Phase II Trial of Immune Checkpoint Inhibitor With Anti-CD3 x Anti-HER2 Bispecific Antibody Armed Activated T Cells in Metastatic Castrate Resistant Prostate Cancer
Phase: PHASE2
Conditions: Castration Levels of Testosterone, Castration-Resistant Prostate Carcinoma, Prostate Carcinoma Metastatic in the Bone, PSA Progression, Stage IV Prostate Adenocarcinoma AJCC v7
Sponsor: Barbara Ann Karmanos Cancer Institute

 
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Phase II Trial of Immune Checkpoint Inhibitor Pembrolizumab  
with Anti-CD3 x Anti-HER2 Bispecific Antibody Armed Activated T Cells in  
Metastatic Castrate Resistant Prostate Cancer 
 
 IND# 9985 
 
PRINCIPAL INVESTIGATOR 
Abhinav Deol, M.D. 
Department of Oncology 
Barbara Ann Karmanos Cancer Institute 
Wayne State University 
Tel # 313-576-8093 
Fax # 313-576-8767 
E-mail: deola@karmanos.org 
 
CO-PRINCIPAL INVESTIGATOR and IND Sponsor BB-IND 9985 
Lawrence G. Lum, M.D., D.Sc. (BATS, LLC) 
Professor of Medicine 
Department of Medicine 
Emily Couric Cancer Center 
University of Virginia 
Tel # 434-243-1375 
Fax # 434-297-4141 
E-mail: lgl4f@virginia.edu  
 
CO-INVESTIGATORS 
 
Ulka Vaishampayan, M.D.  
Chair, GU Oncology Team 
Director, Phase I Clinical Trial Program  
Professor of Oncology 
Barbara Ann Karmanos Cancer Institute  
Wayne State University 
Tel # 313-576-8715 
Fax # 313-576-8487 
E-mail: vaishamu@karmanos.org 
 
Archana Thakur, Ph.D. 
Assistant Professor 
Department of Medicine 
Emily Couric Cancer Center 
University of Virginia 
Tel # 434-243-1397 
E-mail: AT2FX@virginia.edu 
 
Elisabeth Heath, M.D.    
Department of Oncology 
Barbara Ann Karmanos Cancer Institute 
Wayne State University 
Tel # 313-576-8715 
Fax # 313-576-8767 
E-mail: heathe@karmanos.org 

 
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Wael Sakr, M.D.  
Department of Pathology 
Wayne State University 
Tel # 313-745-2525 
E-mail: sakrw@karmanos.org 
 
Dongping Shi, M.D. 
Department of Pathology 
Wayne State University 
Tel # 313-745-2534 
E-mail: dshi@dmc.org 
 
Frank Cackowski M.D. 
Department of Oncology 
Barbara Ann Karmanos Cancer Institute 
Wayne State University 
Tel # 313-576-8321 
E-mail: cackowskif@karmanos.org 
 
BIOSTATISTICIAN 
Wei Chen, Ph.D. 
Department of Oncology 
Barbara Ann Karmanos Cancer Institute 
Wayne State University 
Tel # 313-576-8655 
E-mail: chenw@karmanos.org 
 
STUDY COORDINATORS 
 
Amber Ruyle BSClinical Trials Office 
Barbara Ann Karmanos Cancer Institute 
Tel # 313-576-8506 
Fax # 313-576-9212 
E-mail: ruylea@karmanos.org 
 
Kimberlee C. Dobson 
Clinical Trials Office 
Barbara Ann Karmanos Cancer Institute 
Tel # 313-576- 9837 
Fax # 313-576-8974 
E-mail:  
dobsonk@karmanos.org 
 
REGULATORY COORDINATOR 
Amal Idrees CRC-II 
Clinical Trial Office 
Barbara Ann Karmanos Cancer Institute 
Tel # 313-576-4296 
Fax # 313-576-9684 
Email idreesa@karmanos.org 
 

 
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GRANTS AND CONTRACTS 
Mary Jo O’Loughlin 
Research Administration 
Barbara Ann Karmanos Cancer Institute 
Tel # 313-578-4405 
Fax # 313-578-4419 
E-mail: moloughl@wayne.edu 
 
 
Study Synopsis 
Prostate cancer (PC) is the most common cancer in American men. Most of the deaths related to 
PC are from metastatic disease. Despite recent advances in treatment options, progression 
eventually occurs and metastatic castrate resistant prostate cancer (mCRPC) remains an 
incurable disease. Novel therapies are needed to induce long term remission, decrease pain, and 
improve survival in mCRPC. Sipuleucel T has demonstrated an overall survival (OS) benefit in 
mCRPC, but given the modest magnitude of benefit and rare anti-tumor responses, better 
immune therapies are clearly needed [1]. In this protocol, we will combine the novel immune 
therapy of antibody activated T cells with anti-PD-1 (programed death receptor 1) therapy of 
pembrolizumab to achieve durable anti-tumor responses in mCRPC patients.  
 
Arming anti-CD3 activated T cells (ATC) with anti-CD3 x anti-HER2 bispecific antibody (HER2Bi) 
transforms every T cell into a specific cytotoxic T cell directed against prostate cancer. HER2 is 
overexpressed in about 42-70% of mCRPC cases, and HER2 expression has prognostic 
significance [1]. Preclinical data revealed that bispecific antibody armed T cells (BATs) kill even 
tumors that express low levels of HER2; responses and tumor cell kill were noted in a clinical trial 
in triple negative breast cancer [2].  A phase I study using HER2Bi armed ATC (HER2 BATs) in 
metastatic breast cancer (MBC) induced immune responses and encouraging survival results with 
a median OS of 27 months in the HER2 negative group [3].  Immune responses in a phase I 
clinical trial in mCRPC patients suggest that infusions of HER2 BATs "vaccinate" the patients 
against their own PC by inducing brisk anti-tumor responses [4].  Seven pretreated patients with 
mCRPC were enrolled. There were no dose limiting toxicities, and three of seven patients 
demonstrated significant decreases in their prostate-specific antigen (PSA) levels and relief of 
bone pain. Immune evaluations of peripheral blood mononuclear cells in two patients before and 
after immunotherapy showed increases in interferon-gamma (IFN-γ) ELISpot responses and Th1 
serum cytokines. The preclinical and clinical results provide the rationale for development of a 
phase II trial to determine the anti-tumor efficacy of BATs in mCRPC.  
 
Prostate cancer bone metastases have immunosuppressive characteristics with overexpression 
of CTLA-4, and increased PD-1 expression, that has been reported in the tumor infiltrating 
lymphocytes in prostate cancer metastases [5]. Agents such as CTLA-4, PD-1 and PD-L1 
inhibitors are rapidly becoming the mainstay of immune therapy in solid tumors; however, a phase 
III trial of ipilimumab, a CTLA-4 inhibitor, showed no clinical benefit in mCRPC, and preliminary 
evaluation of PD-1 inhibitors also showed a lack of promising clinical activity.  While immune 
checkpoint inhibitors may not be effective in PC alone, there is data to suggest that they can 
enhance the anti-tumor effect of targeted therapy [6]. We propose adding a monoclonal antibody 
inhibitor of PD-1 (pembrolizumab) to BATs therapy in an attempt to overcome 
immunosuppression and enhance anti-cancer effect.  
 
We will conduct a phase II study in mCRPC patients, to estimate the clinical efficacy of 8 infusions 
of HER2 BATs (up to 1010/infusion) twice per week for 4 weeks in combination anti-PD-1 therapy 
with pembrolizumab once every 3 weeks starting 3 weeks before the 1st BATs infusion by 
assessing the percentage of patients free of clinical progression at 6 months after registration. 
We hypothesize that infusions of HER2 BATs will induce measurable immunologic changes and 

 
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evidence of clinical efficacy and that blocking PD-1 signaling will enhance the T cell mediated 
killing. We will also estimate the magnitude of change in anti-PC immune functions and markers, 
after infusions of HER2 BATs in mCRPC and evaluate the magnitude of increase in tumor 
infiltrating T cells, PD-1 expression, and the Th1/Th2 ratio in prostate cancer tumor tissue before 
and after immunotherapy.  
 
 

 
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Table of Contents 
1.0     OBJECTIVES ........................................................................................................ 5 
2.0     BACKGROUND AND RATIONALE ....................................................................... 5 
3.0     ELIGIBILITY ........................................................................................................ 13 
4.0     TREATMENT PLAN ............................................................................................ 15 
5.0     POTENTIAL TOXICITY, DOSE MODIFICATION, AND MANAGEMENT ............. 18 
6.0     DRUG FORMULATION ....................................................................................... 24 
7.0     PREPARATION OF HER2Bi ARMED ACTIVATED T CELLS ............................. 27 
8.0     REGISTRATION AND REQUIRED DATA ........................................................... 28 
9.0     CRITERIA FOR EVALUATION ........................................................................... 32 
10.0   CRITERIA FOR REMOVAL OF PATIENTS FROM STUDY ................................ 33 
11.0   REPORTING ADVERSE REACTIONS ............................................................... 33 
12.0   CORRELATIVE TESTING................................................................................... 38 
13.0   STATISTICAL CONSIDERATIONS ..................................................................... 41 
14.0   CLINICAL DATA SAFETY MONITORING ........................................................... 42 
15.0   REFERENCES.................................................................................................... 45 
16.0   APPENDICES ..................................................................................................... 49 

 
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1.0 OBJECTIVES 
 
1.1 Primary Objectives: 
 
1.1.1 Phase II clinical trial to estimate efficacy. Conduct a phase II study in mCRPC 
patients, to estimate the clinical efficacy of 8 infusions of HER2 BATs (up to 1010/infusion) 
twice per week for 4 weeks in combination with pembrolizumab once every 3 weeks starting 
with one dose 1 week  before the 1st BATs infusion, by assessing the percentage of patients 
free of clinical progression at 6 months after registration. 
 
1.2 Secondary Objectives: 
 
1.2.1 Monitor immune responses. Evaluate phenotype, cytokine profiles and IFN-γ 
ELISpots, cytotoxicity and antibodies directed at laboratory prostate cancer cell lines for proof 
of principle of immune system activation and to correlate with clinical outcomes of response, 
progression free survival (PFS), and overall survival (OS). 
 
1.2.2 Monitor changes in tumor infiltrating T cells, PD-1 expression, and Th1/Th2 ratio. 
Evaluate the magnitude of change in tumor infiltrating T cells, PD-1 expression, and the 
Th1/Th2 ratio in prostate cancer tumor tissue before and after immunotherapy and correlate it 
with the clinical outcomes of response, PFS, and OS. 
 
 
2.0 BACKGROUND AND RATIONALE 
 
2.1 Castrate Resistant Prostate Cancer:  Prostate cancer (PC) is the most common cancer in 
American men, and the majority of deaths related to PC are from metastatic disease. Despite 
current advances, metastatic PC remains an incurable malignancy. Androgen deprivation therapy 
that suppresses testosterone is effective for a limited period of time, and with the development of 
the castrate resistant state, the addition of chemotherapy, androgen receptor targeted agents, 
and immunotherapy have proven overall survival benefit. Despite these advances, metastatic 
castrate resistant prostate cancer (mCRPC) remains incurable, and novel therapies to achieve a 
cure continue to be a priority. The modest but statistically significant overall survival (OS) benefit 
seen with sipuleucel-T provides proof of principle of the potential of immunotherapy in prostate 
cancer [7].  
 
2.2 HER2 in Prostate Cancer: HER2 expression in 42%-70% of prostate cancers is associated 
with shorter prostate cancer specific survival and higher relapse rates in those with higher 
expression of HER2 compared to those who are HER2 negative [1,8]. Serum levels of HER2 were 
significantly higher in PC patients than controls without cancer and the levels were significantly 
higher in patients with metastatic disease [9]. Furthermore, in localized disease, higher levels 
correlated with shorter times to recurrence [9]. HER2 expression in PC cells increases with 
progression to androgen independence [10,11]. Forced HER2 over-expression in a LAPC-4 PC 
model confers androgen-independent growth to androgen-dependent PC cells [12]. This reveals 
the role and significance of HER2 expression in the progression and survival of CRPC. 
Unfortunately, a unique opportunity to evaluate the effects of trastuzumab, an anti-HER2 
monoclonal antibody (mAb), in PC patients resulted in early closing of the trial due to poor accrual 
of HER2+ (≥ 2+) PC patients [13]. Another phase II clinical trial failed to demonstrate any benefit 
for trastuzumab in CRPC patients suggesting that antibody therapy alone is not potent enough to 
impact PC progression [14]. In a phase II advanced prostate and renal cancer trial using the 
bispecific antibody (BiAb) MDX-H210 (15 g/m2) IV and granulocyte macrophage colony-
stimulating factor (GM-CSF) 5 g/kg/day subcutaneously for 4 days repeated weekly for 6 weeks, 
7 of 20 (35%) patients with prostate cancer had PSA responses (>50% decline in PSA) [15]. Our 

 
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approach combines BiAb and activated T cells (ATC) to direct the non-MHC restricted cytotoxicity 
mediated by activated T cells via independent mechanisms of killing. HER2 BATs induce an 
immune response even in instances of low receptor HER2 receptor expression (e.g. targeting and 
cytotoxicity of breast cancer cell lines that are HER2 negative) or if receptors are present but 
inactivated, conditions that would otherwise impact negatively on treatment outcome with mAb 
therapy alone.  
 
2.3 HER2 Bispecific Antibody Armed T Cells (BATs): Peripheral blood mononuclear cells 
(PBMCs) collected with pheresis are activated ex-vivo with OKT3 to generate activated T cells 
(ATC). These ATC are subsequently “armed” with 
BiAb that targets CD3 and HER2. Arming ATC with 
HER2 BiAb (HER2 BATs) makes every T cell into a 
non-MHC restricted HER2-specific cytotoxic T 
lymphocyte (CTL) [16]. BATs showed repeated 
killing, proliferation, and release of several cytokines 
that induce DC maturation. Dying tumor cells release 
tumor associated antigens (TAA) that can lead to 
increased cross-presentation and epitope spreading 
of TAA by antigen presenting cells. This mechanism, 
illustrated in Fig 1, may vaccinate patients against 
their own TAA. Preclinical studies showed that 
HER2 BATs killed prostate, breast, and ovarian 
cancer cell lines, secreted cytokines, and inhibited 
tumor growth in mice [17,18,19,20].   
 
2.4 Programmed Cell Death Receptor 1 (PD-1): Immune checkpoint pathways restrict T cell 
activation and limit immune activation to minimize normal tissue damage. PD-L1 is a receptor 
expressed by T cells upon activation. PD-1 signaling is activated in T cells in response to PD-L1 
or L2 engagement and limits effector T-cell activity in peripheral tissues to limit normal tissue 
damage. This PD-1/PD-L1/2 pathway is hijacked by cancers to limit anti-tumor immune response 
and immune surveillance [21]. In prostate cancer bone metastases PD-1 expression is reported 
to be one of the reasons for resistance to immunotherapies. mAbs blocking PD-1 or PD-L1 have 
shown efficacy in a variety of cancers. Unfortunately, early phase trials in prostate cancer failed 
to show clinical benefit using anti-PD-1 treatment alone; however, anti-PD-1 does increase the 
efficacy of active immunotherapies such as CAR T cells [5]. Combining PD-1 blockade with the 
specific targeting of HER2 BATs may increase the likelihood of clinical benefit for mCRPC 
patients. Hence our study design incorporates the therapeutic strategy of PD-1 inhibition and 
assesses the expression of PD-1 in tumor tissue biopsies pre and post therapy. 
 
2.5 HER2 BATs Target High HER2 SK-BR-3 and Low HER2 SUM 1315 Expression Cell 
Lines: Preclinical studies showed that HER2 BATs were able to lyse breast cancer cells lines 
that expressed not only high amounts of HER2 (SK-BR-3, high 3+ expression) but, more 
importantly, target and lyse cell lines that express little (MCF-7, a negative control for 
immunohistochemistry) or essentially no HER2 expression (Sum, 1315) [22]. While this is not a 
major concern based on cell line expression, it is reassuring to know that only a few molecules of 
the target antigen on the tumor surface are sufficient to allow binding and triggering of specific 
cytotoxicity (Fig 2). This is consistent with the observation that as few as 10-30 TCR-ligand 
interactions are sufficient to mediate T cell killing [23].  
 
Fig 1: Infusion of targeted T cells induces anti-tumor 
immune responses. T cells kill tumor cells releasing 
cytokines and chemokines that induce DC maturation 
followed by antigen presentation of unknown tumor 
antigens to “vaccinate” the patient against their own 
TAA.
HER2Bi 

 
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2.6 Phase I Safety, Immune and Clinical 
Responses in Metastatic Breast Cancer 
(MBC): A phase I trial in 23 women with 
HER2 0-3+ pretreated MBC consisted of 8 
infusions of HER2 BATs in combination 
with IL-2 and GM-CSF to evaluate safety, 
feasibility, PFS, OS, T cell trafficking and 
immune responses. The median OS for 8 
HER2 3+ patients, 14 HER2 0-2+ patients, 
and all patients were 57.4, 27.4, and 36.2 
months, respectively (Fig 3). Targeting 
HER2 positive and negative tumors 
induced cytotoxic anti-tumor responses, 
increases in Th1 cytokines, and IL-12 
serum levels. These robust immune 
responses suggest that BATs infusions 
may provide a clinical benefit [24,25]. The HER2 BATS 
infused into MBC patients in the phase I trial were safe 
and induced immune and clinical responses. BATs 
infusions induced endogenous immune cells to 
develop anti-breast cancer CTL. This study provides 
PROOF of CONCEPT that BATs can vaccinate and 
provide adoptive transfer of immune cells.  
 
2.7 Preclinical Studies that Support Proposed Research: 
 
2.7.1 HER2 expression on prostate cancer cells.  The prostate cancer cell lines PC-3, 
DU-145, and LNCaP express easily detectable 
levels of HER2 (Fig 4).  SK-BR-3, a breast 
cancer cell line 
that 
exhibits 
high levels of 
expression of 
HER2 is shown 
as a positive 
control and an 
isotype control 
(goat anti-mouse, GaM) was used as the negative control. 
 
2.7.2 HER2 BATs prevent prostate cancer development 
in Winn Assay and induce remission in SCID mice.  SCID-
beige mice were injected subcutaneously in the right rear 
flank with 106 PC-3 tumor cells mixed with IL-2 alone (300 IU), 107 unarmed ATC and IL-2, 
and 1-2 × 107 HER2 BATs and IL-2 (n = 8 mice per group). Fig 5 shows the time to tumor 
formation in each group. None of the mice in the HER2 BATs treated group developed tumors 
Fig 3. Median OS is 57.4 months for the HER2 
3+ group (red), 27.4 months for the HER2 0-2+ 
(blue) group, and is 36.2 months for the entire 
group (black). 
0
10
20
30
40
50
60
70
80
90 100
0
20
40
60
80
100
120
Her2 -ve
Her2 3+
All
Months
Percent survival
Fig 5. Her2 BATs (Her2Bi-aATC) prevent 
tumor growth in Winn Assay.  
Fig 4 
Fig 2. Cytotoxicity remains high in very low HER2 expressing 
SUM1315. a) Western blot showing HER2 protein expression in low 
(SUM1315) and high (SK-BR-3) HER2 expressing breast cancer 
cell lines. b) Flow cytometry data showing that 95% cells were 
HER2 positive in SK-BR-3, while only 6.7% cells were HER2 
positive in SUM 1315 cells.  c) Cytotoxicity remains high in very low 
HER2 expressing cell line.  

 
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GM-CSF
TNF
IFN
IL-4
Pg/106
0
500
1000
1500
2000
Her2Bi 
ATC 
Irrel 
Fig 9 
Fig 8 
at 100 days when >50% of all other groups showed tumor progression. In a separate 
experiment, SCID-beige mice with established PC-3 tumors were treated with IL-2, or HER2 
BATs (1 or 5x107 cells) and IL-2 twice a week until remission or euthanization due to 
excessive tumor burden. 8 of 8 mice treated with IL-2 alone were euthanized after 6 weeks. 
1 of 8 mice treated with 1x107 HER2 BATs and 2 of 8 mice treated with 5x107 HER2 BATs 
went into remission lasting 96 and 136 days, respectively [18]. 
 
2.7.3 BATs kill PC-3, DU-145, and LNCaP PC cell lines. In 51Cr release cytotoxicity assays, 
arming of ATC with HER2Bi significantly enhanced lysis of PC-3, DU-145 and LNCaP targets 
(Fig 6). ATC were expanded from PBMC from normal subjects or cancer patients by anti-
CD3 activation and expansion in low dose IL-2 as described [22]. After 14 days, ATC were 
harvested, counted, and armed with HER2Bi or irrelevant (OKT3 x CD20). Fig 7 shows the 
cytotoxicity directed at PC-3 line mediated by ATC from 6 cancer patients and 10 normal 
donors armed with 5, 50 and 500 ng of HER2Bi /106 ATC or 50 ng of CD20Bi at E/T intervals 
of 5-6.25, 10-12.5, and 20-25. The mean and medians for specific cytotoxicity directed at PC-
3 by HER2 BATs for each group are represented in box plots at the E:T intervals indicated. 
Unarmed ATC-mediated specific lysis was significantly lower than BATs in the normal donor 
(p=0.017) and patient (p=0.04) groups. 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.7.4 BATs secrete cytokines and chemokines when engaging targets cells. Fig 8 
shows the specific cytotoxicity directed at PC-3, DU-145, and LNCaP by HER2Bi BATs from 
3 normal donors (N1, N2, and N3). Cytokines and chemokines are released from the BATs 
when the BATs are exposed to PC-3 tumor cells (Fig 9). There was an increase in Th1 
cytokines GM-CSF, tumor necrosis factor α (TNFα), and IFNγ by 7-, 54-, and 58-fold, 
respectively, but not the Th2 cytokine IL-4 when compared to unarmed ATC or ATC armed 
with an irrelevant (Irrel) BiAb (anti-CD3 x anti-CD20) [2].  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig 6 
Fig 7 

 
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2.8 Phase I HER2 BATs Trial Shows Safety, PSA Responses and Decreased Bone Pain in 
PC: A phase I dose escalation safety trial was conducted with BATs in patients with mCRPC [4]. 
The patients received 2.5, 5 or 10 x 109 BATs per infusion in combination with low dose interleukin 
2 (IL-2) and GM-CSF. All 7 men had bone metastases and 2 had lung and liver involvement. 
Three patients had progressed after chemotherapy. Expansion was done using a single pheresis. 
The total doses achieved ranged from 20 -80 billion.  There were no dose-limiting toxicities (DLT) 
at the doses tested. The only clinically 
relevant toxicity noted was grade 3 rigors 
requiring meperidine.  Overall survival 
ranged from 68 to 598 days (median 170 
days). Three patients experienced a 
decrease in bone pain with a concomitant reduction in their pain medications. All infusions were 
done in the outpatient clinic. One patient who received 40 x 109 BATs had a partial response with 
his PSA decreasing from 32 to 12 that persisted for about 4 months (Fig 10). Two other patients 
had transient decreases in their bone pain and PSA levels. Immune evaluations of fresh 
peripheral blood mononuclear cells in 3 responding patients before and after immunotherapy 
showed increases in IFN-γ ELISpot responses (Fig 11) and Th1 serum cytokines. The pheresis 
products contained a median of 15.1x109 (9.4-25) PBMC prior to 11-16 days of culture which 
yielded a median of 40 x 109 (32-139) ATC after culture.  There was a median viability of 95% 
(90-97%), a median %CD3 of 89 (31-99), a median %CD4 of 51 (19-75), and a median % CD8 
of 34 (2-62) after culture.  
 
Polarized Th1/Th2 and increased levels of IL-12. Serum samples were obtained prior to each 
infusion and tested for IL-2, IL-4, IL-5, IL-10, IL-12 p70, IL-13, GM-CSF, IFNγ, and TNF-α using 
the Bio-Plex Protein Array System. The immune response in 2 CRPC patients remained polarized 
towards a Th1 response throughout treatment (Fig 12). The ratio of type1/type 2 was also highly 
polarized to a type 1 response (data not shown).  Serum levels of IL-12 dramatically increased 
after the 3rd -4th infusion of BATs (Fig 13).  Since IL-12 is produced by endogenous monocytes, 
these data provide evidence of “vaccination” of the endogenous immune system.  
 
In addition, a phase I trial 
in breast cancer has well 
established 
the 
clinical 
safety 
and 
preliminary 
efficacy of BATs. The 
predominant 
toxicities 
noted in this study were 
fever, 
chills 
and 
headaches. 
The 
trial 
enrolled 
22 
pre-treated 
metastatic breast cancer 
patients. 
The 
adverse 
Fig 11 
Fig 10 
Fig 12 
Fig 13 

 
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event incidence increased with increasing doses of BATs. The incidence of chills was 8.6, 20.8, 
and 43.1% at dose levels 1, 2, and 3, respectively. The incidence of headaches was 3.1, 8.3, and 
19.6% at dose levels, 1, 2, and 3, respectively. All patients with grade 3 chills responded to 
meperidine. One patient at dose level 3 experienced a grade 4 headache and hypertension and 
was removed from the study after 3 infusions (65.7 × 109 total aATC). Evidence of clinical and 
immunologic responses in women with HER2 0/1+ status in the Phase I trials suggests a 
therapeutic benefit even in the absence of HER2 over-expression and provides encouraging 
results in HER2 low-negative patients treated with armed activated T cells [16]. The median 
overall survival (OS) was 36.2 months for all 23 patients (22 evaluable and 1 non-evaluable = 23), 
57.4 months for the HER2 3+ patients, and 27.4 months for the HER2 0–2+ patients. BATs 
infusions induced endogenous cytotoxic T-cell and immunokine responses that persisted up to 4 
months [16]. The findings showed that cellular immune responses develop and may augment 
immune based killing of tumors even in patients who were progressing. One explanation for the 
encouraging OS in HER2 0–2+ patients could be a polyclonal immune responses that may target 
residual chemotherapy resistant HER2 positive “cancer stem-like cells” (CSC) that exhibit self-
renewal properties and are responsible for cancer relapse. Prior studies also suggest that anti-
HER2 reagents may be effective against HER2 positive CSC in tumors that are primarily HER2 
negative [16].  
 
2.9 Immune Check Point Inhibitors Enhance EGFR BATs Function: It has been demonstrated 
that combining ipilimumab, a CTLA-4 immune checkpoint inhibitor, with T cells armed with anti-
CD3 x anti-EGFR bispecific antibody (EGFR BATs) can enhance the anti-tumor activity of BATs. 
In PBMC from healthy individuals, the addition of ipilimumab at the initiation of culture significantly 
enhanced T cell 
proliferation 
(p = 0.0029). 
Fig 
14a 
shows 
the 
dose titration effect 
on cytotoxicity in 
the presence or 
absence of EGFR 
BATs, and Fig 14b 
shows 
increased 
killing by normal 
EGFR BATs in the 
presence or absence of ipilimumab at an E:T of 25:1 for COLO356/FG. Fig 14c shows the same 
experiments for 3 colorectal patients. BATs infusions increased the secretion of chemokines 
CCL2, CCL3, CCL4, CCL5, CXCL9, and GM-
CSF [data not shown]. Fig 15 shows that higher 
doses of ipilimumab in the presence of EGFR 
BATs increase IFN-γ, IL-2R, IL-12, and IL-10 
secretion, while reducing IL-10 secretion [6].  
These data provide the rationale for combining 
BATs and an immune checkpoint inhibitor.  
 
In PBMC from healthy individuals, the addition 
of ipilimumab at the initiation of culture 
significantly enhanced T cell proliferation (p = 
0.0029). 
 Anti-CD3 
monoclonal 
antibody 
activated T cells (ATC) grown in the presence 
of ipilimumab showed significantly increased 
mean 
tumor-specific 
cytotoxicity 
at 
Fig 15 
Fig 14 
c
b
a 

 
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effector:target (E:T) ratio of 25:1 directed at COLO356/FG and Daudi by 37.71% (p < 0.0004) and 
27.5% (p < 0.0004), respectively, and increased the secretion of chemokines (CCL2, CCL3, 
CCL4,CCL5, CXCL9, and granulocyte-macrophage colony stimulating factor (GM-CSF)) and 
cytokines (IFN-γ, IL-2R, IL-12, and IL-13), while reducing IL-10 secretion.  Expansion of ATC in 
the presence of ipilimumab significantly improves not only the T cell proliferation but it also 
enhances cytokine secretion and the specific cytotoxicity of T cells armed with bispecific 
antibodies. 
 
2.10 Pembrolizumab: The importance of intact immune surveillance in controlling outgrowth of 
neoplastic transformation has been known for decades.  Accumulating evidence shows a 
correlation between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis 
in various malignancies.  In particular, the presence of CD8+ T-cells and the ratio of CD8+ effector 
T-cells / FoxP3+ regulatory T-cells seems to correlate with improved prognosis and long-term 
survival in many solid tumors. 
 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune 
control.  The normal function of PD-1, expressed on the cell surface of activated T-cells under 
healthy conditions, is to down-modulate unwanted or excessive immune responses, including 
autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig superfamily member related 
to CD28 and CTLA-4 which has been shown to negatively regulate antigen receptor signaling 
upon engagement of its ligands (PD-L1 and/or PD L2).  The structure of murine PD-1 has been 
resolved.  PD-1 and family members are type I transmembrane glycoproteins containing an Ig 
Variable-type (V-type) domain responsible for ligand binding and a cytoplasmic tail which is 
responsible for the binding of signaling molecules.  The cytoplasmic tail of PD-1 contains 2 
tyrosine-based signaling motifs, an immunoreceptor tyrosine-based inhibition motif (ITIM) and an 
immunoreceptor tyrosine-based switch motif (ITSM).  Following T-cell stimulation, PD 1 recruits 
the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif within its cytoplasmic tail, leading 
to the dephosphorylation of effector molecules such as CD3ζ, PKCθ and ZAP70 which are 
involved in the CD3 T-cell signaling cascade.  The mechanism by which PD-1 down modulates 
T-cell responses is similar to, but distinct from that of CTLA-4 as both molecules regulate an 
overlapping set of signaling proteins.  PD-1 was shown to be expressed on activated lymphocytes 
including peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer cells.  Expression 
has also been shown during thymic development on CD4-CD8- (double negative) T-cells as well 
as subsets of macrophages and dendritic cells.  The ligands for PD-1 (PD-L1 and PD-L2) are 
constitutively expressed or can be induced in a variety of cell types, including non-hematopoietic 
tissues as well as in various tumors.  Both ligands are type I transmembrane receptors containing 
both IgV- and IgC-like domains in the extracellular region and contain short cytoplasmic regions 
with no known signaling motifs.  Binding of either PD-1 ligand to PD-1 inhibits T-cell activation 
triggered through the T-cell receptor.  PD-L1 is expressed at low levels on various non-
hematopoietic tissues, most notably on vascular endothelium, whereas PD-L2 protein is only 
detectably expressed on antigen-presenting cells found in lymphoid tissue or chronic 
inflammatory environments.  PD-L2 is thought to control immune T-cell activation in lymphoid 
organs, whereas PD-L1 serves to dampen unwarranted T-cell function in peripheral tissues.  
Although healthy organs express little (if any) PD-L1, a variety of cancers were demonstrated to 
express abundant levels of this T-cell inhibitor.  PD-1 has been suggested to regulate tumor-
specific T-cell expansion in subjects with melanoma (MEL).  This suggests that the PD-1/PD-L1 
pathway plays a critical role in tumor immune evasion and should be considered as an attractive 
target for therapeutic intervention. 
 
Pembrolizumab is a potent and highly selective humanized monoclonal antibody (mAb) of the 
IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-
L1 and PD-L2.  KeytrudaTM (pembrolizumab) has recently been approved in the United States for 

 
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the treatment of patients with unresectable or metastatic melanoma and disease progression 
following ipilimumab as well as in metastatic non-small cell lung cancer. This agent has been 
evaluated in multiple malignancies and has established safety and efficacy profile. 
 
2.11 Rationale for Dose Selection/Regimen/Modification: An open-label Phase I trial (Protocol 
001) is being conducted to evaluate the safety and clinical activity of single agent pembrolizumab 
(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 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 was identified 
to date.  10.0 mg/kg Q2W, the highest dose tested in PN001, was the dose and schedule utilized 
in multiple cohorts 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. 
 
Pharmacokinetic (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 pharmacodynamics (PD) data provides scientific rationale 
for utilizing a Q3W dosing schedule.   
 
A population PK analysis of pembrolizumab was performed using serum concentration time data 
from 476 patients. Within the resulting population PK model, clearance and volume parameters 
of pembrolizumab were found to be dependent on body weight. The relationship between 
clearance and body weight, with an allometric exponent of 0.59, is within the range observed for 
other antibodies and would support both body weight normalized dosing or a fixed dose across 
all body weights.  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. 
 
The rationale for further exploration of 2 mg/kg and comparable doses of pembrolizumab in solid 
tumors is based on: 1) similar efficacy and safety of pembrolizumab when dosed at either 2 mg/kg 
or 10 mg/kg Q3W in melanoma patients, 2) the flat exposure-response relationships of 
pembrolizumab for both efficacy and safety in the dose ranges of 2 mg/kg Q3W to 10 mg/kg Q3W, 
3) the lack of effect of tumor burden or indication on distribution behavior of pembrolizumab (as 
assessed by the population PK model) and 4) the assumption that the dynamics of 
pembrolizumab target engagement will not vary meaningfully with tumor type. 
 
The choice of the 200 mg Q3W as an appropriate dose for the switch to fixed dosing is based on 
simulations performed using the population PK model of pembrolizumab showing that the fixed 
dose of 200 mg every 3 weeks will provide exposures that 1) are optimally consistent with those 
obtained with the 2 mg/kg dose every 3 weeks, 2) will maintain individual patient exposures in the 
exposure range established in melanoma as associated with maximal efficacy response and 3) 
will maintain individual patients exposure in the exposure range established in melanoma that are 
well tolerated and safe.  

 
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A fixed dose regimen will simplify the dosing regimen to be more convenient for physicians and 
to reduce potential for dosing errors.  A fixed dosing scheme will also reduce complexity in the 
logistical chain at treatment facilities and reduce wastage. Hence the dose used in this study 
is 200mg IV every 3 weeks.  
 
2.12 Summary of Clinical and Preclinical Data: Preclinical testing of HER2 BATs revealed 
efficacy in binding and killing PC-3, DU-145, and LNCaP cell lines [25,26]. PC-3 cells are low 
expressors of HER2; despite this cell kill was observed.  Anti-CD3 cross-linking leads to T cell 
activation, proliferation, and cytokine synthesis [27-30]. T cells expanded in IL-2 after anti-CD3 
activation exhibited non-major histocompatibility restricted cytotoxicity, and produced tumoricidal 
cytokines such as IFNγ, TNFα, and GM-CSF [31-41]. HER2 BATs administered with PC-3 (Winn 
Assay) or injected intratumorally prevented development of, or induced remissions, respectively, 
in PC-3 tumors in severe combined immunodeficient beige mice [18]. Intravenously administered 
BATs localized to PC-3 xenografts mediated cytotoxicity toward tumor cells and produced 
significant delay in tumor of PC-3 tumors, but not in HER2-negative LS174T colon 
adenocarcinoma xenografts. By flow cytometry analyses, HER2 BATs had a proliferative 
advantage over unarmed ATCs and persisted in the circulation and tumor tissues longer than 
unarmed ATCs. The addition of CTLA-4 immune check point inhibitor enhanced T cell proliferation 
and cytotoxicity in vivo.  
 
These findings suggest that HER2 BATs therapy in combination with anti-PD-1 monoclonal 
antibody may be an effective, nontoxic, tumor-specific treatment for HER2-positive mCRPC. 
 
3.0 ELIGIBILITY 
 
3.1 Subject Inclusion Criteria: In order to be eligible for participation in this trial, the subject 
must: 
1. 
Be willing and able to provide written informed consent/assent for the trial 
2. 
Be > 18 years of age on day of signing informed consent 
3. 
Have histologically confirmed prostate adenocarcinoma, with metastases  
4. 
Progression by either PSA, RECIST 1.1 criteria for measurable disease or new areas of 
metastases on bone scan or symptom progression related to prostate cancer despite 
castrate levels of testosterone. (Level<50 ng/ml) 
5. 
Be agreeable to continue to maintain castrate levels of testosterone  
6. 
At least 2 weeks should have elapsed since any immunosuppressive therapy  
7. 
At least 4 weeks since prior chemotherapy for metastatic disease or at least 2 weeks 
since prior androgen targeting agents such as ketoconazole, abiraterone, 
enzalutamide, etc.  
8. 
Discontinue anti-androgens prior to therapy; at least 6 weeks since last dose of 
bicalutamide or nilutamide and at least 4 weeks from last dose of flutamide  
9. 
Have adequate  bone marrow, renal and hepatic function as deemed by the treating 
physician to be clinically acceptable 
10. Not have concurrent anti-cancer therapy 
11. Not have concurrent immunosuppressive therapy or medical condition likely to cause 
immunosuppression 
12. Have life expectancy > 6 months 
13. Have a performance status of 0 or 1 on the ECOG/Zubrod  Performance Scale 
14. Agree to use an adequate method of contraception starting with the first dose of study 
therapy through 120 days after the last dose of study therapy 

 
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Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception 
for the subject 
15. Demonstrate adequate organ function as defined in Table 1. All screening labs should 
be performed within 28 days of  registration. 
 
Table 1. Adequate Organ Function Laboratory Values 
System 
Laboratory Value 
Hematological 
 
Absolute neutrophil count (ANC) 
≥1,500 /mcL 
Platelets 
≥100,000 / mcL 
Hemoglobin 
≥9 g/dL or ≥5.6 mmol/L without transfusion or EPO 
dependency (within 7 days of assessment) 
Renal 
 
Serum creatinine OR 
Measured or calculateda creatinine 
clearance 
(GFR can also be used in place of 
creatinine or CrCl) 
≤1.5 X upper limit of normal (ULN) OR 
 
≥60 mL/min for subject with creatinine levels > 1.5 X 
institutional ULN 
Hepatic 
 
Serum total bilirubin 
≤ 1.5 X ULN OR 
 
Direct bilirubin ≤ ULN for subjects with total bilirubin levels 
> 1.5 ULN 
AST (SGOT) and ALT (SGPT) 
≤ 2.5 X ULN  OR 
≤ 5 X ULN for subjects with liver metastases 
Albumin 
>2.5 mg/dL 
Coagulation 
International Normalized Ratio (INR) or 
Prothrombin Time (PT) 
 
Activated Partial Thromboplastin Time 
(aPTT) 
≤1.5 X ULN unless subject is receiving anticoagulant 
therapy 
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants 
≤1.5 X ULN unless subject is receiving anticoagulant 
therapy 
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants 
a Creatinine clearance should be calculated per institutional standard. 
 
 
3.2 Subject Exclusion Criteria: The subject must be excluded from participating in the trial if the 
subject: 
1. 
Is currently participating and receiving study therapy or has participated in a study of an 
investigational agent and received study therapy or used an investigational device within 
4 weeks of registration. 
2. 
Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy (>10 mg 
of prednisone daily or equivalent steroid doses) or any other form of immunosuppressive 
therapy within 7 days of registration. 
 
 
3. 
Has a known history of active TB   (Bacillus Tuberculosis) 
4. 
Has hypersensitivity to pembrolizumab or any of its excipients. 
5. 
Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study 
Day 1 or has not recovered (i.e. ≤ Grade 1 or at baseline) from adverse events due to 
agents administered earlier. Note:  Subjects with ≤ Grade 2 neuropathy are an exception 
to this criterion and may qualify for the study. 
6. 
Has received major surgery, subject must have recovered adequately from the toxicity 
and/or complications from the intervention prior to starting therapy.   
7. 
Has a known additional malignancy that is progressing or requires active treatment.  
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the 
skin that has undergone potentially curative therapy or in situ cervical cancer. 

 
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8. 
Has known active central nervous system (CNS) metastases and/or carcinomatous 
meningitis.  Subjects with previously treated brain metastases may participate provided 
they are stable (without evidence of progression by imaging for at least four weeks prior 
to registration and any neurologic symptoms have returned to baseline), have no 
evidence of new or enlarging brain metastases, and are not using steroids for at least 7 
days prior to registration.  This exception does not include carcinomatous meningitis 
which is excluded regardless of clinical stability.   
9. 
Has active autoimmune disease that has required systemic treatment in the past 2 years 
(i.e. with use of disease modifying agents, corticosteroids or immunosuppressive drugs). 
Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement 
therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic 
treatment.  
10. Has known history of, or any evidence of active, non-infectious pneumonitis. 
11. Has an active infection requiring systemic therapy. 
12. Has a history or current evidence of any condition, therapy, or laboratory abnormality 
that might confound the results of the trial, interfere with the subject’s participation for 
the full duration of the trial, or is not in the best interest of the subject to participate, in 
the opinion of the treating investigator.   
13. Has known psychiatric or substance abuse disorders that would interfere with 
cooperation with the requirements of the trial. 
14. Father children within the projected duration of the trial, starting with the pre-screening 
or screening visit through 120 days after the last dose of trial treatment. 
15. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent. 
16. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies). 
17. Has known active Hepatitis B (e.g. HBsAg reactive) or Hepatitis C (e.g. HCV RNA 
[qualitative/quantitative] is detected). 
18. Has received a live vaccine within 30 days of registration. Note:  Seasonal influenza 
vaccines for injection are generally inactivated flu vaccines and are allowed; however 
intranasal influenza vaccines (e.g. Flu-Mist®) are live attenuated vaccines, and are not 
allowed. 
19. Has history of cardiac or pulmonary impairment either by clinical history or symptoms or 
cardiac ejection fraction <40%. 
 
 
4.0 TREATMENT PLAN 
 
4.1 Summary: 
 
Table 2. Schema 
Drug 
Dose 
Route Timing 
Pembrolizumab 
200mg 
IV 
Every three weeks beginning after pheresis and at 
least 1 week prior to BATs and continuing up to a 
maximum of9 doses. The interval between 
pembrolizumab should be a minimum of 21 and a 
maximum of 42 days. If pembrolizumab cannot be 
administered for >42 days then it should be 
discontinued. 
BATs 
5-10 billion cells 
IV 
2 times weekly (minimum 42 hours between doses) 
for 4 weeks beginning at least 1 week after 
pembrolizumab. BATs therapy  should be 

 
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administered over a maximum of 8 weeks from first 
dose. Any dose of BATs given after the 8 weeks 
should be considered under the retreatment criteria 
in section 5.7. 
 
The clinical protocol will enroll mCRPC patients who are progressing per Prostate Cancer working 
Group II (PCWGII) criteria, on treatment with androgen suppression therapy [42]. Scientific, 
regulatory, and FDA approval will be obtained for the clinical trial protocol. The study will be 
conducted at Karmanos Cancer Institute (KCI) under the direction of Dr. Deol as the Principal 
Investigator. Dr. Lum at University of Virginia (UVA) will oversee the manufacturing and 
preparation of BATs product which will be shipped to KCI for patient infusion.  
 
Dr. Lum at UVA is the sponsor of the currently active IND #9985 for the BATs therapy and will be 
responsible for manufacturing product and conducting quality checks and shipping it to KCI. Dr. 
Lum will also be responsible for IND reporting and maintenance. Dr. Deol and Dr. Lum will have 
periodic teleconferences and will communicate and exchange information after every patient is 
registered.  
 
All pheresis procedures for the patients enrolled will be conducted in KCI pheresis unit. The fresh 
pheresis product from KCI will be shipped by overnight courier service to UVA GMP laboratory 
for processing (see section 7.0). Pheresis procedure will be done in accordance with institutional 
procedures using mononuclear cells (MNC) collection program. Up to a total of 5 circulating blood 
volumes (CBV) will be processed. Midpoint procedure (after 2 CBVs have been processed) cell 
count from the collection bag will be done to estimate the final yield with the goal of at least 5 x 
109 PBMCs, however, this is not a requirement and any collection will be used for generation of 
activated T cells.  HER2 BATs will be prepared by qualified personnel in the Cancer 
Immunotherapy GMP facility at University of Virginia.   
 
We have selected a dose-range of 5-10 billion HER2 BATs per infusion (a total dose of 40-80 
billion BATs) based on the 
immune and clinical responses 
and proven safety noted in our 
prior phase I trials.  BATs will be 
infused twice a week for 4 weeks 
for a total of 8 doses. Booster 
doses maybe administered after 
assessment of primary endpoint. 
This will be a decision based on 
extent and duration of patient 
response and patient willingness.  
PD-1 inhibitor therapy (MK-3475 
2 mg/kg IV every 3 weeks) will 
start atleast 1 week prior to BATs 
infusion. 
This 
treatment 
will 
continue every 3 weeks thereafter 
until patient continues on study or 
for a maximum of 9 doses If 
patient has any grade 3 or 4 toxicity attributable to the PD-1 inhibitor that is sustained for >12 
weeksdespite adequate treatment then the immune checkpoint inhibitor will be discontinued. 
BATs doses can be held or delayed  if there is grade 2-4 related toxicity that has not resolved to 
grade 1 or less at the time of next dose. Maximum duration for BATs administration will be over 

 
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8 weeks if hold or delay is necessary. The lead time while the patient is on PD-1 inhibitor will allow 
assessment for any toxicity and safety concerns before the initiation of BATs. Disease evaluation 
with scans will occurevery 12 weeks  (+/- 1 week) after first pembrolizumab dose for one year, 
unless progression occurs. The primary endpoint will be the proportion of patients that are free of 
progression at 6 months. Additional clinical outcome parameters will include time to PSA, skeletal 
and radiologic progression, time to next systemic therapy intervention, and overall survival (OS) 
of the patients enrolled on the clinical trial. The response to immune therapy is likely to be delayed 
and an immediate PSA decline or decrease in metastases cannot be expected. We have hence 
chosen a 6 month time point to evaluate patients as being progression free or not, to use as a 
go/no go signal for future development of BATs in mCRPC.  
 
4.2 Activation and Expansion of T cells with OKT3 and IL-2:  Pheresis will be performed at 
KCI, and the fresh pheresis product will be shipped to UVA for processing. Armed ATC are 
prepared in the Cancer Immunotherapy Laboratory at UVA under BB-IND #9985 sponsored by 
Dr. Lum.  The lymphocytes will be activated with anti-CD3 antibody (OKT3) which cross-links the 
CD3 receptors on T cells and activates T cells.  The ATC will be expanded in the presence of IL-
2 up to 14 days.  After culture, ATC will be harvested, washed, armed with OKT3 x Herceptin, 
and cryopreserved in 10% DMSO and 20% protein (albumin or autologous plasma) in liquid 
nitrogen at the doses for IV infusions.  No exogenous IL-2, OKT3, or other culture reagents (e.g. 
medium components) are present in the final cryopreserved product.  Evaluation of cryopreserved 
versus freshly cultured ATC has shown no differences in viability, phenotype, or function (e.g. lytic 
activity, cytokine production, response to cytokines, and proliferation) in these cell preparations. 
The cytotoxicity mediated by ATC armed prior to cryopreservation was equivalent to those armed 
after thawing of cryopreserved ATC.  
 
4.3 Treatment Regimen with BATs:  
 
4.3.1 HER2 BATs infusions. The BATs infusions will be performed by an Oncology 
Certified Nurse trained by the sponsor’s staff on the SOP for infusing the BATs.  An 
infusaport or any central line will be acceptable for infusing the BATs IV. The Immunotherapy 
Program Coordinator will deliver and coordinate the timing and site for thawing the frozen 
product for IV infusions.  All appropriate assurances for identification of product, patient, 
sterility, etc. will be performed during the transfer to the infusion site prior to infusions.  
Frozen BATs will be thawed and infused into the patient at the bedside per SOPs. The time 
for BATs infusions will vary from patient to patient, but the dose of BATs will be given over 
5-15 min based on the endotoxin level calculations.  All patients will be observed for at least 
4 hours after an infusion. If stable, patients will be discharged home.  Dr. Deol, or other 
designated coinvestigators will be responsible for the coordination of infusion activities. The 
protocol will have been approved by the FDA, the KCI Protocol Review Medical Committee, 
and the Wayne State University IRB and the UVA IRB before any clinical studies begin. 
  
4.3.2 Recommended concomitant medications. Patients will not routinely receive pre-
medications for their infusions since earlier patients have not experienced toxicities related 
to ATC infusions.  If there is a history of reactions to ATC or other blood products, then 
Benadryl 50 mg IV or P.O. will be given as a premedication 30 minutes prior to infusion of 
cryopreserved cells. Tylenol, 1000 mg, may be given 30 minutes prior to cell infusion to as 
pre-medications to prevent fever, chills, and pain if there is a history of infusion side effects.  
Demerol 25-50 mg IV may be used to treat chills.  These medications may be repeated 
every 4-6 hours as needed.  Patients will be prehydrated with 250-500 ml of normal saline 
prior to BATs IV infusions. Hydrocortisone (50-100 mg IV) may be given to control severe 
reactions to infusions.   

 
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4.3.3 Ancillary therapy. Patients should receive full supportive care including transfusion 
of blood and blood products, antibiotics, and anti-emetics, when appropriate.  The reason(s) 
for treatment, dosage and the dates of treatment should be recorded. 
 
4.3.4 Steroids/Other therapy. With the exception of steroids for adrenal failure, severe 
hypersensitivity, septic shock, pulmonary toxicity or hormones administered for non-
disease-related condition (e.g. insulin for diabetes), steroids will not be administered.   
 
4.4 Treatment with Pembrolizumab: All patients will receive pembrolizumab infusions once 
every 3 weeks beginning after pheresis and 1 week prior to BATs therapy and ending a maximum 
of 7 months from start of treatment. Merck will supply the pembrolizumab for this study. 
Pembrolizumab will be administered at a dose of 200mg IV over 30 minutes, repeated every 3 
weeks for a maximum of 9 doses. The interval between pembrolizumab doses should be a 
minimum of 21 days and a maximum of 42 days. BATs should be started at least 1 week after the 
first dose of pembrolizumab.  Every effort should be made to target infusion timing to be as close 
to 30 minutes as possible.  However, given the variability of infusion pumps a window of -5 
minutes and +10 minutes is permitted (i.e., infusion time is 30 minutes: -5 min/+10 min).  
 
 
5.0 POTENTIAL TOXICITY, DOSE MODIFICATION, AND MANAGEMENT 
 
5.1 Pheresis Procedure: Reported toxicity from pheresis is minimal. If patients have adequate 
IV access then a central catheter may not be necessary. This will be determined with a vein check 
performed by qualified staff. Patients have a small potential for infection from the placement of 
central catheters. Use of the anticoagulant citrate dextrose may cause symptoms of mild 
hypocalcemia, which are controlled with calcium carbonate (TUMS). 
 
 
5.2 HER2Bi Armed Activated T Cells: Toxicity associated with BATs has been minimal. The 
reported symptoms have been reversible with cessation of therapy.  Most patients treated with 
BATs experienced no side effects during infusions.  Fever and chills were the most common 
reported reaction.  Other rarely reported affects included mild gastrointestinal and neurologic 
symptoms.  Toxicity associated with reinfusion of cryopreserved cells is generally attributable to 
the DMSO preservative.  These include fever, nausea and fatigue. No one has died due to a cell-
related toxicity.  
5.3 Pembrolizumab (MK-3475) Dose Modification: There are no changes in dose for 
pembrolizumab. Treatment can be held for specific toxicities as per Table 3 below. Adverse 
events (both non-serious and serious) associated with pembrolizumab exposure may represent 
an immunologic etiology.  These adverse events may occur shortly after the first dose or several 
months after the last dose of treatment. Pembrolizumab must be withheld for drug-related 
toxicities and severe or life-threatening AEs as per Table 3 below. See Section 5.5 for supportive 
care guidelines, including use of corticosteroids.  
 
 
 
 
 
Table 3. Dose Modification Guidelines for Drug-Related Adverse Events 

 
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Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting Treatment 
Treatment Discontinuation 
Diarrhea/Colitis 
2-3 
 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose 
or inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks 
4 
Permanently discontinue 
Permanently discontinue 
AST, ALT, or 
Increased 
Bilirubin 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose 
3-4 
Permanently discontinue 
(see exception below)a 
Permanently discontinue 
Type 1 diabetes 
mellitus (if new 
onset) or 
Hyperglycemia 
T1DM or  
3-4 
Hold pembrolizumab for new onset Type 
1 diabetes mellitus or Grade 3-4 
hyperglycemia associated with evidence of 
beta cell failure 
Resume pembrolizumab when patients are clinically 
and metabolically stable 
Hypophysitis 
2-4 
Toxicity resolves to Grade 0-1. Therapy 
with pembrolizumab can be continued 
while endocrine replacement therapy is 
instituted 
Toxicity does not resolve within 12 weeks of last dose 
or inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks 
Hyperthyroidism  
3 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose 
or inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks 
4 
Permanently discontinue 
Permanently discontinue 
Hypothyroidism 
 
Therapy with pembrolizumab can be 
continued while thyroid replacement 
therapy is instituted 
Therapy with pembrolizumab can be continued while 
thyroid replacement therapy is instituted 
 
Infusion 
Reaction 
2b 
Toxicity resolves to Grade 0-1  
Permanently discontinue if toxicity develops despite 
adequate premedication  
3-4 
Permanently discontinue 
Permanently discontinue 
Pneumonitis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose 
or inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks 
3-4 
Permanently discontinue 
Permanently discontinue 
Renal Failure or 
Nephritis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose 
or inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks 
3-4 
Permanently discontinue 
Permanently discontinue 
All Other Drug-
Related Toxicityc 
3 or Severe 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose 
or inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks 
4 
Permanently discontinue 
Permanently discontinue 
Note: Permanently discontinue for any severe or Grade 3 drug-related AE that recurs or any life-threatening event. 
a For patients with liver metastasis who begin treatment with Grade 2 AST or ALT, if AST or ALT increases by greater than or equal to 50% 
relative to baseline and lasts for at least 1 week then patients should be discontinued. 
b 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 pre-medicated for the next scheduled dose; 
Refer to Table 4 – Infusion Treatment Guidelines for further management details. 
c Patients with intolerable or persistent Grade 2 drug-related AE may hold study medication at physician discretion.  Permanently discontinue 
study drug for persistent Grade 2 adverse reactions for which treatment with study drug has been held, that do not recover to Grade 0-1 within 12 
weeks of the last dose. 
 
Dosing interruptions are permitted in the case of medical / surgical events or logistical reasons 
not related to study therapy (e.g., elective surgery, unrelated medical events, patient vacation, 
and/or holidays). Subjects should be placed back on study therapy within 3 weeks of the 
scheduled interruption. The reason for interruption should be documented in the patient's study 
record. 
5.4 Concomitant Medications/Vaccinations (allowed & prohibited): Medications or 
vaccinations specifically prohibited in the exclusion criteria are not allowed during the ongoing 

 
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trial.  If there is a clinical indication for one of these or other medications or vaccinations 
specifically prohibited during the trial, discontinuation from trial therapy or vaccination may be 
required.  The investigator should discuss any questions regarding this with the Merck Clinical 
team.  The final decision on any supportive therapy or vaccination rests with the investigator 
and/or the subject's primary physician.  
 
5.4.1 Acceptable concomitant medications. All treatments that the investigator considers 
necessary for a subject’s welfare may be administered at the discretion of the investigator 
in keeping with the community standards of medical care.  All concomitant medication will 
be recorded on the case report form (CRF) including all prescription, over-the-counter 
(OTC), herbal supplements, and IV medications and fluids.  If changes occur during the trial 
period, documentation of drug dosage, frequency, route, and date may also be included on 
the CRF. 
 
All concomitant medications received within 28 days before registration and 30 days after 
the last dose of trial treatment should be recorded.  Concomitant medications administered 
after 30 days after the last dose of trial treatment should be recorded for SAEs and ECIs as 
defined in Section 11.5. 
 
5.4.2 Prohibited concomitant medications. Subjects are prohibited from receiving the 
following therapies during the Screening and Treatment Phase (including retreatment for 
post-complete response relapse) of this trial: 
 
Antineoplastic systemic chemotherapy or biological therapy  
 
Immunotherapy not specified in this protocol 
 
Chemotherapy not specified in this protocol 
 
Investigational agents other than pembrolizumab 
 
Radiation therapy  
o Note:  Radiation therapy to a symptomatic solitary lesion or to the brain may 
be allowed at the investigator’s discretion.   
 
Live vaccines within 30 days prior to registration and while participating in the trial.  
Examples of live vaccines include, but are not limited to, the following: measles, 
mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and typhoid vaccine.  
 
Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
event of clinical interest of suspected immunologic etiology.  The use of physiologic 
doses of corticosteroids may be approved after consultation with the PI. 
Subjects who, in the assessment by the investigator, require the use of any of the 
aforementioned treatments for clinical management should be removed from the trial.  
Subjects may receive other medications that the investigator deems to be medically 
necessary. The Exclusion Criteria describes other medications which are prohibited in this 
trial. There are no prohibited therapies during the Post-Treatment Follow-up Phase. 
 
5.5 Rescue Medications & Supportive Care: 
 
5.5.1 Supportive care guidelines. Subjects should receive appropriate supportive care 
measures as deemed necessary by the treating investigator.  Suggested supportive care 
measures for the management of adverse events with potential immunologic etiology are 
outlined below. Where appropriate, these guidelines include the use of oral or intravenous 
treatment with corticosteroids as well as additional anti-inflammatory agents if symptoms do 
not improve with administration of corticosteroids.   Note that several courses of steroid 
tapering may be necessary as symptoms may worsen when the steroid dose is decreased. 
For each disorder, attempts should be made to rule out other causes such as metastatic 

 
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disease or bacterial or viral infection, which might require additional supportive care. The 
treatment guidelines are intended to be applied when the investigator determines the events 
to be related to pembrolizumab. Note: if after the evaluation the event is determined not to 
be related, the investigator does not need to follow the treatment guidance (as outlined 
below). Refer to Section 5.3 for dose modification. It may be necessary to perform 
conditional procedures such as bronchoscopy, endoscopy, or skin photography as part of 
evaluation of the event.  
 
Pneumonitis:  
 
For Grade 2 events, treat with systemic corticosteroids. When symptoms improve to 
Grade 1 or less, steroid taper should be started and continued over no less than 4 
weeks. 
 
For Grade 3-4 events, immediately treat with intravenous steroids.  Administer 
additional anti-inflammatory measures, as needed. 
 
Add prophylactic antibiotics for opportunistic infections in the case of prolonged 
steroid administration. 
 
Diarrhea/Colitis:  
Subjects should be carefully monitored for signs and symptoms of enterocolitis (such as 
diarrhea, abdominal pain, blood or mucus in stool, with or without fever) and of bowel 
perforation (such as peritoneal signs and ileus).   
 
All subjects who experience diarrhea/colitis should be advised to drink liberal 
quantities of clear fluids.  If sufficient oral fluid intake is not feasible, fluid and 
electrolytes should be substituted via IV infusion.  For Grade 2 or higher diarrhea, 
consider GI consultation and endoscopy to confirm or rule out colitis. 
 
For Grade 2 diarrhea/colitis, administer oral corticosteroids.  
 
For Grade 3 or 4 diarrhea/colitis, treat with intravenous steroids followed by high 
dose oral steroids.   
 
When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks. 
 
Type 1 diabetes mellitus (if new onset, including diabetic ketoacidosis [DKA]) or ≥ Grade 3 
Hyperglycemia, if associated with ketosis (ketonuria) or metabolic acidosis (DKA): 
 
For T1DM or Grade 3-4 Hyperglycemia 
o Insulin replacement therapy is recommended for Type I diabetes mellitus and 
for Grade 3-4 hyperglycemia associated with metabolic acidosis or ketonuria.  
o Evaluate patients with serum glucose and a metabolic panel, urine ketones, 
glycosylated hemoglobin, and C-peptide.  
 
Hypophysitis: 
 
For Grade 2 events, treat with corticosteroids. When symptoms improve to Grade 1 
or less, steroid taper should be started and continued over no less than 4 weeks. 
Replacement of appropriate hormones may be required as the steroid dose is 
tapered. 
 
For Grade 3-4 events, treat with an initial dose of IV corticosteroids followed by oral 
corticosteroids. When symptoms improve to Grade 1 or less, steroid taper should be 
started and continued over no less than 4 weeks. Replacement of appropriate 
hormones may be required as the steroid dose is tapered. 
 
Hyperthyroidism or Hypothyroidism:  
Thyroid disorders can occur at any time during treatment. Thyroid function (TSH, free/total 

 
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T3 and free/total T4 will be checked at baseline and check TSH at dose # 3, 6 and 9 of 
pembrolizumab. Monitor patients for changes in thyroid function (at the start of treatment, 
periodically during treatment, and as indicated based on clinical evaluation) and for clinical 
signs and symptoms of thyroid disorders. If symptoms are noted or if thyroid function is 
abnormal further evaluation and appropriate treatment is required. 
 
Grade 2 hyperthyroidism events (and Grade 2-4 hypothyroidism): 
o In hyperthyroidism, non-selective beta-blockers (e.g. propranolol) are 
suggested as initial therapy. 
o In hypothyroidism, thyroid hormone replacement therapy, with levothyroxine 
or liothyroinine, is indicated per standard of care. 
 
Grade 3-4 hyperthyroidism  
o Treat with an initial dose of IV corticosteroid followed by oral corticosteroids. 
When symptoms improve to Grade 1 or less, steroid taper should be started 
and continued over no less than 4 weeks. Replacement of appropriate 
hormones may be required as the steroid dose is tapered. 
 
Hepatic: 
 
For Grade 2 events, monitor liver function tests more frequently until returned to 
baseline values (consider weekly). 
o Treat with IV or oral corticosteroids 
 
For Grade 3-4 events, treat with intravenous corticosteroids for 24 to 48 hours.  
 
When symptoms improve to Grade 1 or less, a steroid taper should be started and 
continued over no less than 4 weeks. 
 
Renal Failure or Nephritis: 
 
For Grade 2 events, treat with corticosteroids. 
 
For Grade 3-4 events, treat with systemic corticosteroids. 
 
When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks.  
 
Stevens Johnson Syndrome, Toxic Epidermal Necrolysis, and immune myocarditis have 
been reported with pembrolizumab therapy. If any of these conditions occur please treat 
with corticosteroids and supportive care and discontinue therapy permanently. 
 
5.5.2 Management of infusion reactions. Signs and symptoms usually develop during or 
shortly after drug infusion and generally resolve completely within 24 hours of completion of 
infusion.  
 
 
 
 
 
 
 
Table 4 below shows treatment guidelines for subjects who experience an infusion reaction 
associated with administration of pembrolizumab (MK-3475). 
 
Table 4. Infusion Reaction Treatment Guidelines 

 
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NCI CTCAE Grade 
Treatment 
Premedication at subsequent 
dosing 
Grade 1 
Mild reaction; infusion interruption 
not indicated; intervention not 
indicated 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
None 
Grade 2 
Requires infusion interruption but 
responds promptly to symptomatic 
treatment (e.g., antihistamines, 
NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated for 
< =24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
If symptoms resolve within one hour of stopping 
drug infusion, the infusion may be restarted at 
50% of the original infusion rate (e.g., from 100 
mL/hr to 50 mL/hr).  Otherwise dosing will be 
held until symptoms resolve and the subject 
should be premedicated for the next scheduled 
dose. 
Subjects who develop Grade 2 toxicity despite 
adequate premedication should be 
permanently discontinued from further trial 
treatment administration. 
Subject may be premedicated 1.5h 
(± 30 minutes) prior to infusion of 
pembrolizumab (MK-3475) with: 
 
Diphenhydramine 50 mg po (or 
equivalent dose of antihistamine). 
 
Acetaminophen 500-1000 mg po 
(or equivalent dose of antipyretic). 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly responsive 
to symptomatic medication and/or 
brief interruption of infusion); 
recurrence of symptoms following 
initial improvement; hospitalization 
indicated for other clinical sequelae 
(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. 
 
 
5.6 Toxicity Grading: The NCI CTEP CTCAE version 4.0 Toxicity Tables and 0-4 Grading Scale 
will be used. 
 
5.7 Retreatment Criteria: Patients removed from study due to toxicities other than cell-based 
toxicity may be re-entered upon complete resolution of toxicity, providing the toxicity appears to 
be unrelated to therapy.  Retreatment criteria are the same criteria required for initial treatment.  
Patients re-entered into the study will continue with their therapy at the same point at which it was 
discontinued. The patient may also be retreated at the same dose of BATs if they have a 
prolonged clinical response and are deemed to be candidates for retreatment per the treating 
physician and approved by Dr. Deol and Dr. Lum.  
 
5.8 Criteria for Removal from Protocol: Patients will be removed from protocol for the following: 
 
 
Grade 4 non-hematologic treatment related toxicity. 

 
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 
Initiation of other therapy. 
 
Patient decision to discontinue therapy. 
 
When deemed in the best medical interest of the patient by the physician. 
 
Protocol violation: Unexplained delay in delivery of treatment. 
 
 
6.0 DRUG FORMULATION 
 
6.1 Pembrolizumab/MK-3475/Keytruda (Merck): 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 [44].  It is available in 100mg 
vials. This medication will be provided by Merck for this study. 
 
Pembrolizumab (MK-3475/Keytruda) is a programmed death receptor-1 (PD-1)-blocking 
antibody indicated for the treatment of:  
 
patients with unresectable or metastatic melanoma and disease progression 
following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor.  
 
patients with metastatic NSCLC whose tumors express PD-L1 as determined by an 
FDA-approved test and who have disease progression on or after platinum-
containing chemotherapy. 
 
6.1.1 Dosage and administration.  
 
Administer 200 mg as an intravenous infusion over 30 minutes every 3 weeks 
(maximum dose of 200 mg per infusion).  
 
Dilute prior to intravenous infusion.  
 
6.1.2 Preparation and administration.  
 
Reconstitution of KEYTRUDA for Injection (Lyophilized Powder): 
 
Add 2.3 mL of Sterile Water for Injection, USP by injecting the water along the walls 
of the vial and not directly on the lyophilized powder (resulting concentration 25 
mg/mL). 
 
Slowly swirl the vial. Allow up to 5 minutes for the bubbles to clear. Do not shake the 
vial. 
 
Preparation for Intravenous Infusion: 
 
Visually inspect the solution for particulate matter and discoloration prior to 
administration. The solution is clear to slightly opalescent, colorless to slightly 
yellow. Discard the vial if visible particles are observed. 
 
Dilute KEYTRUDA injection (solution) or reconstituted lyophilized powder prior to 
intravenous administration. 
 
Withdraw the required volume from the vial(s) of KEYTRUDA and transfer into an 
intravenous (IV) bag containing 0.9% Sodium Chloride Injection, USP or 5% 
Dextrose Injection, USP. Mix diluted solution by gentle inversion. The final 
concentration of the diluted solution should be between 1 mg/mL to 10 mg/mL. 
 
Discard any unused portion left in the vial. Storage of Reconstituted and Diluted 
Solutions 
 
The product does not contain a preservative. Store the reconstituted and diluted 
solution from the KEYTRUDA 50 mg vial either: 

 
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 
At room temperature for no more than 6 hours from the time of reconstitution. This 
includes room temperature storage of reconstituted vials, storage of the infusion 
solution in the IV bag, and the duration of infusion. 
 
Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the 
time of reconstitution. If refrigerated, allow the diluted solution to come to room 
temperature prior to administration. Store the diluted solution from the KEYTRUDA 
100 mg/4 mL vial either: 
 
At room temperature for no more than 6 hours from the time of dilution. This 
includes room temperature storage of the infusion solution in the IV bag, and the 
duration of infusion. 
 
Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the 
time of dilution. If refrigerated, allow the diluted solution to come to room 
temperature prior to administration. Do not freeze. 
 
Administration: 
 
Administer infusion solution intravenously over approximately 30 minutes through 
an intravenous line containing a sterile, non-pyrogenic, low-protein binding 0.2 
micron to 5 micron in-line or add-on filter. 
 
Do not co-administer other drugs through the same infusion line. 
 
 
6.1.3 Dosage forms and strengths.  
 
For injection: 50 mg lyophilized powder in a single-use vial for reconstitution 
 
Injection: 100 mg/4 mL (25 mg/mL) solution in a single-use vial (3) 
 
6.1.4 Dose modifications. Withhold KEYTRUDA for any of the following: 
 
Grade 2 pneumonitis  
 
Grade 2 or 3 colitis  
 
Grade 3 or 4 endocrinopathies  
 
Grade 2 nephritis  
 
Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) greater than 
3 and up to 5 times upper limit of normal (ULN) or total bilirubin greater than 1.5 and 
up to 3 times ULN 
 
Any other severe or Grade 3 treatment-related adverse reaction  
 
Resume KEYTRUDA in patients whose adverse reactions recover to Grade 0-1. 
 
Permanently discontinue KEYTRUDA for any of the following: 
 
Any life-threatening adverse reaction (excluding endocrinopathies controlled with 
hormone replacement therapy) 
 
Grade 3 or 4 pneumonitis or recurrent pneumonitis of Grade 2 severity  
 
Grade 3 or 4 nephritis [see Warnings and Precautions (5.2)] 
 
AST or ALT greater than 5 times ULN or total bilirubin greater than 3 times ULN for 
patients with liver metastasis who begin treatment with Grade 2 AST or ALT, if AST 
or ALT 
 
increases by greater than or equal to 50% relative to baseline and lasts for at least 
1 week 
 
Grade 3 or 4 infusion-related reactions  
 
Inability to reduce corticosteroid dose to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
 
Persistent Grade 2 or 3 adverse reactions (excluding endocrinopathies controlled 
with hormone replacement therapy) that do not recover to Grade 0-1 within 12 weeks 
after last dose of KEYTRUDA 

 
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 
Any severe or Grade 3 treatment-related adverse reaction that recurs  
 
6.1.5 Contraindications. None. 
 
6.2 OKT3: This is a murine IgG2a monoclonal antibody directed at human CD3 
commercially available from OrthoBiotech, Raritan, NJ.  It is purchased in vials containing 5 mg/5 
ml of reconstituted bacteriostatic water.  OKT3 is used to activate T cells for growth and for 
heteroconjugation with Herceptin® to produce anti-CD3 x anti-HER2 bispecific antibody. 
 
 
6.3 Anti-HER2/neu Monoclonal Antibody-Herceptin (Trastuzumab, Genentech, Inc., CA):  
Herceptin is a humanized murine monoclonal antibody directed at HER2/neu, and is commercially 
available in multi-dose vials containing 440 mg of drug.  The binding characteristics and its ability 
to mediate cytotoxicity towards MCF-7 and SK-BR-3 (breast cancer cell lines and ovarian cancer 
cell lines) have been well documented in our preclinical studies. 
 
6.4 Anti-CD3 (OKT3) x anti-HER2/neu (Herceptin) Heteroconjugated Bispecific Monoclonal 
Antibody:  See section 7.3 on the production of anti-CD3 x anti-HER2 per GMP conditions. IND 
#9985 was approved by the FDA that specifies the production of bispecific antibody, sterility 
testing, and the standard operation procedures for arming of activated T cells. 
 
6.5 Labeling, Packaging, Storage and Return of Clinical Supplies: 
 
6.5.1 Investigational product. The investigator shall take responsibility for and shall take all 
steps to maintain appropriate records and ensure appropriate supply, storage, handling, 
distribution and usage of investigational product in accordance with the protocol and any 
applicable laws and regulations. Clinical Supplies will be provided by Merck as summarized 
in Table 5. 
 
Table 5. Product Descriptions 
Product Name & Potency 
Dosage Form 
Pembrolizumab 100 mg/ 4mL 
Solution for Injection 
 
6.5.2 Packaging and labeling information.  Clinical supplies will be affixed with a clinical 
label in accordance with regulatory requirements. 
 
6.5.3 Clinical supplies disclosure. This trial is open-label; therefore, the subject, the trial 
site personnel, the Sponsor and/or designee are not blinded to treatment. Drug identity 
(name, strength) is included in the label text; random code/disclosure envelopes or lists are 
not provided. 
 
6.5.4 Storage and handling requirements. Clinical supplies must be stored in a secure, 
limited-access location under the storage conditions specified on the label. Receipt and 
dispensing of trial medication must be recorded by an authorized person at the trial site. 
Clinical supplies may not be used for any purpose other than that stated in the protocol. 
 
6.5.5 Returns and reconciliation. The investigator is responsible for keeping accurate 
records of the clinical supplies received from Merck or designee, the amount dispensed to 
and returned by the subjects and the amount remaining at the conclusion of the trial. Upon 
completion or termination of the study, all unused and/or partially used investigational product 
will be destroyed at the site per institutional policy. It is the Investigator’s responsibility to 
arrange for disposal of all empty containers, provided that procedures for proper disposal 

 
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have been established according to applicable federal, state, local and institutional guidelines 
and procedures, and provided that appropriate records of disposal are kept. 
 
 
7.0 PREPARATION OF HER2Bi ARMED ACTIVATED T CELLS  
 
7.1 Facility:  Qualified personnel who are familiar with procedures which minimize undue 
exposure to themselves and to the environment should undertake the preparation, handling, and 
safe disposal of immunotherapeutic agents in a self-contained protective environment. Cells will 
be generated in the UVA Cancer Immunotherapy Laboratory under FDA #BB-IND 9985 with 
standard operating procedures and master batch records (SOPs and MBRs) for growing, splitting, 
harvesting, arming of ATC, cryopreservation, and infusion of BATs.  
 
The fresh pheresis product from KCI will be shipped by overnight courier service to UVA GMP 
laboratory for processing. 
 
Shipping Address for Pheresis Product: 
University of Virginia  
GMP Facility  
Aurbach Medical Research Building  
Suite 2339D  
450 Ray C. Hunt Dr.  
Charlottesville, VA 22903 
 
 
 
Please notify Archana Thakur by phone or email when samples are sent: 
Tel # 434-243-1397 
E-mail: AT2FX@virginia.edu 
 
 
7.2 Activation, Culture, and Freezing of BATs.  Lymphocytes are obtained by pheresis and 
cultured in RPMI 1640 media (Biowhittaker or Gibco), containing low dose IL-2, OKT3, and human 
serum.  Cells will be cultured for a maximum of 14 days in media to which no additional OKT3 will 
be added when the cultures are expanded. 
 
7.3 Preparation of Anti-CD3 x Anti-HER2 Bispecific Antibody: The specific details for the 
production, purification, and quality control testing are part IND #9985 (already active). 
 
7.4 Arming of ATC with HER2Bi:  The harvested ATC will be counted and a dose of 50 ng of 
HER2Bi per million ATC will be added to the solution and incubated for 1 hour at 4o C.  The BATs 
will be washed, counted, and resuspended in the final solution that will be cryopreserved in 
aliquots specific for each infusion. 
 
7.5 Testing of HER2Bi Armed-ATC: Aliquots of 24 hour cell culture supernatants will be 
evaluated for IFN-γ and TNF-α secretion by ELISA in the presence or absence of a known HER2 
positive breast and ovarian cancer lines. 
 
7.6 Cytotoxicity Assay:  Cytotoxicity is measured in a 20 hour 51Cr -release assay.  Tumor cells 
are plated in a flat-bottomed microtiter plate and incubated at 37oC.  The targets are washed and 
labeled the next day with 51Cr at 37oC.  The wells containing tumor cells will be washed and armed 
or unarmed ATC will be plated and incubated for 20 hours at 37oC.  The next day, the 

 
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supernatants harvested from the microtiter wells will counted and the percent specific lysis will be 
calculated [22].  
 
7.7 Quality Assurance of ATC Cell Product: Lists of suppliers of monoclonal antibodies, 
heteroconjugation reagents, and culture reagents will be maintained as well as lot numbers used 
and supplier provided documentation of sterility and documentation that all reagents are free of 
endotoxin and mycoplasma. The final bag of cells to be administered will be tested for anaerobic 
and aerobic bacteria, fungus, and mycoplasma, and determined to be endotoxin free. Records of 
all quality control measures will be maintained by Dr. Lum’s laboratory. 
 
7.8  Transfer of HER2 BATs to KCI: Cryopreserved ATC units will be transferred to the KCI 
Stem Cell Lab. (Please refer to the QCP # 14-v2 for the full description of the transfer procedure). 
The Immunotherapy facility at UVA will notify the KCI Stem Cell Lab that HER2 BATs will be 
shipped. After matching the stored product to the KCI patient information and determining the 
date of shipment, the vapor shipper is prepared 24 hours before shipment by filling its cavity with 
liquid nitrogen and allowing the liquid nitrogen to soak into the shipper’s absorbent overnight. The 
Activated T Cell Unit Product Packing Log (Log-26) will be used to document the dry shipper’s ID 
number, the time the charging was initiated, and the internal temperature of the dry shipper. On 
the day of shipment via overnight courier service, the requested ATC unit(s) are located and 
removed from long term storage. A supplemental ATC Unit label is attached with a plastic tie tag 
stating ”Properly Identify Intended Recipient and Product”, “For Use by Intended Recipient Only”, 
“Leukoreduction Filters Should Not Be Used”, and “Do Not Irradiate”. The released ATC unit(s) 
are removed from storage and placed in dry shipper on the Activated T Cell Unit Product Packing 
Log (Log-26). The temperature probe is extended into the center holding canister. Both the 
shipper and shipping container are labeled with separate labels that include the Infusion center 
contact person and telephone number as well as ATC recipient Unique Identifier. The contents 
Label has the following statements: “Non – Hazardous”, “Medical Specimen, Handle with Care”, 
“Do not X – ray”, “Do not Open”, “Extremely Low Temperature (-150ºC or Colder )” ,”Perishable”, 
“Transfer to permanent storage as soon as possible”. The dry shipper’s weight is recorded on 
Log-26 Activated T Cell Unit Product Packing Log. The UVA Immunotherapy facility will arrange 
the shipment through the FedEx courier service. The KCI Stem Cell Lab will verify the dry shipper 
maintained the temperature of < -150°C by completing Log-27 Activated T Cell Unit Shipment, 
Receipt and Inspection form and faxing it to the UVA Immunotherapy facility for documentation. 
Also at the time of return of the dry shipper, temperature data from the data logger will be 
downloaded and analyzed for archival storage according to OP-07 ShipsLOG Data Logger for 
Liquid Nitrogen Vapor Dry Shipments or OP-08 MVE Data Logger for Liquid Nitrogen Dry 
Shipments. 
 
 
 
 
 
 
8.0 REGISTRATION AND REQUIRED DATA 
 
8.1 Pre-Study:  All patients registered will be evaluated and staged prior to initiation of therapy.  
Eligibility criteria will be assessed as stated in Section 3.0.  Baseline studies will be completed 
within 28 days prior to registration.  The principal investigators may allow exceptions for not 
retesting due to delays in obtaining approvals (all exceptions will be documented). 
 
 

 
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8.2 Informed Consent: The Investigator must obtain documented consent from each potential 
subject prior to participating in a clinical trial. 
 
8.2.1 General informed consent. Consent must be documented by the subject’s dated 
signature or by the subject’s legally acceptable representative’s dated signature on a 
consent form along with the dated signature of the person conducting the consent 
discussion. A copy of the signed and dated consent form should be given to the subject 
before participation in the trial. The initial informed consent form, any subsequent revised 
written informed consent form and any written information provided to the subject must 
receive the IRB/ERC’s approval/favorable opinion in advance of use.  The subject or his/her 
legally acceptable representative should be informed in a timely manner if new information 
becomes available that may be relevant to the subject’s willingness to continue participation 
in the trial.  The communication of this information will be provided and documented via a 
revised consent form or addendum to the original consent form that captures the subject’s 
dated signature or by the subject’s legally acceptable representative’s dated signature. 
Specifics about a trial and the trial population will be added to the consent form template at 
the protocol level. The informed consent will adhere to IRB/ERC requirements, applicable 
laws and regulations and Sponsor requirements. 

 
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Table 6. Tests and 
Observations 
 
Pre –Registration1 
Pheresis 
Pembro 
Week 1 
Week 2 
Pembro 
Week 3 
Week 4 
1-2 wks Post #8 
2 mos after last 
BATSinfusion
4 mos after last 
BATSinfusion
6 mos after last 
BATSinfusion
 
BAT #12 
BAT #2 
BAT #3 
BAT #4 
BAT #5 
BAT #6 
BAT #7 
BAT #8 
Follow up 
History and Physical3 
X 
 
X 
 
 
X 
 
X 
 
 
 
 
X 
X 
X 
X 
 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Performance Status3 
X 
 
X 
 
 
X 
 
X 
 
 
 
 
X 
X 
X 
X 
 
CBC diff platelets 
X 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
 
Metabolic Panel4 
w/ Mg + Phosphorus 
X 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
 
Thyroid function4 
X 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
 
PSA 
X 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
 
HBsAg B & HCV RNA 
and HIV, 
PT/PTT, testosterone 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urinalysis & CrCl4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immune Studies5 
 
X 
 
X9 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
 
EKG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MUGA or ECHO 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
CT or PET/CT and bone 
scan6 
X 
 
X 
 
 
 
 
 
 
 
 
 
X 
X 
 
X 
 
Tumor Measurements7 
X 
 
X 
 
 
 
 
 
 
 
 
 
X 
X 
 
X 
 
Pheresis8 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PD-1 inhibitor/Pembro 
 
 
X10 
 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
 
BATs Infusion 
 
 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
 
 
 
 
 
Safety Assessment12 
 
 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
 
 
 
 
 
Tumor Biopsy 
 
X11 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
Follow Up 13 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
1. All tests performed 28 days prior to registration 
2. Patient should receive BATs #1-8 infusions twice per week for 4 weeks (+/- 2 days but minimum 42 
hours between doses. Maximum duration 8 weeks 
3. History, Physical, and Performance Status: To be performed by one of the protocol investigators or their 
designee 
4. Metabolic tests are required prestudy and for every cycle of pembrolizumab and will include electrolytes, 
BUN, Creatinine , AST, ALT, total Bilirubin, calcium, albumin, alkaline phosphatase and glucose. TSH, 
free/total T3 and T4 will be conducted at baseline. TSH needed at doses 3, 6 and 9 of pembrolizumab. 
(Free/total T3 and T4 needed only if TSH is abnormal).   
5. Immune evaluation assessment (± 1 week) 
6. CT, MRI or PET/CT and bone scan: To be done every 12 weeks from day 1 of pembrolizumab upto 1 
year or until disease progression. (+/-1 week window) 
7.  
Tumor evaluation will be done with the discretion of the PI according to the table above 
8. T-cells will be collected by pheresis and shipped to Dr. Lum’s UVA GMP facility where the cells will be 
cultured & armed 
9. Prior to BATs infusion (-3 days to day of infusion) 
10. 1 week prior to BATs and every 3 weeks after. A minimum of 21 days and maximum of 42 days interval 
between pembrolizumab doses is permitted. 
11. Before starting Pembrolizumab (optional archival and fresh tissue acceptable, as feasible) 

 
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12. Vital signs prior to pembrolizumab dose and vital signs on day of BATs will be done pre-infusion , , 
immediately post infusion   and 1, 2 and 4 hours after infusion. 
13. Patients will be followed every 3 months for the first two years for progression and OS and every 6 
months after that for progression and survival. Based on clinical situation determined by treating physician, 
pt might have scans, blood tests and optional immune testing 
. 

 
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9.0 CRITERIA FOR EVALUATION 
 
9.1 Tumor Measurements: All tumor measurements will be measured in centimeters prior to 
initiation of therapy.  These measurements should be done according to RECIST 1.1 criteria [45]. 
The Prostate Cancer Clinical Trials Working Group (PCWG2) criteria will also be used to 
determine a response in non-measurable disease [42]. PCWG2 recommends a two-objective 
paradigm in metastatic CRPC: (1) controlling, relieving, or eliminating disease manifestations that 
are present when treatment is initiated and (2) preventing or delaying disease manifestations 
expected to occur. PSA decline and changes in imaging will also be reported. An estimate of 
overall objective and subjective response will be made and recorded at the end of treatment, 2 
months after the first infusion. Since it is expected that immune activity would lead to tumor flare, 
the restaging CTs may be repeated 3 months later based on immune-related response criteria 
(irRC), and the designation of CR, PR, SD, or PD will be made at that time [46].   
 
9.2 Response Definitions: Response will be defined by using the irRC criteria, or the RECIST 
1.1 criteria with the allowance of an initial mild PD due to the nature of immunologic therapies as 
above. 
 
9.2.1 Complete response (CR). Disappearance of all clinical evidence of active tumor for 
a minimum of eight (8) weeks.  The patient must be free of all symptoms.  All measurable, 
evaluable and non-evaluable lesions and sites must be assessed. 
 
9.2.2 Partial response (PR). At least a 30% decrease in the sum of the target lesions 
compared to the baseline sum. No lesion may increase in size and no new lesions may 
appear. 
 
9.2.3 Progressive disease (PD). For measurable disease, an increase of 20% in the sum 
of the target lesions or unequivocal progression of non-target lesions.  
 
9.2.4 Time to progression in patients with bone metastases. Majority of the patients with 
prostate cancer have bone metastases which are not considered measurable sites of 
disease. Progression in patients with bone metastases will be defined as either the 
appearance of a minimum of 2 new lesions on bone scan which are related to metastatic 
disease per the judgement of the treating physician, or the occurrence of a new skeletal 
related event. Skeletal-related event is defined as occurrence of new pathologic bone 
fractures (vertebral or nonvertebral), spinal cord compression, requirement of surgery or 
radiation therapy to bone metastases (including the use of radioisotopes), or a requirement 
to change antineoplastic therapy to treat bone pain or other related symptoms. 
 
9.2.5 Stable disease (SD). Neither sufficient shrinkage to qualify for PR nor sufficient 
increase/change to qualify for PD. 
 
9.2.6 Response evaluable patients. All patients registered on the protocol and completing 
a minimum of one dose of pembrolizumab and one dose of BATs therapy followed by 
clinical, and radiologic or PSA assessment of disease status. 
 
9.2.7 Toxicity evaluable patients. All patients registered on the protocol and starting 
therapy with protocol medication will be considered toxicity evaluable. 
 
 

 
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9.2.8 Follow up /Overall survival. Overall survival will be measured from date of 
registration to death or last follow up. After treatment is discontinued for any reason patients 
will be followed every 3 months for progression and survival. 
 
 
10.0 CRITERIA FOR REMOVAL OF PATIENTS FROM STUDY 
 
10.1 Disease Progression: Patients with progressive disease will be removed from study . 
 
10.2 Extraordinary Medical Circumstances: If at any time the constraints of this protocol are 
detrimental to the patient’s health, the patient shall be withdrawn from treatment.  In this event: 
 
10.2.1 Document reasons for withdrawal and record whether this action was patient or 
physician directed. 
 
10.2.2 The patient will remain technically “on-study” although treatment has been discontin-
ued.  The patients will be followed for PFS, OS, and immune responses. 
 
 
10.3 Unexpected or Life-Threatening Toxicity: 
 
10.3.1 Direct questions regarding drug therapy to the Principal Investigator. 
 
10.3.2 Reporting requirements and procedures depend upon: (1) whether agents are sus-
pected of causing toxicity, (2) whether possibility of such toxicity was reported in the consent 
form, or manufacturer’s literature (Published Toxicity), (3) the severity or grade of the 
toxicity. 
 
10.3.2.1 Expected toxicities. Grade 4 myelosuppression: Report only as part of 
regular data submission.  All other toxicities, Grades 4 and 5: Written Report to 
Principal and Co-Investigators, within 10 working days.  All other toxicities, Grades 
1 to 3: Report only as part of regular data submission. 
 
10.3.2.2 Unexpected toxicities. Unexpected toxicities are toxicities that are not 
listed in the toxicity management section of the protocol, the consent form, or the 
manufacturer’s package insert.  All unexpected toxicities will be reported to Principal 
and Co-Investigators, within 15 working days. 
 
 
 
 
11.0 REPORTING ADVERSE REACTIONS 
 
11.1 Investigators are required to notify the FDA and IRB of all serious and unexpected adverse 
drug reactions.  Copies of all safety reports will be sent to both Dr. Deol and Dr. Lum (the IND 
Sponsor at UVA). 
 
11.2 All reactions in a “reportable” category must be reported unless it is documented in the 
medical record chart that treatment is definitely not responsible for the toxicity. 
 
11.3 Serious and unexpected adverse reactions will be reported to the following sources within 
the stated time frame.   
 
  
 

 
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11.3.1 FDA. Written IND safety report within 7 calendar days.  The SAE will be reported 
by telephone within 3 working days.  SAE reports will be included in annual reports. 
 
11.3.2 All participating investigators. Written IND safety report within 7 calendar 
days. 
 
11.3.3 IRB. Written report within 10 working days. 
 
11.4   Procedure for calling the FDA is as follows. Dr. Lum will be responsible for notifying 
the FDA: 
 
11.4.1 The research nurses or PI will call for ADRs. 
 
11.4.2 The PI or his designee will call for regulatory/protocol issues. 
 
11.4.3 The medical reviewer at the FDA TBN, M.D.: 
 
  
 
 
  
ATTN: To be named 
 
  
 
 
  
U.S. Food and Drug Administration 
 
  
Center for Biologic Evaluation and Research 
 
  
10903 New Hampshire Avenue 
 
  
WO71, G112 
 
  
Silver Spring, MD 20993-0002 
 
 
 11.4.4 Document as completely as possible, and send copies to: 
 
  
Patient's chart 
 
  
FDA correspondence binder 
 
  
Protocol binder 
 
  
Lawrence G. Lum, M.D., D.Sc. 
 
Email: lgl4f@virginia.edu 
 
Phone:  434-243-1375 
 
Cell phone: 313-410-0797 
 
11.5 Reporting Guidelines for Pembrolizumab SAE: Pembrolizumab will be provided by 
Merck. 
 
11.5.1 Assessing and recording adverse events. An adverse event is defined as any 
untoward medical occurrence in a patient or clinical investigation subject administered 
a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment. An adverse event can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding, for example), symptom, or 
disease temporally associated with the use of a medicinal product or protocol-specified 
procedure, whether or not considered related to the medicinal product or protocol-
specified procedure.  Any worsening (i.e., any clinically significant adverse change in 
frequency and/or intensity) of a preexisting condition that is temporally associated with 
the use of the Merck’s product, is also an adverse event. 
 
Merck product includes any pharmaceutical product, biological product, device, 
diagnostic agent or protocol-specified procedure, whether investigational (including 

 
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placebo or active comparator medication) or marketed, manufactured by, licensed by, 
provided by or distributed by Merck for human use. 
 
Adverse events may occur during the course of the use of Merck product in clinical 
trials, or as prescribed in clinical practice, from overdose (whether accidental or 
intentional), from abuse and from withdrawal. 
 
Progression of the cancer under study is not considered an adverse event. 
 
All adverse events that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject 
to be excluded from the trial, or are the result of a protocol-specified intervention, 
including but not limited to washout or discontinuation of usual therapy, diet, placebo 
treatment or a procedure. 
 
From the time of treatment allocation/randomization through 30 days following 
cessation of treatment, all adverse events must be reported by the investigator. Such 
events will be recorded at each examination on the Adverse Event case report 
forms/worksheets.  The reporting timeframe for adverse events meeting any serious 
criteria is described in Section 11.5.4. 
 
The investigator will make every attempt to follow all subjects with non-serious adverse 
events for outcome. 
 
11.5.2 Definition of an overdose for this protocol and reporting of overdose to the 
Sponsor and to Merck. For purposes of this trial, an overdose of pembrolizumab will 
be defined as any dose of 1,000 mg or greater (≥5 times the indicated dose).  No 
specific information is available on the treatment of overdose of pembrolizumab. 
Appropriate supportive treatment should be provided if clinically indicated. In the event 
of overdose, the subject should be observed closely for signs of toxicity.  Appropriate 
supportive treatment should be provided if clinically indicated. 
 
If an adverse event(s) is associated with (“results from”) the overdose of a Merck 
product, the adverse event(s) is reported as a serious adverse event, even if no other 
seriousness criteria are met. 
 
If a dose of Merck’s product meeting the protocol definition of overdose is taken without 
any associated clinical symptoms or abnormal laboratory results, the overdose is 
reported as a non-serious Event of Clinical Interest (ECI), using the terminology 
“accidental or intentional overdose without adverse effect.” 
 
All reports of overdose with and without an adverse event must be reported within 24 
hours to the Sponsor and within 2 working days hours to Merck Global Safety. (Attn: 
Worldwide Product Safety; FAX 215 993-1220) 
 
11.5.3  Reporting of pregnancy and lactation to the Sponsor and to Merck. 
Although pregnancy and lactation are not considered adverse events, it is the 
responsibility of investigators or their designees to report any pregnancy or lactation 
that results from intercourse with a subject (spontaneously reported to them) that 
occurs during the trial. 
 

 
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Pregnancies and lactations that occur in partners of subjects from the time of treatment 
allocation/randomization through 120 days following cessation of Merck’s product, or 
30 days following cessation of treatment if the subject initiates new anticancer therapy, 
whichever is earlier, must be reported by the investigator.  All reported pregnancies 
must be followed to the completion/termination of the pregnancy. Pregnancy outcomes 
of spontaneous abortion, missed abortion, benign hydatidiform mole, blighted ovum, 
fetal death, intrauterine death, miscarriage and stillbirth must be reported as serious 
events (Important Medical Events). If the pregnancy continues to term, the outcome 
(health of infant) must also be reported. 
 
Such events must be reported within 24 hours to the Sponsor and within 2 working days 
to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220) 
 
11.5.4 Immediate reporting of adverse events to the Sponsor and to Merck 
A serious adverse event is any adverse event occurring at any dose or during any use 
of Merck’s product that: 
 
Results in death; 
 
Is life threatening; 
 
Results in persistent or significant disability/incapacity; 
 
Results in or prolongs an existing inpatient hospitalization; 
 
Is a congenital anomaly/birth defect; 
 
Is an other important medical event  
 
Note: In addition to the above criteria, adverse events meeting either of the below 
criteria, although not serious per ICH definition, are reportable to the Merck in the same 
timeframe as SAEs to meet certain local requirements. Therefore, these events are 
considered serious by Merck for collection purposes. 
 
Is a new cancer (that is not a condition of the study); 
 
Is associated with an overdose. 
 
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, any serious adverse event, or follow up to a serious adverse 
event, including death due to any cause other than progression of the cancer under 
study that occurs to any subject must be reported within 24 hours to the Sponsor and 
within 2 working days to Merck Global Safety using the Medwatch form  if it causes the 
subject to be excluded from the trial, or is the result of a protocol-specified intervention, 
including but not limited to washout or discontinuation of usual therapy, diet, placebo 
treatment or a procedure. 
 
For the time period beginning at treatment allocation/randomization through 90 days 
following cessation of treatment, or 30 days following cessation of treatment if the 
subject initiates new anticancer therapy, whichever is earlier, any serious adverse 
event, or follow up to a serious adverse event, including death due to any cause other 
than progression of the cancer under study, whether or not related to the Merck product, 
must be reported within 24 hours to the Sponsor and within 2 working days to Merck 
Global Safety. 
 
Additionally, any serious adverse event, considered by an investigator who is a qualified 
physician to be related to Merck product that is brought to the attention of the 
investigator at any time following consent through the end of the specified safety follow-
up period specified in the paragraph above, or at any time outside of the time period 

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

 
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causal relationship between the drug and the event. Any such event will be submitted 
to the Sponsor within 24 hours and to Merck Global Safety within 2 working days either 
by electronic or paper media. 
 
Specifically, the suspected/actual events covered in this exception include any event 
that is disease progression of the cancer under study. 
 
The Sponsor will monitor unblinded aggregated efficacy endpoint events and safety 
data to ensure the safety of the subjects in the trial. Any suspected endpoint which upon 
review is not progression of the cancer under study will be forwarded to Merck Global 
Safety as a SAE within 2 working days of determination that the event is not progression 
of the cancer under study 
 
Hospitalization related to convenience (e.g. transportation issues etc.) will not be 
considered a SAE. 
 
11.5.7 Evaluating adverse events. An investigator who is a qualified physician will 
evaluate all adverse events according to the NCI Common Terminology for Adverse 
Events (CTCAE), version 4.0. Any adverse event which changes CTCAE grade over 
the course of a given episode will have each change of grade recorded on the adverse 
event case report forms/worksheets. 
 
All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 
 
12.0 CORRELATIVE TESTING 
 
 
12.1 Monitor Immune Responses: Estimate the magnitude of change in anti-PC immune 
functions and markers in the serum after BATs infusions in mCRPC.  
 
12.1.1 Sample delivery. Immune function testing samples will be sent to Dr. Lum’s 
laboratory at UVA. Please call the KCI PK Core lab for immune function specimen pickup. 
Do not leave the blood overnight. A total of approximately 60ml of blood will be drawn at 
each of the designated points - one 10 ml red top tube and five 10 ml green or lavender 
top tubes containing anti-coagulant. 
 
 
Shipping Address for Immune Evaluations: 
 
University of Virginia  
 
West Complex MSB 7191 
 
1300 Jefferson Park Ave 
 
Charlottesville, VA 22903 
 
 
Please notify Archana Thakur by phone or email when samples are sent: 
Tel # 434-243-1397 
E-mail: AT2FX@virginia.edu 
 
 
12.1.2 Background. In the phase I clinical trial in MBC patients, infusion of HER2 BATs 
induced endogenous CTLs against breast cancer cell lines, Th1 cytokines in the serum. 
After 4 infusions of HER2 BATs, MBC patients develop a Th1-type skewing of the serum 
cytokine pattern, consisting of significant levels of IL-2, IL-7, IL-12, IFN-γ, TNF-α, and GM-
CSF. Although some of these responses may directly result from BATs functions in vivo, 
other responses, such as IL-12 production, cannot be attributed to T cells but rather reflect 

 
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secretion of IL-12 by endogenous monocytes that are responding to stimulation. Based 
on these data, BATS may have the short-term direct benefit of tumor lysis and the long-
term benefits of longer lasting endogenous anti-tumor activity [3]. The studies show that 
IgG2a-depleted PBMC exhibited high levels of breast cancer specific cytotoxicity and IFN-
γ EliSpots after immunotherapy; evidence for the development of endogenous anti-tumor 
activity [47]. Moreover, we predict that evidence of endogenous immune activity will 
correlate with improvements in clinical outcomes.  
 
12.1.3 Strategy. We will sequentially test the patient’s lymphocytes for phenotype, 
cytotoxicity directed PC cell lines, and antibodies directed at PC cell lines and selected 
cytokines in the serum at designated time points in the protocol. Specific cytotoxic 
responses will be measured with IFN-γ ELISpot and 51Cr release assays. Serum will be 
tested for the Th1/Th2 serum cytokine profiles and serum antibodies directed at PC cells 
using a cell based ELISA as described [48,49]. Baseline serum and cells will be aliquoted 
from the pheresis. Blood draws (4 green top tubes containing approximately 40 ml of anti-
coagulated blood and 1 red top tube containing 8 ml of serum) will be collected pre 
therapy, pre-BATs infusion, after the 4th infusion, approximately 1-2 weeks, 2 months 
(90 days ± 7 days), 4 months (120 days ± 7 days), 6 months (180 days ± 7 days) and 
optionally every 6 months thereafter (180 days ± 7 days) after the last infusion.  Optional 
immune evaluations (IEs) will be done if there continues to be immune response at 6 
month intervals until the responses have disappeared. Patient immune function data will 
be compared to their baseline to evaluate changes induced by BATs. IFN-γ ELISpots will 
be considered positive if they change ≥2 fold above a baseline with ≥30 ELISpots/106 cells 
plated.  
 
12.2. Monitor Changes in Tumor Infiltrating T cells, PD-1 Expression, and Th1/Th2 Ratio: 
These will be considered exploratory biomarkers to assess the rationale for future combinations 
with immune checkpoint inhibitors. Tumor infiltrating cells (TILs) have shown to be surrogates of 
improved outcome in metastatic solid tumor malignancies. In advanced breast cancer the 
induction of tumor infiltrating lymphocytes was noted to correlate closely with improved OS [50]. 
The TILs were analyzed and quantified in 10% increments in metastatic breast cancer trials. 
Tumor tissue biopsies will be obtained pre and post therapy and evaluated for TILs. In addition 
PD-1 expression on the TILs will be assessed by immunohistochemistry (IHC). 
 
12.2.1 Biopsy collection. Every attempt should be made to obtain archival tissue for 
testing on this study. Tumor Biopsies pre and post therapy are optional on this 
study and are highly encouraged.  If patient consents to biopsy, these will be 
obtained prior to beginning treatment with pembrolizumab or BATs. Post therapy biopsy 
will be obtained 1-2 weeks after the last BATs infusion. 
 
 
Shipping Address for tissue samples: 
 
University of Virginia  
 
West Complex MSB 7191 
 
1300 Jefferson Park Ave 
 
Charlottesville, VA 22903 
 
 
Please notify Archana Thakur by phone or email when samples are sent: 
Tel # 434-243-1397 
E-mail: AT2FX@virginia.edu 
 
 

 
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12.2.2 Rationale. In this aim we will determine the spectrum of biomarkers to identify the 
T cells subpopulations, activation status of T cells, immune suppressive cells and immune 
inhibitory molecules (PD-1/PD-L1) in the tumor samples. The analysis of host–tumor 
interactions and immune reaction within the tumor may provide information. Fukunaga et 
al [51] showed that the presence of tumor infiltrating CD4+ and CD8+ lymphocytes provide 
a good indicator of patient's outcome after surgical treatment. Another study analyzing 
599 early-stage (stage I and II) colorectal cancers showed that tumors with low cytotoxic 
(CD8) T cells had poor prognosis, while patients with Th1 polarized, highly cytotoxic T cells 
in the center and the invasive margin of the tumor experienced a very low level of 
recurrence [52]. These studies suggest that the immune landscape of the tumor may 
provide useful prognostic information.  
 
12.2.3 Strategy. The paraffin blocks will be processed by Dr. Lum’s laboratory.  In the 
past year, we developed immunohistochemical staining for cytoplasmic or extracellular 
IFN-γ and IL-10 as well as CD3 (Thakur, unpublished data) in paraffin sections (Fig 17).  
Original biopsies will be stained for CD3+, CD4+, CD8+, CD127+, cytoplasmic IFN-γ (Th1 
representative cytokine) and IL-10 (Th2 representative cytokine), Tregs, M2-macrophages, 
MDSC, PD-1/ PD-L1 in the tumor sections. We will calculate the ratio of CD4/CD8, and 
the ratio of Th1/Th2 to evaluate potential clinical correlates. 
 
 
 
 
 
 
 
 
12.2.4 Immunohistochemical staining. Tissue microarray sections will be incubated 
with mAbs against CD3, CD4, CD8, IFN-γ, IL-10, PD-1, and PD-L1. Staining will be carried 
out on paraffin embedded resected tumor tissue sections by staining for Th1 using anti-
CD3/anti-IFN-γ anti-CD8/Granzyme B and for IL-10 expression, slide will be stained for 
anti-CD19/ anti-IL-10 and anti-CD68/anti-IL-10 antibody cocktails followed by incubation 
with enzyme-conjugated polymer backbone coupled to secondary antibodies, and color 
development 
using 
3,3′-diaminobenzidine 
(DAB) 
as 
substrate. 
Hematoxylin-
counterstained sections will used for the analysis. For double staining, HRP Polymer anti-
Mouse secondary antibody and AP Polymer anti-Rabbit secondary antibody will be used 
(GBI Labs Polink DS-MR-Hu A1 Kit). Color will be developed using DAB Chromogen and 
GBI Permanent Red Chromogen followed by counterstain with hematoxylin. Isotype-
matched mouse monoclonal antibodies will be used as negative control.  Slides will be 
analyzed using a Panoramic Digital Scanner and Viewer (Caliper Life Sciences). The 
Fig 17. Over lay staining for CD3, IFN-γ, IL-10 in breast cancer. Insets show zoomed sections 
mapped in blue rectangles. Left panel shows cytokeratin stained breast cancer cells, IFN-γ 
secreting brown stained CD3+ T cells (pink surround cells).  The right panel shows cytokeratin 
positive breast cancer with T cell secreting IL-10 (inset). Stromal or tumor producing IL-10 
(indicated by arrow)     

 
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density will be recorded as the number of positive cells per unit tissue surface area.  
 
 
13.0 STATISTICAL CONSIDERATIONS 
 
13.1 Clinical Trial: This is a phase II study in mCRPC patients with a single arm two-stage design. 
The primary objective is to study the clinical efficacy.  The primary endpoint is the proportion of 
patients achieving clinical progression-free interval of 6 months from study registration.  The 
clinical progression is defined by PCWG II criteria and will be monitored by clinical evaluation, 
monthly PSA monitoring and radiologic assessment at 3 and 6 months, and every 6-month 
interval thereafter.  
 
Sample Size/Power calculation: The study will use Simon’s two-stage design to test the null 
hypothesis of 20% or less versus the alternative hypothesis of more than 20% patients achieving 
progression free time of ≥ 6 months.  Our expected percentage is 40%. With 5% Type I error and 
80% power, the Simon’s two-stage minmax design requires a total of 33 patients and has a 
probability of early termination of 0.716 if the treatment is not promising. The PASS12 was used 
for sample size calculation [53].  At the first stage, 18 evaluable patients will be enrolled.  The trial 
will be terminated if 4 or fewer patients are progression free at 6 months. If the trial goes on to the 
second stage, 15 more patients will be enrolled.  It the total number of progression free at 6 
months is 11 or higher, the null hypothesis will be rejected.  The treatment will be considered 
promising with more than 20% clinical progression free at 6 months.  The secondary objective is 
to estimate the OS with KM method. 
 
The accrual rate at KCI is about 2 per month. The 18 patients in stage I will require 9 months to 
accrue and 6 months to follow up for primary endpoint.  If the trial proceeds to stage II, 8 months 
accrual for 15 additional patients and 6 months follow up will result in study duration of 29 months. 
 
13.2 Immune Function Testing: For those aforementioned quantitative immune response 
variables (Section 12.1), we will produce summary statistics (including means, medians, and 
standard deviations) pre- and post-BATs treatment. Subsequent analyses will compare the 
immune response variables (after a suitable transformation, if necessary) pre- and post-treatment 
using a paired t-test (or Wilcoxon sign ranked test if the data are not approximately normally 
distributed after log transformation). To explore whether immune responses associate with clinical 
responses, the association between the baseline of each biomarker and clinical endpoints (such 
as response, or OS) will be analyzed using logistic regression for binary endpoints and Cox 
regression for time to event endpoints. Analyses will adjust for other covariates such as age and 
tumor stage.   
 
Power calculation:  For this correlative endpoint, we have at least 18 patients (or 33 patients if 
the trial proceeds to stage II). For one-sample Student t test a sample size of 18 pairs achieves 
80% power to detect a median to large effect of 0.69 using a two-sided paired t-test with 
significance level of 0.05. All the raw p values will be reported together with False Discovery Rate 
(FDR) adjusted p values for multiple testing [54].   
 
13.3 IHC Testing: For the qualitative IHC measurements, we will produce summary statistics 
(including frequency table and percentage of positivity). The McNemar test will be used for testing 
protein positivity concordance pre- and post-BATs treatment. To explore whether protein positivity 
associate with clinical responses, the association between the baseline of each biomarker and 
clinical endpoints (such as response, or OS) will be analyzed using logistic regression for binary 
endpoints and Cox regression for time to event endpoints. Analyses will adjust for other covariates 
such as age and tumor stage.   

 
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Power calculation:  For this objective we estimate that about 23 patients (~70% have quality 
tissue materials for IHC) will have baseline IHC measurements. About 16 patients will have paired 
pre- and post- treatment IHC measurements. The sample size will decrease if the trial stops at 
stage I.  In that case, only descriptive analysis will be provided for biomarkers.  For power 
calculation, the primary analysis is the Fisher’s exact test between the baseline marker status 
(positive vs. negative) and clinical response.  Assuming 40% response and 10% protein positives 
in non-responder, a sample size of 23 achieves 80% power to detect a large effect of 60% 
difference with a two sided test at significance level of 0.05. All the raw p values will be reported 
together with False Discovery Rate (FDR) adjusted p values for multiple testing [54]. 
 
13.4 Statistical Monitoring Plan for Toxicity: Data and Safety Monitoring Committee (DSMC) 
will examine the overall safety data monthly.  Frequency and severity of all toxicities will be 
tabulated and summarized for review by PI and the DSMC. Interim safety analysis will be 
performed after first 5 and at the completion of first stage of the Simon’s two-stage design (18 
subjects) on patients who received at least one cycle of treatment.  
 
Interim safety analyses will be focused on two criteria separately: definitely treatment-related 
(pembrolizumab or BATs) deaths; and grade 4 treatment-related AEs that persisted ≥72 hours 
despite adequate treatment and management. Two-sided 90% exact binomial confidence 
intervals (CIs) will be calculated.    
 
Definitely treatment-related deaths:  We assume that rare fatal events should not exceed 1%. 
If the lower CI (LCI) exceeds 1%, the study will be suspended. This corresponds to ≥ 1+ (1 or 
more) out of 5 and ≥ 2+ out of 18 subjects in the interim safety analyses.  
 
Definitely treatment-related grade 4 SAEs:  We assume that rate should not exceed 10%. If 
the LCI exceeds 10%, the accrual will be suspended. This corresponds to ≥ 3+ (3 or more) out of 
5 and ≥ 5+ out of 18 subjects in the interim safety analyses.  
 
If the LCI exceeds the pre-defined levels, study accrual will be halted and the study DSMC will 
meet to assess the safety of the drug regimen. The committee could decide to reconsider the 
treatment and/or modify the protocol before proceeding or to stop the study permanently. 
 
14.0  CLINICAL DATA SAFETY MONITORING 
  
14.1 Recruitment: To address concerns related to decreased minority recruitment in local and 
national protocols, we will take specific steps to enhance the awareness in the Detroit Metro 
region and the State of Michigan to recruit minority groups for this study. The location of KCI 
provides a unique opportunity to recruit African Americans to the protocol. Our previous accrual 
records also indicate that we have been successful in recruitment to this patient population with 
a track record of about 40% African American patients enrolled on prostate cancer protocols.  
 
14.2 Informed Consent: Patients will be enrolled after signed written informed consent is 
obtained following a detailed review of the study design, schedule and side effects and discussion 
of all therapeutic alternatives, with the investigator/s in a consultation visit of approximately 1 hour 
with a follow up and reinforcement of the risks and benefits with the research nurse coordinator. 
The consent forms are signed in the presence of one of the investigators and/or the Nurse 
Coordinator. The patients are given the consent forms after the consult and asked to write down 
any questions after reading the consent forms and to bring the questions to the signing meeting.    
 

 
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14.3. Data Safety and Monitoring Plan: Patient safety will be monitored by the PI and protocol 
data manager(s) on a monthly basis. The safety of protocol participants will be reviewed and 
adherence to stopping rules will be monitored. Adherence to the protocol, i.e., protocol violations, 
data completeness and integrity will also be reviewed. Overall assessment of accrual, toxicities 
and responses will be done at this time to determine whether significant benefits or risks are 
occurring that would warrant study closure. A monthly summary will be provided to the Karmanos 
Cancer Institute Data and Safety Monitoring Committee and will be reviewed quarterly. One 
month prior to anniversary date of the IRB original approval, a yearly summary report of trial 
activities will be made to all participating co-investigators and the Karmanos Cancer Institute 
Protocol Review and Monitoring Committee. This report will include the number of patients, the 
number of patients treated, a summary of all adverse events reported to date, a specific list of 
serious adverse events requiring immediate reporting and any significant developments that may 
affect the safety of the participants or ethics of the study. 
 
14.3.1 Meetings: Scheduled meetings will be held as necessary and at least monthly, on 
the activity of the protocol. These meetings will include the protocol investigators, data 
managers, and key personnel involved with the conduct of the protocol. 
 
 
14.3.2 Evaluations: During these meetings the investigators will discuss matters related 
to: 
 
Safety of protocol participants (Adverse Event reporting) 
 
Validity and integrity of the data 
 
Enrollment rate relative to expectation of target accrual, characteristics of the 
participants 
 
Retention of participants, adherence to the protocol (potential or real protocol 
violations) 
 
Data completeness on case report forms and complete source documentation 
 
14.3.3 Completed data and safety monitoring reports: Reports of these regular 
investigator meetings will be kept on file in the office of the Clinical Trials Core. The data 
manager assigned to the clinical trial will be responsible for completing the report form. 
The completed reports will be reviewed and signed off by the Principal Investigator (PI) or 
by one of the Co-investigators in the absence of the PI. The signed off forms will then be 
forwarded to the Quality Manager, Clinical Trials Office for review of completeness and 
processing with the Karmanos Cancer Institute Data and Safety Monitoring Committee. 
 
14.3.4 Data Safety Monitoring Committee: The Barbara Ann Karmanos Cancer 
Institute, Data and Safety Monitoring Committee will meet on a monthly basis to review 
the Serious Adverse Event forms and Data and Safety study specific reports that have 
been filed. 
 
14.3.5 Retention of records: All documentation of adverse events, records of study drug 
receipt and dispensation, and all IRB correspondence will be retained for a minimum of 2 
years after the investigation is completed. 
 
14.3.6 Protocol activation: This protocol will not be activated until the Karmanos Cancer 
Institute Protocol Review Committee, the Wayne State University IRB, and the US Food 
and Drug Administration have approved the initiation of this protocol. 
      
An internal Quality Control Coordinator (QCC) will be monitoring the clinical protocol being 
conducted under FDA-approved IND studies initiated at the WSU/Karmanos Cancer 

 
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Institute. A CTO study monitor will review all required study documents against source 
documents for the study as well the SOPs for the manufacturing of EGFRBi and activated 
T cells. A Study Monitor will report to the CTO and the Data Safety Monitoring Committee 
of the KCI. The Study Monitor must be familiar with the protocol, the investigational 
product, written informed consent, Standard Operating Procedures (SOPs), Good Clinical 
Practices (GCPs), and Applicable Regulatory Requirements. Monitoring will be performed 
annually.  
 
 
 

 
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prostate cancer through modulation of androgen receptor signaling by the HER-2/neu 
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antibody effectively redirects armed T cells to inhibit tumor development and growth in 
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mice. Clin Prostate Cancer. 2004;3(2):112-121. 
19. Lum HE, Miller M, Davol PA, Grabert RC, Davis JB, Lum LG. Preclinical studies 
comparing different bispecific antibodies for redirecting T cell cytotoxicity to extracellular 
antigens on prostate carcinomas. Anticancer Res. 2005;25(1A):43-52. 
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antibody for redirecting cytotoxicity of activated T cells toward HER2/neu+ tumors. J 
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23. Irvine DJ, Purbhoo MA, Krogsgaard M, Davis MM. Direct observation of ligand 
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With OKT3 x Anti-HER2/New Bispecific Monoclonal Antibodies(Biabs). Experimental 
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dose IL-2 after SCT for high-risk non-Hodgkin's lymphoma: a pilot study. Bone Marrow 
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(ATC) Armed with Anti-CD3 x Anti-CD20 Bispecific Antibody (CD20Bi)&nbsp;after Stem 
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outcome in patients with early-stage colorectal cancer. J Clin Oncol. 2009;27(35):5944-
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16.0 
APPENDICES 
 
16.1 
ECOG/Zubrod  Performance Status:  
For this study only ECOG/Zubrod score is used to evaluate patients. 
ECOG PERFORMANCE STATUS 
KARNOFSKY PERFORMANCE 
STATUS 
0—Fully active, able to carry on all pre-disease 
performance without restriction 
 
100—Normal, no complaints; no 
evidence of disease 
90—Able to carry on normal 
activity; minor signs or symptoms of 
disease 
1—Restricted in physically strenuous activity but 
ambulatory and able to carry out work of a light or 
sedentary nature, e.g., light house work, office work 
80—Normal activity with effort, 
some signs or symptoms of disease 
70—Cares for self but unable to 
carry on normal activity or to do 
active work 
2—Ambulatory and capable of all selfcare but unable to 
carry out any work activities; up and about more than 
50% of waking hours 
60—Requires occasional assistance 
but is able to care for most of 
personal needs 
50—Requires considerable 
assistance and frequent medical care 
3—Capable of only limited selfcare; confined to bed or 
chair more than 50% of waking hours 
40—Disabled; requires special care 
and assistance 
30—Severely disabled; 
hospitalization is indicated although 
death not imminent 
4—Completely disabled; cannot carry on any selfcare; 
totally confined to bed or chair 
20—Very ill; hospitalization and 
active supportive care necessary 
10—Moribund 
5—Dead 
0—Dead 
 
*Karnofsky D, Burchenal J, The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod C, ed. Evaluation of Chemotherapeutic 
Agents. New York, NY: Columbia University Press; 1949:191–205. 
**Zubrod C, et al. Appraisal of methods for the study of chemotherapy in man: Comparative therapeutic trial of nitrogen mustard and 
thiophosphoramide. Journal of Chronic Diseases; 1960:11:7-33. 
 
 
 
 
 
 
 
 
 
 

 
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16.2 Common Terminology Criteria for Adverse Events V4.0 (CTCAE): 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 will be utilized for adverse event reporting. 
(http://ctep.cancer.gov/reporting/ctc.html) 
 
 
16.3 Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 Criteria for Evaluating 
Response in Solid Tumors: 
RECIST version 1.1* will be used in this study for assessment of tumor response. While either 
CT or MRI may be utilized, as per RECIST 1.1, CT is the preferred imaging technique in this 
study. 
* As published in the European Journal of Cancer: 
E.A. Eisenhauer, P. Therasse, J. Bogaerts, L.H. Schwartz, D. Sargent, R. Ford, J. Dancey, S. 
Arbuck, S. Gwyther, M. Mooney, L. Rubinstein, L. Shankar, L. Dodd, R. Kaplan, D. Lacombe, J. 
Verweij. New response evaluation criteria in solid tumors: Revised RECIST guideline (version 
1.1). Eur J Cancer. 2009 Jan;45(2):228-47.