 21 CFR 312.32:  
 
Definition: any untoward medical occurrence associated with the use of a drug in humans, whether 
or not considered drug-related. 
 
Grading: the descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for all toxicity reporting.  A copy 
of the CTCAE version 4.0 can be downloaded from the CTEP website. 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for the terms listed 
that should be used are those provided by the Department of Health and Human Services’ Office 
for Human Research Protections (OHRP).  A copy of this guidance can be found on OHRP’s 
website: 
http://www.hhs.gov/ohrp/policy/advevntguid.html 
 
B. Suspected Adverse Reaction (SAR) 
 
As defined in 21 CFR 312.32: 
 
Definition: any adverse event for which there is a reasonable possibility that the drug caused the 
adverse event.  “Reasonable possibility” means there is evidence to suggest a causal relationship 
between the drug and the adverse event.  “Suspected adverse reaction” implies a lesser degree of 
certainty about causality than adverse reaction, which means any adverse event caused by a drug. 
 
C. Life-Threatening Adverse Event / Life Threatening Suspected Adverse Reaction  
 
As defined in 21 CFR 312.32: 
 
Definition: any adverse drug event or suspected adverse reaction is considered “life-threatening” 
if, in the view of the investigator, its occurrence places the patient at immediate risk of death. It 
does not include an adverse event or suspected adverse reaction that, had it occurred in a more 
severe form, might have caused death. 
 
D. Serious Adverse Event (SAE) or Serious Suspected Adverse Reaction 
 
As defined in 21 CFR 312.32: 
 
Definition:  an adverse event or suspected adverse reaction is considered “serious” if, in the view 
of the investigator, it results in any of the following outcomes: 
o Death 
o A life-threatening adverse event 
o Inpatient hospitalization or prolongation of existing hospitalization 

Protocol Amendment 16, 10/06/2021 
 
page 66 of 70 
o A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
o A congenital anomaly/birth defect 
o Any other important medical event that does not fit the criteria above but, based upon 
appropriate medical judgment, may jeopardize the subject and may require medical or 
surgical intervention to prevent one of the outcomes listed above 
 
E. Events of Clinical Interest 
 
Events of clinical interest for this trial include: 
1. an overdose of Merck product that is not associated with clinical symptoms or abnormal 
laboratory results.  
2. an elevated AST or ALT lab value that is ≥ 3 x IULN and an elevated total bilirubin lab 
value that is ≥ 2 x IULN and, at the same time, an alkaline phosphatase lab value that is < 
2 x IULN, as determined by way of protocol-specified laboratory testing or unscheduled 
laboratory testing. 
 
F. Protocol Exceptions 
 
Definition: A planned change in the conduct of the research for one participant. 
 
G. Deviation 
 
Definition: Any alteration or modification to the IRB-approved research without prospective IRB 
approval.  The term “research” encompasses all IRB-approved materials and documents including 
the detailed protocol, IRB application, consent form, recruitment materials, questionnaires/data 
collection forms, and any other information relating to the research study. 
 
A minor or administrative deviation is one that does not have the potential to negatively impact 
the rights, safety, or welfare of participants or others or the scientific validity of the study. 
 
A major deviation is one that does have the potential to negatively impact the rights, safety, or 
welfare of participants or others or the scientific validity of the study. 
 
 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 67 of 70 
APPENDIX C: Reporting Timelines 
 
Expedited Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
Merck & Co. 
Serious AND 
unexpected suspected 
adverse reaction 
 
 
Report no later than 15 calendar 
days after it is determined that the 
information qualifies for 
reporting 
Report to Merck & Co. within 24 
hours of Sponsor-Investigator 
notification. 
Unexpected fatal or 
life-threatening 
suspected adverse 
reaction 
 
 
Report no later than 7 calendar 
days after initial receipt of the 
information 
 
Unanticipated 
problem involving risk 
to participants or 
others 
Report within 10 working days.  If the 
event results in the death of a 
participant enrolled at WU/BJH/SLCH, 
report within 1 working day. 
Report via email 
after IRB 
acknowledgment 
 
 
Pregnancy 
 
 
 
Report to Merck & Co. within 24 
hours of Sponsor-Investigator 
notification. 
Overdose 
 
 
 
Report to Merck & Co. within 24 
hours of Sponsor-Investigator 
notification. 
Events of Clinical 
Interest 
 
 
 
Report to Merck & Co. within 24 
hours of Sponsor-Investigator 
notification. 
Major deviation 
Report within 10 working days.  If the 
event results in the death of a 
participant enrolled at WU/BJH/SLCH, 
report within 1 working day. 
 
 
 
A series of minor 
deviations that are 
being reported as a 
continuing 
noncompliance 
Report within 10 working days.   
 
 
 
Protocol exception 
Approval must be obtained prior to 
implementing the change 
 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 68 of 70 
Expedited Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
Merck & Co. 
Clinically important 
increase in the rate of 
a serious suspected 
adverse reaction of 
that list in the protocol 
or IB 
 
 
Report no later than 15 calendar 
days after it is determined that the 
information qualifies for 
reporting 
 
Complaints 
If the complaint reveals an 
unanticipated problem involving risks 
to participants or others OR 
noncompliance, report within 10 
working days.  If the event results in the 
death of a participant enrolled at 
WU/BJH/SLCH, report within 1 
working day.  Otherwise, report at the 
time of continuing review. 
 
 
 
Breach of 
confidentiality 
Within 10 working days. 
 
 
 
Incarceration 
If withdrawing the participant poses a 
safety issue, report within 10 working 
days.   
 
If withdrawing the participant does not 
represent a safety issue and the patient 
will be withdrawn, report at continuing 
review. 
 
 
 
 
Routine Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
Merck & Co. 
Adverse event or SAE 
that does not require 
expedited reporting 
If they do not meet the definition of an 
unanticipated problem involving risks to 
participants or others, report summary 
information at the time of continuing review 
Adverse events will be 
reported in the toxicity 
table in the DSM report 
which is typically due 
every 6 months. 
The most current 
toxicity table from the 
DSM report is provided 
to the FDA with the 
IND’s annual report. 
Notify monthly via AE 
notification or cross-reporting 
reports/documents. 

Protocol Amendment 16, 10/06/2021 
 
page 69 of 70 
Routine Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
Merck & Co. 
Minor deviation 
Report summary information at the time of 
continuing review. 
 
 
 
Complaints 
If the complaint reveals an unanticipated problem 
involving risks to participants or others OR 
noncompliance, report within 10 working days.  If 
the event results in the death of a participant 
enrolled at WU/BJH/SLCH, report within 1 
working day.  Otherwise, report at the time of 
continuing review. 
 
 
 
Incarceration 
If withdrawing the participant poses a safety 
issue, report within 10 working days.   
 
If withdrawing the participant does not represent a 
safety issue and the patient will be withdrawn, 
report at continuing review. 
 
 
 
 
Expedited Reporting Timelines for Secondary Sites 
Event 
WU (Coordinating Center) 
Local IRB 
FDA 
Merck & Co. 
Serious AND unexpected 
suspected adverse reaction 
Report no later than 11 calendar days 
after it is determined that the information 
qualifies for reporting. 
Report all applicable 
events to local IRB 
according to local 
institutional guidelines. 
The research team at 
Washington University is 
responsible for reporting all 
applicable events to the 
FDA as needed. 
The research team at 
Washington University is 
responsible for reporting all 
applicable events to Polaris 
as needed. 
Unexpected fatal or life-
threatening suspected 
adverse reaction 
Report no later than 4 calendar days after 
initial receipt of the information. 
Unanticipated problem 
involving risk to participants 
or others 
Report no later than 4 calendar days after 
initial receipt of the information. 
Adverse event or SAE that 
does not require expedited 
reporting 
As per routine data entry expectations 
Protocol exception 
Approval must be obtained prior to 
implementing the change. 
 
 

Protocol Amendment 16, 10/06/2021 
 
page 70 of 70 
APPENDIX D: Washington University Serious Adverse Event Reporting Cover Sheet 
 
SAE COVER SHEET- Secondary Site Assessment 
 
Washington University HRPO#:  
Sponsor-Investigator:  
Subject Initials:   
Subject ID:  
Treating MD:  
Treating Site:  
EVENT TERM:  
Event Start Date:  
EVENT GRADE: 
Date of site’s first notification: 
 
Treating MD Event Assessment:  
 
 
Is this event possibly, probably, or definitely related study treatment? 
 
 yes  
 
 no 
 
If yes, please list which drug (if more than one)______________________________ 
 
       
Explain ______________________________________________________________________ 
 
______________________________________________________________________________ 
 
 
 
_________________________           ___________________________      _________________  
Physician’s Name 
 
 
Physician’s Signature 
 
Date