A Phase II Study of Atezolizumab in Combination With Stereotactic Radiation for Patients With Triple-negative Breast Cancer and Brain Metastasis
Phase: PHASE2
Conditions: Breast Cancer
Sponsor: Dana-Farber Cancer Institute



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SCHEMA

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TABLE OF CONTENTS
SCHEMA.........................................................................................................................................2
1.
OBJECTIVES......................................................................................................................7
1.1
Study Design............................................................................................................7
1.2
Primary Objectives...................................................................................................7
1.3
Key secondary objectives ........................................................................................7
1.4
Exploratory Objectives ............................................................................................7
1.5
Correlative Objectives .............................................................................................9
2.
BACKGROUND ...............................................................................................................10
2.1
Study Disease(s).....................................................................................................10
2.2
The PD-1/PD-L1 pathway in cancer......................................................................10
2.3
Atezolizumab (MPDL3280A) ...............................................................................11
2.4
Stereotactic radiation .............................................................................................15
2.5
Rationale ................................................................................................................16
2.6
Correlative Studies Background ............................................................................18
3.
PARTICIPANT SELECTION...........................................................................................20
3.1
Eligibility Criteria..................................................................................................21
3.2
Exclusion Criteria ..................................................................................................23
3.3
Inclusion of Women and Minorities ......................................................................24
4.
REGISTRATION PROCEDURES ...................................................................................24
4.1
General Guidelines for DF/HCC Institutions ........................................................24
4.2
Registration Process for DF/HCC Institutions.......................................................25
5.
TREATMENT PLAN........................................................................................................25
5.1
Treatment Regimen................................................................................................25
5.2
Pre-Treatment Criteria ...........................................................................................26
5.3
General Concomitant Medication and Supportive Care Guidelines......................30
5.4
Definition of Dose-Limiting Toxicity....................................................................32
5.5
Criteria for Taking a Participant Off Protocol Therapy.........................................32
5.6
Duration of Follow Up...........................................................................................33
5.7
Criteria for Taking a Participant Off Study ...........................................................34
6.
DOSING DELAYS/DOSE MODIFICATIONS ...............................................................34
6.1
Management of toxicities attributable to atezolizumab.........................................34
7.
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS .............................44
7.1
Adverse Events Lists..............................................................................................44
7.2
Methods and Timing for Assessing AND Recording Safety variables .................47
7.3
Procedures for Eliciting, Recording, and Reporting Adverse Events....................48
7.4
Reporting to Principal investigator........................................................................50
7.5
Expedited Reporting to 
........................................................................50

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7.6
Reporting to the Institutional Review Board (IRB)...............................................52
7.7
Expedited Reporting to the Food and Drug Administration (FDA) ......................52
7.8
Expedited Reporting to Hospital Risk Management .............................................52
7.9
Routine Adverse Event Reporting .........................................................................52
8.
PHARMACEUTICAL INFORMATION..........................................................................52
8.1
ATEZOLIZUMAB ................................................................................................52
9.
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................54
9.1
Archival Tissue Collection ....................................................................................55
9.2
Fresh Tissue Collection..........................................................................................56
9.3
Blood Collection....................................................................................................57
9.4
Cerebrospinal fluid (CSF)......................................................................................59
9.5
Planned Assays for Correlative Objectives............................................................60
9.6
Additional analysis.................................................................................................62
10.
STUDY CALENDAR .......................................................................................................62
11.
MEASUREMENT OF EFFECT .......................................................................................65
11.1
Antitumor Effect – CNS disease............................................................................65
11.2
Antitumor Effect – non-CNS disease ....................................................................70
11.3
Antitumor Effect – Hematologic Tumors..............................................................76
11.4
Other Response Parameters ...................................................................................76
12.
DATA REPORTING / REGULATORY REQUIREMENTS...........................................82
12.1
Data Reporting.......................................................................................................83
12.2
Data Safety Monitoring..........................................................................................83
12.3
Multicenter Guidelines...........................................................................................83
12.4
Collaborative Agreements Language.....................................................................84
13.
STATISTICAL CONSIDERATIONS...............................................................................84
13.1
Study Design/Endpoints ........................................................................................84
13.2
Sample Size, Accrual Rate and Study Duration ....................................................84
13.3
Stratification Factors..............................................................................................85
13.4
Interim Monitoring Plan ........................................................................................85
13.5
Analysis of Primary Endpoint................................................................................86
13.6
Analysis of Key Secondary Endpoints ..................................................................87
13.7
Analysis of Exploratory and Correlative Endpoints..............................................88
13.8
Reporting and Exclusions ......................................................................................91
14.
PUBLICATION PLAN .....................................................................................................92
REFERENCES ..............................................................................................................................93
APPENDIX A
PERFORMANCE STATUS CRITERIA ................................................101
APPENDIX B
ANAPHYLAXIS PRECAUTIONS ........................................................102

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APPENDIX C     M.D. Anderson Symptom Inventory-Brain Tumor (MDASI-BT)..................103
APPENDIX D NANO SCALE....................................................................................................108
APPENDIX E EQ-5D ENGLIGH QUESTIONARIE.................................................................111
APPENDIX h
Guidelines for collecting research biopsy tissue......................................120
Risks of Research Biopsy and Procedures for Minimizing Risk.....................................120
Risks of Anesthesia..........................................................................................................121
APPENDIX I:
 SAFETY REPORTING FAX COVERSHEET..........................124

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1.
OBJECTIVES
1.1
Study Design
1.1.1
This is an open-label, single arm phase II study assessing progression-free survival 
(PFS) in patients with triple-negative breast cancer (TNBC) and brain metastases who 
will receive stereotactic radiation in combination with atezolizumab. Atezolizumab 
will be administered at 1200mg IV every 3 weeks until disease progression in either 
CNS or extra-CNS site(s) according to RANO-BM and RECIST criteria, respectively. 
The first dose of Atezolizumab should be administered 2-7 days prior to starting 
radiation. Research biopsies will be performed at baseline (mandatory if there is 
accessible extracranial metastasis) and at Cycle 2 Day 1. An optional research biopsy 
will be collected at time of progression if a participant has achieved a prolonged 
response defined as complete or partial response or stable disease for ≥ 24 weeks).
1.2
Primary Objectives
1.2.1
To evaluate the efficacy of atezolizumab in combination with stereotactic radiation, as 
defined by bi-compartmental PFS according to RANO-BM criteria, in patients with 
TNBC and brain metastases.
1.3
Key secondary objectives
1.3.1
To evaluate the extracranial objective response rate (ORR) by RECIST 1.1 criteria 
among patients with TNBC and brain metastasis treated with atezolizumab in 
combination with stereotactic radiation [Eisenhauer et al., 2009].
1.3.2
To evaluate overall survival (OS) of patients with TNBC and brain metastasis treated 
with atezolizumab in combination with stereotactic radiation.
1.4
Exploratory Objectives
Exploratory safety objectives
1.4.1
To evaluate the short term, 6-month, and 12-month safety and tolerability of 
atezolizumab in combination with stereotactic radiation in patients with TNBC and 
brain metastases.

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Exploratory efficacy objectives
1.4.2
To evaluate the central nervous system (CNS) response rates according to response 
assessment in neuro-oncology-brain metastases (RANO-BM) criteria[Lin et al., 2015] 
(Section 11.1.1).
1.4.3
To evaluate the CNS response rates according to response assessment in 
immunotherapy neuro-oncology-brain metastases (iRANO-BM) criteria[Okada et al., 
2015].
1.4.4
To evaluate the extracranial ORR according to immune-related response criteria 
(irRC)[Wolchok et al., 2009].
1.4.5
To evaluate the abscopal response rate (ARR), according abscopal response definition 
[Golden et al., 2015](Section 11.4.3). 
1.4.6
To evaluate the proportion of participants with stable or responsive disease in both 
CNS and non-CNS at 16 and 24 weeks.
1.4.7
To evaluate PFS according to the RECIST 1.1 single-compartmental model.
1.4.8
To evaluate PFS according to the RANO-BM criteria.
1.4.9
To describe the site of first progression (CNS vs extracranial vs both) 
1.4.10 To describe the type of CNS progression (new lesion(s), progression of non-target 
lesions, progression of target lesions, progression of stereotactic radiation-treated 
lesions, radiation necrosis in stereotactic radiation-treated lesions, or a combination of 
these)
1.4.11 To describe the type of extracranial progression (new lesion(s), progression of non-
target lesions, progression of target lesions, or a combination of these)
Exploratory patient-reported outcome objectives
1.4.12 To evaluate the impact of treatment with atezolizumab and stereotactic radiation in 
patients with TNBC and brain metastases on PROs, as measured by the M.D. 
Anderson Symptom Inventory-Brain Tumor (MDASI-BT) assessment
1.4.13 To evaluate the relationship of CNS ORRs according the RANO-BM criteria with 
PRO endpoints, as measured by the MDASI-BT
1.4.14 To evaluate the relationship of CNS ORRs according the iRANO criteria with PRO 
endpoints, as measured by the MDASI-BT
1.4.15 To evaluate the impact of the study treatment, for these same patients, on general 
health status assessed by EQ-5D questionnaire. 

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Exploratory investigator-assessed neurological evaluation objectives
1.4.16 To evaluate the impact of treatment with atezolizumab and stereotactic radiation in 
patients with TNBC and brain metastases on investigator-assessed neurological 
evaluation, as measured by the Neurological Assessment in Neuro-Oncology (NANO) 
scale.
1.4.17 To evaluate the relationship of CNS ORRs according the RANO-BM criteria and 
investigator-assessed neurological evaluation, as measured by the Neurological 
Assessment in Neuro-Oncology (NANO) scale.
1.4.18 To evaluate the relationship of CNS ORRs according the iRANO criteria with 
investigator-assessed neurological evaluation, as measured by the Neurological 
Assessment in Neuro-Oncology (NANO) scale.
1.5
Correlative Objectives
1.5.1
To explore whether the number and/or type of mutations identified using a next 
generation sequencing (NGS) panel is correlated with patient outcomes (PFS, ORR, 
CBR, and OS).
1.5.2
To collect blood to study cell-free DNA for quantification of tumor DNA content and 
copy number variation, using ultra-low pass whole genome sequencing, and to explore 
whether cfDNA load is associated with patient outcomes (PFS, ORR, CBR, and OS).
1.5.3
To collect blood to study cell-free DNA for targeted sequencing and/or whole exome 
sequencing  To compare mutations and copy number variation between cfDNA and 
tumor biopsies.
1.5.4
To characterize a broad array of immune markers in metastatic TNBC 
(characterization will be based on histology, protein expression, and mRNA 
expression), and their changes with immune checkpoint blockade. 
1.5.5
To explore how different immunosuppressive and/or immune-stimulating immune 
marker profiles at baseline correlate with patient outcomes (PFS, CNS ORR, CBR and 
OS).
1.5.6
To characterize changes in immune marker profiles on treatment and at time of 
progression
1.5.7
To characterize serial changes in immune marker profile in peripheral blood 
mononuclear cells (PBMCs) and in plasma over the course of the trial treatment.
1.5.8
To explore whether induction of changes in the immunosuppressive and/or immune-
stimulating immune marker profile in PBMC correlates with clinical outcomes (PFS, 
ORR, and OS).
1.5.9
To collect cerebrospinal fluid (CSF) to study cell-free DNA for quantification of 
tumor DNA content and copy number variation, using ultra-low pass whole genome 
sequencing, and to compare patterns of cfDNA serially over time in CSF compared to 
plasma. 
1.5.10 To explore whether cfDNA load in CSF is associated with clinical outcomes (PFS, 
ORR, CBR, and OS).
1.5.11 To collect CSF to study cell-free DNA for targeted sequencing and/or whole exome 
sequencing before, on and after immunotherapy. To compare mutations and copy 
number variation between cfDNA in plasma versus CSF.

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2.
BACKGROUND
2.1
Study Disease(s)
Breast cancer is the most frequently diagnosed cancer and the second cause of cancer 
death in American women[Jemal et al., 2011, Siegel et al., 2013]. Approximately, 15% of these 
cancers are classified as triple-negative breast cancer (TNBC), comprising those with absent 
expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth 
factor receptor 2 (HER2)[Foulkes et al., 2010]. Together with human epidermal growth factor 
receptor 2 (HER2)-positive breast cancer subtype, triple negative breast cancer (TNBC) have the 
highest rates of brain metastases, with studies reporting up to 50% rate of CNS involvement 
among those subtypes[Lin et al., 2008, Niwinska et al., 2010, Lin et al., 2012]. 
Initial treatment for patients with brain metastases typically includes surgery or 
radiotherapy, either whole brain radiotherapy (WBRT), stereotactic radiation, or both, depending 
of factors such as performance status, expected prognosis as well the localization and the number 
of CNS metastasis[Lim et al., 2014]. In patients with limited metastases and good performance 
status, stereotactic radiation has emerged as a preferred definitive modality because it offers 
excellent local control, is associated with minimal acute and long-term toxicity, and does not 
significantly interfere with systemic therapy schedules[Lim et al., 2014].
Even with improvement in local and systemic therapies, the prognosis of patients with 
breast cancer BM is poor, especially in TNBC[Kennecke et al., 2010, Sperduto et al., 2012]. A 
recent large retrospective study of 865 patients with BCBMs reported the median overall 
survival following the diagnosis of BCBMs of 7.3 months in patients with TNBC[Sperduto et 
al., 2013]. Therefore, there is a great necessity of developing new therapeutic strategies for 
TNBC BMs.
2.2
The PD-1/PD-L1 pathway in cancer
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades[Schreiber et al., Schreiber, 2012]. Accumulating 
evidence shows a correlation between tumor-infiltrating lymphocytes (TILs) in cancer tissue and 
favorable prognosis in various malignancies[Mlecnik et al., 2014]. 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[Tosolini et al., 
2006, Adams et al., 2014, Denkert et al., 2015].
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 

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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[Intlekofer et 
al., 2013].
The PD-1/PD-L1 pathway in breast cancer
Unlike melanoma and NSCLC, BC has not been intensively investigated for its 
susceptibility to immunotherapy in clinical settings. However, there are accumulating preclinical 
and clinical evidence suggesting that immune system is critical during natural history of breast 
cancer and the immune system can be modulated to improve outcomes in this disease[Kroemer 
et al., 2015]. It has been recognized that BC is capable of stimulating the immune system, as 
many breast tumors have substantial lymphocyte infiltration [Denkert et al., 2010, Denkert et al., 
2015]. Additionally, this pathologic feature has prognostic implications, as lymphocyte 
predominant breast cancers are associated with improved prognosis [Denkert et al., 2010, Loi et 
al., 2013]. However, the degree of immune infiltration differs by BC subtype; while a substantial 
proportion of triple negative BC can be richly infiltrated, hormone-receptor positive BC is poorly 
T-cell infiltrated[Dushyanthen et al., 2015]. Recently, it has been demonstrated that the 
expression of PD-1 and PD-L1 differs among breast tumors subtype: HR-positive (30% PD-1; 
33% PD-L1), triple-negative (70% PD-1; 59% PD-L1) and HER2-positive (60% PD-1; 20% PD-
L1)[Gatalica et al., 2014].
2.3
Atezolizumab (MPDL3280A)
Atezolizumab is a human immunoglobulin (Ig) G1 monoclonal antibody consisting of 
two heavy chains (448 amino acids) and two light chains (214 amino acids) and is produced in 
Chinese hamster ovary cells. Atezolizumab was engineered to eliminate Fc-effector function via 
a single amino acid substitution (asparagine to alanine) at position 298 on the heavy chain, which 
results in a non-glycosylated antibody that has minimal binding to Fc receptors and prevents Fc-
effector function at expected concentrations in humans. Atezolizumab targets human 
programmed death-ligand 1 (PD-L1) and inhibits its interaction with its receptor, programmed 

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death-1 (PD-1). Atezolizumab also blocks the binding of PD-L1 to B7.1, an interaction that is 
reported to provide additional inhibitory signals to T cells.
Atezolizumab is being investigated as a potential therapy against solid tumors and 
hematologic malignancies in humans.
2.3.1
Summary of Nonclinical Experience
The nonclinical strategy of the Atezolizumab program was to demonstrate in vitro and 
in vivo activity, to determine in vivo pharmacokinetic (PK) behavior, to demonstrate an 
acceptable safety profile, and to identify a Phase I starting dose. Comprehensive pharmacology, 
PK, and toxicology evaluations were thus undertaken with Atezolizumab.
The safety, pharmacokinetics, and toxicokinetics of Atezolizumab were investigated in 
mice and cynomolgus monkeys to support intravenous (IV) administration and to aid in 
projecting the appropriate starting dose in humans. Given the similar binding of Atezolizumab 
for cynomolgus monkey and human PD-L1, the cynomolgus monkey was selected as the primary 
and relevant nonclinical model for understanding the safety, pharmacokinetics, and 
toxicokinetics of Atezolizumab. 
Overall, the nonclinical pharmacokinetics and toxicokinetics observed for Atezolizumab 
supported entry into clinical studies, including providing adequate safety factors for the proposed 
Phase I starting doses. The results of the toxicology program were consistent with the anticipated 
pharmacologic activity of down-modulating the PD-L1/PD-1 pathway and supported entry into 
clinical trials in patients.
Refer to the Atezolizumab Investigator’s Brochure for details on the nonclinical studies. 
2.3.2
Clinical Experience with Atezolizumab
2.3.2.1
Ongoing Clinical Studies
Current studies of Atezolizumab include one ongoing Phase Ia monotherapy study, three 
ongoing combination studies, five Phase II studies, and one Phase III study. Details of all 
ongoing studies can be found in the Atezolizumab Investigator’s Brochure.
Phase Ia Study PCD4989g
Study PCD4989g is a multicenter, first-in-human, open-label, dose-escalation study 
evaluating 
the 
safety, 
tolerability, 
immunogenicity, 
pharmacokinetics, 
exploratory 
pharmacodynamics, and preliminary evidence of biologic activity of Atezolizumab administered 
as a single agent by IV infusion every 3 weeks to patients with locally advanced or metastatic 
solid malignancies or hematologic malignancies. Ongoing expansion cohorts are studying the 
efficacy in patients with pancreatic cancer, bladder cancer, breast cancer, esophageal cancer, 
prostate cancer, small-cell lung cancer, malignant lymphoma, multiple myeloma, and other less 
common tumor types.
Phase Ib Study GP28328
Ongoing Phase Ib Study GP28328 is evaluating the safety and pharmacology of 
Atezolizumab administered with bevacizumab alone (Arm A) or with bevacizumab plus 
leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX; Arm B) in patients with advanced solid 
tumors. Additional cohorts have been included to investigate Atezolizumab in combination with 
carboplatin plus paclitaxel, in combination with carboplatin plus pemetrexed, and in combination 
with carboplatin plus nab paclitaxel, pemetrexed, and cisplatin in patients with advanced or 
metastatic non-small cell lung cancer (NSCLC).
Phase Ib Study GP28384

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Ongoing Phase Ib Study GP28384 is evaluating the safety and pharmacology of 
Atezolizumab administered in combination with vemurafenib in patients with previously 
untreated BRAFV600-mutationpositive metastatic melanoma.
Phase Ib Study GP28363
Ongoing Phase Ib Study GP28363 is evaluating the safety and pharmacology of 
Atezolizumab administered in combination with cobimetinib (MEK inhibitor) in locally 
advanced or metastatic solid tumors.
Phase II Study GO28625 (FIR)
Ongoing, single-arm, Phase II Study GO28625 is evaluating the safety and efficacy of 
Atezolizumab monotherapy in PD-L1positive patients with NSCLC. In particular, this study is 
evaluating whether archival or fresh tumor tissue is more predictive of response to 
Atezolizumab. Safety and efficacy data are not yet available for this study. 
Phase II Study GO28753 (POPLAR)
Study GO28753 is a randomized, open-label, Phase II study in patients with locally 
advanced or metastatic NSCLC who have failed a prior platinum-containing regimen. Patients in 
the control arm of Study GO28753 will receive docetaxel alone. Eligible patients will be enrolled 
regardless of PD-L1 status and will be stratified by PD-L1 expression. The primary endpoint is 
overall survival (OS) for both the PD-L1positive population and the overall study population.
Phase II Study GO28754 (BIRCH)
Ongoing, single-arm, Phase II Study GO28754 is evaluating the safety and efficacy of 
Atezolizumab monotherapy in PD-L1positive patients with NSCLC. Safety and efficacy data 
are not yet available for this study.
Phase II Study WO29074
Ongoing Phase II Study WO29074 is evaluating the safety and efficacy of Atezolizumab 
monotherapy or the combination of Atezolizumab and bevacizumab versus sunitinib in 
treatment-naïve patients with renal cell carcinoma (RCC). Safety and efficacy data are not yet 
available for this study.
Phase II Study GO29293
Ongoing Study GO29293 is a single-arm, open label, Phase II study to assess the clinical 
benefit of Atezolizumab as a single agent in patients with locally advanced or metastatic UBC. 
The co-primary endpoints of this study are independent review facility (IRF)assessed objective 
response rate (ORR) according to Response Evaluation Criteria in Solid Tumors, Version 1.1 
(RECIST v1.1) and investigator-assessed ORR according to modified Response Evaluation 
Criteria in Solid Tumors (RECIST) criteria.
Phase III Study GO28915 (OAK)
Study GO28915 is a randomized, open-label, Phase III study in patients with locally 
advanced or metastatic NSCLC who have failed a prior platinum-containing regimen. Patients in 
the control arm of Study GO28915 will receive docetaxel alone. Eligible patients will be enrolled 
regardless of PD-L1 status and will be stratified by PD-L1 expression. The primary endpoint is 
OS for both the PD-L1positive population and the overall study population.
2.3.2.2
Clinical Safety
The presented safety data for Atezolizumab have been derived mainly from the treatment 
of patients in Phase Ia Study PCD4989g. As of 10 May 2014, Atezolizumab has been 
administered to approximately 775 patients with solid and hematologic malignancies. No dose-

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limiting toxicities (DLTs) have been observed at any dose level, and no maximum tolerated dose 
(MTD) was established. Fatigue was the most frequently reported adverse event (AE). 
Adverse Events
The following safety data are from PCD4989g, in which Atezolizumab is being used as 
single-agent therapy in patients with locally advanced or metastatic solid tumors or hematologic 
malignancies. In 412 treated patients, 97.1% reported an AE while on study. Of these AEs, 
48.8% were Grade 1 or 2 in maximum severity on the basis of National Cancer Institute 
Common Terminology Criteria for Adverse Events, Version 4.0 (NCI CTCAE v4.0). The most 
frequently observed AEs (occurring in  10% of treated patients) included fatigue, nausea, 
decreased appetite, pyrexia, dyspnea, diarrhea, constipation, cough, headache, back pain, 
vomiting, anemia, arthralgia, rash, insomnia, asthenia, abdominal pain, chills, pruritus, and upper 
respiratory tract infection. 
Grade  3 AEs were reported by 199 of 412 patients (48.3%). There were 51 patients 
(12.4%) who reported Grade  3 AEs that were assessed as related to study drug by the 
investigators. The most frequently reported related Grade  3 AEs included fatigue (5 patients 
[1.2%]), increased ALT and increased AST (each reported in 4 patients [1.0%]); and asthenia, 
autoimmune hepatitis, and hypoxia (each reported in 3 patients [0.7%]). 
Immune-Related Adverse Events
Given the mechanism of action of Atezolizumab, events associated with inflammation 
and/or immune-mediated AEs have been closely monitored during the Atezolizumab clinical 
program. These include potential dermatologic, hepatic, endocrine, and respiratory events as well 
as events of hepatitis/elevated liver function tests (LFTs) and influenza-like illness. Expected 
adverse 
drug 
reactions 
associated 
with 
Atezolizumab 
include 
the 
following: 
hepatitis/transaminitis, hypothyroidism, infusion-related reactions (IRRs), pneumonitis, 
influenza-like illness, and dermatologic reactions. Potential adverse drug reactions include the 
following: anti-therapeutic antibodies (ATAs), colitis, endocrine disorders, hypersensitivity, 
neurologic disorders, and pericardial effusion. 
For further details, see the Atezolizumab Investigator’s Brochure.
2.3.2.3
Clinical Activity 
As of the data cutoff of 1 January 2014, efficacy analyses were performed on 386 
efficacy evaluable patients who were defined as those patients, with measurable disease at 
baseline, treated by 1 July 2013 in Study PCD4989g (to ensure that each patient had a minimum 
of 6 months follow-up). Patients with multiple tumor types were included in the study, with the 
largest cohorts consisting of patients with NSCLC, RCC, and bladder cancer. Objective 
responses with Atezolizumab monotherapy were observed in a broad range of malignancies, 
including NSCLC, RCC, melanoma, bladder cancer, colorectal cancer, head and neck cancer, 
gastric cancer, breast cancer and sarcoma. Altogether, there were 47 patients with responses with 
a median duration of response of 75.7 weeks (range: 11.7 to 85.9 weeks, where “  ” denotes 
censored value). The majority of these responses have been durable, with 72.3% (34/47) of 
responses ongoing as of the clinical cutoff date.
Analyses of tumor-infiltrating immune cells for PD-L1 expression on baseline tumor 
tissue have been performed for Study PCD4989g. Preliminary results from Study PCD4989g 

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suggest that PD-L1 expression in tumor-infiltrating immune cells is likely to be associated with 
response to Atezolizumab. 
In addition, as of the clinical cutoff date of 21 April 2014, efficacy analyses were 
performed on 33 immunohistochemistry (IHC) 2/3 and 36 IHC 0/1 efficacy-evaluable patients 
with locally advanced or metastatic urothelial bladder cancer (UBC) who were dosed by 
27 January 2014 in Study PCD4989g[Powles et al., 2014]. In the 33 IHC 2/3 efficacy-evaluable 
patients with UBC, the median follow-up was 6 months (range: 1 to 12 months). The 
investigator-assessed ORR per RECIST v1.1 in this IHC 2/3 cohort was 52% (95% CI: 34%, 
69%) with three complete responses. The median duration of response was not yet reached 
(range: 0.1 to 42 weeks). The median progression-free survival (PFS) was 24 weeks (range: 5 
to 50 weeks), respectively. Among 36 IHC 0/1 efficacy-evaluable patients with UBC, there 
were 5 patients with responses. The investigator-assessed ORR per RECIST v1.1 in this IHC 0/1 
cohort was 14% (95% CI: 6%, 28%). Median duration of follow-up for these patients was 4 
months (range: 1 to 7 months). For these five responses, the median duration of response has 
not been reached (range: 6 to 19 weeks). The majority of responses have been durable, with 
86.4% of responses (19 of 22) still ongoing as of the clinical cutoff date.
For further details, see the Atezolizumab Investigator’s Brochure.
2.3.2.4
Clinical Pharmacokinetics and Immunogenicity
On the basis of available preliminary PK data (0.0320 mg/kg), Atezolizumab appeared 
to show linear pharmacokinetics at doses  1 mg/kg. For the 1-mg/kg and 20-mg/kg dose groups, 
the mean clearance (CL) and the mean volume at steady state (Vss) had a range of 3.204.43 
mL/kg and 48.164.1 mL/kg, respectively, which is consistent with the expected profile of an 
IgG1 antibody in humans.
The development of ATAs has been observed in patients in all dose cohorts and was 
associated with changes in pharmacokinetics for some patients in the lower dose cohorts (0.3, 1, 
and 3 mg/kg). The development of detectable ATAs has not had a significant impact on 
pharmacokinetics for doses from 1020 mg/kg. Patients dosed at the 10-, 15-, and 20-mg/kg 
dose levels have maintained the expected target trough levels of drug despite the detection of 
ATAs. To date, no clear relationship between detection of ATAs and AEs or IRRs has been 
observed.
2.4
Stereotactic radiation
Multiple randomized controlled trials have compared stereotactic radiation with or 
without initial whole brain radiotherapy in patients with up to 4 brain metastases and have 
demonstrated equivalent overall survival outcomes (ref: Patchell JAMA 1998, JROSG 99-1 
study, JAMA 2006; MDACC study Lancet Oncol 2009; EORTC 22952 study JCO 2011; 
NCCTG N0574 study, ASCO 2015; JCOG 0504 study ASCO 2016) whether or not WBRT is 
included in the initial treatment approach. Because of valid concerns about short- and long-term 
neurotoxicity with WBRT, stereotactic radiation has become the preferred initial approach in the 
treatment of patients who present with a limited number of brain metastases.  In patients who 
develop new and/or progressive brain metastases after WBRT, stereotactic radiation can 
frequently be employed as salvage therapy.
However, the available data indicates that breast cancer subtype strongly influences the 

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outcomes after stereotactic radiation in patients with brain metastases. For example, in a 
retrospective study of patients treated at Dana-Farber Cancer Institute, median duration of 
intracranial control was significantly shorter among patients with TNBC compared to those with 
HER2+ breast cancer (Dyer et al, IJROBP 2012). In addition, patients with TNBC and brain 
metastases frequently experience extra-cranial disease progression as well; thus, control of both 
intracranial and extracranial compartments is critical (Lin et al, Cancer 2008).  
2.5
Rationale
The recognizing that overexpression of immune checkpoint molecules in tumor 
microenvironment has a crucial role for antitumor immunity evasion and for cancer progression 
has been revolutionized the cancer treatment[Pardoll, 2012]. In particular, anti-PD-1/PD-L1 
antibodies have demonstrated clinical activity in more than 15 cancer types, and have proved to 
increase overall survival in melanoma, non-small-cell lung carcinoma and renal cell 
carcinoma[Brahmer et al., 2012, Topalian et al., 2012, Topalian et al., 2015, Rosenberg et al., 
2016].
Despite the fact that BC has not been considered an immunogenic neoplasm, there are 
accumulating preclinical and clinical evidence suggesting that the immune system is critical for 
disease outcome[Kroemer et al., 2015]. It is now recognized that a fraction of breast tumors, 
especially TNBC, have substantial lymphocyte infiltration and that this pathologic feature has 
prognostic implications[Savas et al., 2015]. Furthermore, the high rates of PD-L1 and PD-1 
expression in patients with TNBCs led to clinical trials to address the role of PD-1 blockers in 
this population[Gatalica et al., 2014]. The anti-PD-L1 atezolizumab was evaluated in patients 
with metastatic TNBC PD-L1 positive and showed an objective response rate (ORR) of 19% and 
a 6-month PFS of 27%[Emens et al., 2015]. Similar results were found in a PD-L1 positive 
population with the anti-PD-1 inhibitor pembrolizumab (ORR of 18% and 6-month PFS of 
23%)[Nanda et al., 2016]. Data from a trial with avelumab has demonstrated that in a non-
selected population, the use of PD-1/PD-L1 inhibitors presented an objective response rate 
(ORR) of 8.6%[Dirix et al., 2015]. Clearly, these results show that even in the most 
immunogenic of breast tumors, other therapeutic strategies must be added to anti-PD-1/PD-L1 
agents in order to benefit more patients. Indeed, preliminary results suggest that the combination 
of atezolizumab plus nab-paclitaxel is tolerable and has a very promising activity in patients with 
metastatic TNBC. Of note, upfront treatment showed an ORR of 66.7%[Adams et al., 2016]. 
These results suggest that combinatorial approaches can achieve a high rate of clinical benefit. 
In this context, there is strong preclinical rationale to evaluate the combination of 
radiotherapy (RT) with PD-1/PD-L1 blockade. Previous studies demonstrated that, in addition to 
its direct cytoreductive effect, RT-induced cell death can be immunogenic, facilitating the 
recruitment and activation of antigen presenting cells (APCs) and priming of tumor antigen-
specific T-cells[Shahabi et al., 2015]. Recently, different groups demonstrated that RT to the 
tumor bed led to upregulation of PD-L1 on tumor cells, dendritic cells, and on myeloid-derived 
suppressive cells (MDSCs), which may contribute to impairment of T-cell function in the 
tumor[Liang et al., 2013, Deng et al., 2014, Sharabi et al., 2014]. Furthermore, these groups also 
demonstrated that the combination of RT plus blockade of the PD-1/PD-L1 axis improved 
outcomes in different preclinical models compared with RT or anti-PD-1/PD-L1 alone, including 
breast cancer models (Figure 1).

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Moreover, the effect of localized radiotherapy mediating systemic responses distant from 
the field of radiation (the abscopal effect), has been reported in several types of human 
malignancies, such as melanoma and renal cell carcinoma, after treatment combining RT and 
immune checkpoint inhibitors[Adamow et al., 2012]. Although there is no definitive data 
confirming the host immune response caused the response, the tumor responses observed in these 
cases were accompanied by immunological changes in peripheral blood, including changes in a 
variety of tumor-associated antigens and a decrease in MDSCs. Additionally, the abscopal effect 
was recently demonstrated in mice treated with the combination of RT and anti–PD-L1 therapy, 
but not in groups receiving either treatment alone, suggesting that this combination may 
potentiate an abscopal effect on distant tumors (Figure 2)[Deng et al., 2014, Dovedi et al., 2015].
Given the above rationale, there is an increased interest in to investigate the benefit of 
combining stereotactic radiation and immune checkpoint inhibitors. Multiples series have 
showed that the anti-CTLA-4 ipilimumab in combination with cranial radiation is well tolerated 
and can result in prolonged survival[Mathew et al., 2013, Kiess et al., 2015, Schoenfeld et al., 
2015]. Recently, Ahmed et al reported good local control and minimal neurotoxicity with the 
combination of the anti-PD1 Nivolumab and stereotactic radiation in the management of 
melanoma brain metastases [Ahmed et al., 2016]. Additionally, they also showed an 
improvement in OS and distant brain metastases control compared with a historical control. 
Thus, we hypothesize that RT may potentiate the efficacy of PD-L1 blockade and we propose 
evaluating the combination of the Atezolizumab with stereotactic radiation in patients with brain 
metastases due to TNBC. 

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Thus, we propose to evaluate the combination of atezolizumab with stereotactic radiation 
in patients with TNBC and brain metastases. This is an open-label, single arm phase II study. 
The primary endpoint is bi-compartmental PFS. Because of the strong interest in exploring a 
potential abscopal effect, evaluable extracranial disease is required. Patients included in this trial 
will be those in which a course of stereotactic radiation for CNS metastases is indicated. Patients 
will receive the first dose of Atezolizumab 2-7 days before the beginning of stereotactic 
radiation. Atezolizumab 1200mg will be administered every 3 weeks thereafter until disease 
progression. Research biopsies will be performed at baseline (required if accessible extra-CNS 
metastases) and from C2D1-C2D21.
2.6
Correlative Studies Background
Immune biomarkers
The importance of tumor microenvironment and the immunosurveillance in natural history of 
cancer and its outcomes was proved to be true in the last years, with clinical approval of immune 
checkpoint inhibitors[Sharma et al., 2015]. However, less than half of patients with solid tumors 
will derive benefit with these drugs [Hwu et al., 2012, Smith et al., 2012]. Thus, it is crucial to 
elucidate the exact mechanisms of antitumor immunity evasion ongoing in tumor 
microenvironment to successfully develop new cancer immunotherapy and correctly choose the 
best drug for the right patient. This goal can be pursuit through the discovery and validation of 
prognostic and predictive biomarkers.
A growing body of evidence suggests that patients with advanced solid tumors shows differences 
in tumor microenvironment regarding the presence or absence of a gene expression profile 
indicative of a pre-existing T-cell–inflamed tumor microenvironment[Gajewski, 2015]. Tumors 
classified as T-cell inflamed present a significant infiltration of CD8+ T cells and a type I IFN 
signature. In this group, the main mechanisms of immune evasion are the overexpression of 
immunessupressor molecules acting at the level of the tumor micro- environment, such as 
immune checkpoint molecules (CTLA-4, PD-1/PD-L1, TIM-3, LAG-3), indoleamine-2,3-
dioxygenase (IDO), and FoxP3. Interestingly, such immunosuppressive molecules seem to be 
upregulated after deflagration of a type I Interferon antitumor response, resulting in T-cell 
exhaustion, and the so called adaptive immune resistance[Gajewski, 2015, Ribas, 2015]. The 
other group of patients presents tumors characterized by a low or absence of intratumoral CD8 T 
cells and a lack evidence of a type I IFN transcriptional signature. This tumor phenotype is called 
non-T-cell-inflamed[Gajewski, 2015].
The T-cell inflamed phenotype has positive prognostic value for several types of early stage 
cancer, including breast cancer[Dushyanthen et al., 2015, Perez et al., 2015], suggesting that the 
attempt by the host to generate an anti-tumor immune response reflects a biologic process 
associated with improved patient outcomes[Gajewski, 2015]. In breast oncology, different 
groups have demonstrated that the amount of tumor-infiltrating lymphocytes (TILs) in a tumor 
specimen, commonly assessed simply by histological evaluation of a standard hematoxylin and 
eosin-stained slide by a trained pathologist, is a significant predictor of both response to therapy 
and overall disease outcomes in the neoadjuvant and adjuvant settings [Denkert et al., 2010, Loi 
et al., 2013, Adams et al., 2014, Ali et al., 2014, Salgado et al., 2014, Denkert et al., 2015, 

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Denkert et al., 2015]. Recently, more in-depth methods of immunologic profiling are being 
explored in breast cancer, for example mRNA expression of immune-activating and 
immunosuppressive factors, and these additional immune profiles also appear to have prognostic 
significance[Perez et al., 2015]. Furthermore, in metastatic setting, the phenotype T-cell-
inflamed appears to be associated with clinical response to several immunotherapies, including 
checkpoint blockade[Herbst et al., 2014]. Patients with this tumor phenotype seem to be good 
candidates for immune checkpoint inhibitor therapy, alone or in combination. Thus, the bulk of 
our correlative science in this trial highlights our special interest in characterizing a broad array 
of immune markers in metastatic HR-positive breast cancer, investigating whether those markers 
predict disease response to therapy.
Thus, considering the mechanism of action of drugs like anti-PD-1/anti-PD-L1, is the lack of a 
significant T-cell infiltrate and low expression of immune checkpoint molecules may explain the 
reason that certain non-inflamed tumor phenotype are associated with de novo resistance to those 
class of drugs. For this group of patients, therapeutic strategies that promote a boost in innate 
immunity, such as a course of radiation therapy, will be crucial to successfully overcoming T-
cell exclusion and improve the likelihood of benefit of PD-1 blockers. 
In breast tumors, particularly the HR-positive subset, the vast majority of patient’s tumors do not 
harbor significant TILs or demonstrate PD-L1 expression and will therefore most likely be 
classified as non-T-cell-inflamed tumors. This explains why ORR recently reported in this 
population ranges from 2.8%-12%[Dirix et al., 2015, Hugo et al., 2015]. Clearly, new 
approaches to boost antitumor immunity are needed in this population. RT can potentially 
improve the activity of immune checkpoint inhibitors. Because of the preclinical data supporting 
RT induced immune modulation of the tumor microenvironment, we intend to explore how 
immune biomarkers change after the beginning of treatment, including the expression of immune 
checkpoint molecules, TILs and T-cell receptor diversity.
Additionally, as a correlative study to this trial, we will characterize the immune marker profile 
of peripheral blood mononuclear cells (PBMCs) in enrolled breast cancer patients. Furthermore, 
given the demonstrated clinical significance of TILs in breast cancer specimens, we will 
investigate whether there is a peripheral marker whose level corresponds to TIL percentage. 
Lastly, we will evaluate whether there is a correlation between changes in PBMC immune 
profiles and disease response. Evidence of a correlation would be of significant interest as it 
would suggest the potential presence of a predictive biomarker in the peripheral blood.
These correlative projects are made possible by collaboration with Drs. Scott Rodig and Evisa 
Gjini, and Mariano Severgnini, all of whom are laboratory scientists with extensive experience 
with immune profiling in melanoma. Further details can be found in Section 9.
Tumor Genomic Profile
In addition to the immune microenvironment, intrinsic tumor factors may be associated 
with response to immune checkpoint inhibitors. Although some of the mechanisms related to de 
novo or acquired resistance to ICI have been recently described, including loss of function in 
beta-2- microglobulin or defects in the interferon signaling pathway[Gao et al., 2016, Zaretsky et 
al., 2016], the knowledge of immune resistance remains largely unknown. Several 

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gene/pathways have been described as possible candidates of having an immunosuppressive role 
in different advanced solid tumor, including MYC amplification[Casey et al., 2016], activation 
in WNT--catenin pathway[Spranger et al., 2015], activation in MAPK pathway, loss of 
PTEN[Li et al., 2016, Peng et al., 2016, George et al., 2017]. On the other hand, few possible 
biomarkers of response to ICI have emerged, including mutational load[Snyder et al., 2014, 
Rizvi et al., 2015], tumor aneuploidy[Davoli et al., 2017], mismatch repair defects[Le et al., 
2015], and BRCA2 mutation[Hugo et al., 2016]. Notably, there is no data on genomic 
mechanisms of de novo resistance to anti-PD-1 therapy in patients with breast cancer.
Therefore, as a correlative study to this trial, we will to explore whether the number 
and/or type of mutations identified using a next generation sequencing (NGS) panel – OncoPanel 
- is correlated with patient outcomes (PFS, CNS ORR, CBR, and OS). This tool is a cancer 
genomic assay to detect somatic mutations, copy number variations and structural variants in 
tumor DNA extracted from fresh, frozen or formalin-fixed paraffin-embedded samples. The 
OncoPanel assay surveys exonic DNA sequences of 447 cancer genes and 191 regions across 60 
genes for rearrangement detection. DNA is isolated from tissue containing at least 20% tumor 
nuclei and analyzed by massively parallel sequencing using a solution-phase Agilent SureSelect 
hybrid capture kit and an Illumina HiSeq 2500 sequencer. The targeted NGS assay (OncoPanel) 
will be performed at the Center for Advanced Molecular Diagnostics (Department of Pathology, 
Brigham and Women's Hospital). This assay has been extensively validated and is used as a 
CLIA-approved clinical molecular test in our institution without any additional sequencing 
assays to validate the findings [Wagle et al., 2012]. 
Circulating free DNA
We will collaborate with Dr. Heather Parsons and investigators at the Broad Institute to study 
cfDNA serially over time. cfDNA provides a less invasive method by which to characterize 
tumor genomics. In addition, there is the potential to capture heterogeneity across multiple 
metastatic sites, in a more practical way than tissue biopsies of multiple sites. Particularly, in 
patients with brain metastases, research biopsies of CNS tumors are not feasible. cfDNA also 
provides an alternate method by which to quantify tumor burden over time. Given the intended 
population of patients with brain metastases who will receive immune checkpoint blockade, 
transient increases in the size of brain metastases may be explained by: true tumor progression, 
radiation necrosis, or immune infiltration. There is currently no non-invasive test that has been 
demonstrated to match the gold standard of surgical resection, and the guidelines reflect this 
uncertainty[Lin et al., 2013]. Developing better tests to differentiate between these entities would 
be a tremendous clinical advance in terms of everyday patient care. Finally, the correlation 
between cfDNA in plasma versus CSF is currently unknown, as is their relationship to patient 
outcomes in patients with brain metastases.
3.
PARTICIPANT SELECTION
Eligibility will be assessed as part of the screening procedures for all patients.

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3.1
Eligibility Criteria
3.1.1
Participants must have histologically or cytologically confirmed Stage IV invasive 
breast cancer. Participants without pathologic or cytologic confirmation of metastatic 
disease should have unequivocal evidence of metastasis from physical examination or 
radiologic evaluation.
3.1.2
Either the primary tumor and/or metastatic tumor must be triple-negative as defined 
below:

Hormone receptor status: the invasive tumor must be ER- and PR-
negative, or staining present in <1% by immunohistochemistry (IHC) 

HER2 status: the invasive tumor must be Human Epidermal Growth 
Factor Receptor 2 Negative (HER2-negative) by the ASCO CAP 
guidelines
Note: In cases where both primary tumor and metastatic sample(s) have been tested 
for ER, PR, and HER2, the triple-negative status of the most recent sample should be 
used. 
3.1.3
Participants must have a diagnosis of brain metastases for which stereotactic radiation 
is indicated, as determined by a radiation oncologist.
3.1.4
The contrast-enhancing intraparenchymal brain metastases(s) must be well 
circumscribed and must have a maximum diameter of ≤ 3.0 cm in any direction on the 
enhanced scan. 
3.1.5
Participants must not have more than 5 new or progressive lesions in the brain 
requiring stereotactic radiation treatment (greater than 5 total brain lesions are allowed 
as long as no more than 5 lesions require stereotactic radiation treatment). 
3.1.6
Participants must have measurable extracranial disease as defined by RECIST 1.1.
3.1.7
Participants must be willing to undergo a research biopsy at baseline and at Cycle 2 
Day 1 if extracranial metastases are safely accessible. Participants for whom biopsies 
cannot be safely performed must be willing to submit an archival primary and/or 
metastatic specimen. The biopsies may be waived with prior PI approval for the first 6 
participants enrolled to the safety run in phase.
3.1.8
Prior systemic therapy: 

Participants must have discontinued systemic therapy at least 14 days prior to 
initiating protocol therapy.

There is no limit to the number of prior lines of systemic therapy. Participants who 
have not received any systemic therapy for metastatic disease are also eligible. 
 

Participants may initiate or continue bisphosphonate therapy on study. 

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3.1.9
Prior local therapy: 

Prior surgery, whole brain radiation or stereotactic radiation is allowed as long as the 
most recent brain progression is amenable to stereotactic radiation treatment.  
3.1.10 Resolution of all chemotherapy-related or radiation-related toxicities to Grade 1 
severity or lower, except for stable sensory neuropathy (≤ Grade 2 allowed) and 
alopecia (of any grade).
3.1.11 Participant is 18 years old.
3.1.12 ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A) 
3.1.13 Stable dose of dexamethasone 2mg or less for at least 7 days prior to initiation of 
treatment
3.1.14 Participants must have normal organ and marrow function as defined below:

absolute neutrophil count
≥1,000/μl

platelets
≥75,000/μl

hemoglobin
9 g/dL

total bilirubin
≤1.5mg/dL (≤2.0 in patients with known Gilberts 
syndrome)

AST(SGOT)/ALT(SGPT)
≤2.5 × institutional ULN. ≤5.0 × institutional ULN for 
patients with documented liver metastases.

albumin
>2.5mg/dL

serum creatinine
≤1.5mg/dL or calculated GFR ≥60 mL/min
3.1.15 Female subjects of childbearing potential must have a negative serum or urine 
pregnancy test within 8 days of initiating protocol therapy. 

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3.1.16 For women of childbearing potential: agreement to remain abstinent (refrain from 
heterosexual intercourse) or use contraceptive methods that result in a failure rate of < 
1% per year during the treatment period and for at least 90 days after the last dose of 
study treatment. A woman is considered to be of childbearing potential if she is 
postmenarcheal, has not reached a postmenopausal state (≥ 12 continuous months of 
amenorrhea with no identified cause other than menopause), and has not undergone 
surgical sterilization (removal of ovaries and/or uterus). Examples of contraceptive 
methods with a failure rate of < 1% per year include bilateral tubal ligation, male 
sterilization, established, proper use of hormonal contraceptives that inhibit ovulation, 
hormone-releasing intrauterine devices, and copper intrauterine devices. The reliability 
of sexual abstinence should be evaluated in relation to the duration of the clinical trial 
and the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, 
ovulation, symptothermal, or postovulation methods) and withdrawal are not 
acceptable methods of contraception. The effects of atezolizumab on the developing 
human fetus are unknown and radiotherapy has known teratogenic effects so women 
of child-bearing potential and men must agree to use adequate contraception (barrier 
method of birth control; abstinence) prior to study entry and for the duration of study 
participation and 90 days after completion of atezolizumab administration.
3.1.17 The subject is capable of understanding and complying with the protocol and has 
signed the informed consent document.
3.2
Exclusion Criteria
3.2.1
CNS complications for whom urgent neurosurgical intervention is indicated (e.g., 
resection, shunt placement).
3.2.2
Known leptomeningeal or brainstem metastases. The presence of leptomeningeal 
enhancement alone, without associated clinical manifestations and/or positive CSF 
cytology, will not be constituted as known leptomeningeal metastases. 
3.2.3
Treatment with high dose systemic corticosteroids defined as dexamethasone 
>2mg/day or bioequivalent within 7 days of initiating therapy. 
3.2.4
Patients unable to undergo gadolinium contrast-enhanced MRI or receive IV contrast 
for any reason (e.g., due to pacemaker, ferromagnetic implants, claustrophobia, 
extreme obesity, hypersensitity).
3.2.5
Participants who are receiving any other investigational agents.
3.2.6
Previous treatment with any anti-PD-1, PD-L1, or PD-L2 agent.
3.2.7
Subjects with a history of hypersensitivity to compounds of similar biologic 
composition to atezolizumab or any constituent of the product

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3.2.8
The participant has an uncontrolled intercurrent illness, including, but not limited to 
uncontrolled hypertension, unstable angina pectoris, uncontrolled cardiac arrhythmia, 
congestive heart failure-New York Heart Association Class III or IV, active ischemic 
heart disease, myocardial infarction within the previous six months, uncontrolled 
diabetes mellitus, gastric or duodenal ulceration diagnosed within the previous 6 
months, severe malnutrition or psychiatric illness/social situations that would limit 
compliance with study requirements.
3.2.9
Participant has a medical condition that requires chronic systemic steroid therapy or on 
any other form of immunosuppressive medication. For example, patients with 
autoimmune disease that requires systemic steroids or immunosuppression agents 
should be excluded. Replacement therapy (eg., thyroxine, insulin, or physiologic 
corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not 
considered a form of systemic treatment.
3.2.10 Has evidence of active, noninfectious pneumonitis that requires treatment with 
steroids.
3.2.11 Has a history of interstitial lung disease.
3.2.12 The participant is known to be positive for the human immunodeficiency virus (HIV), 
HepBsAg, or HCV RNA. HIV-positive participants on combination antiretroviral 
therapy are ineligible because of the potential for pharmacokinetic interactions with 
atezolizumab. 
3.2.13 Individuals with a history of different malignancy are ineligible except for the 
following circumstances. Individuals with a history of other malignancies are eligible 
if they have been disease-free for at least 3 years or are deemed by the principal 
investigator to be at low risk for recurrence of that malignancy. 
3.2.14 Has received a live vaccine within 28 days of planned start of study therapy.
3.2.15 The participant is pregnant or breast-feeding.
3.3
Inclusion of Women and Minorities
Both men and women of all races and ethnic groups are eligible for this trial.
4.
REGISTRATION PROCEDURES
4.1
General Guidelines for DF/HCC Institutions
Institutions will register eligible participants in the Clinical Trials Management System 
(CTMS) OnCore. Registrations must occur prior to the initiation of protocol therapy. Any 
participant not registered to the protocol before protocol therapy begins will be considered 
ineligible and registration will be denied.

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An investigator will confirm eligibility criteria and a member of the study team will 
complete the protocol-specific eligibility checklist.
Following registration, participants may begin protocol therapy. Issues that would cause 
treatment delays should be discussed with the Overall Principal Investigator (PI). If a participant 
does not receive protocol therapy following registration, the participant’s registration on the 
study must be canceled. Registration cancellations must be made in OnCore as soon as possible. 
4.2
Registration Process for DF/HCC Institutions
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed. 
5. TREATMENT PLAN
5.1
Treatment Regimen
Forty-five participants will participate in this open-label, single arm phase II study 
assessing PFS in patients TNBC and brain metastasis. Participants will receive stereotactic 
radiation in combination with Atezolizumab (1200mg IV) on day 1 of each 21-day (3 week) 
cycle. The first dose of Atezolizumab will be administered 2-7 days prior to beginning 
stereotactic radiation. Treatments will be administered on an outpatient basis.
Regimen Description
Agent
Premedication; 
Precautions
Dose
Route
Schedule
Cycle 
Length
Atezolizumab
Not routinely 
necessary unless 
prior infusion 
reaction.
1200 mg 
IV
The initial dose of 
atezolizumab will be 
delivered over 60 
( 15) minutes. If the 
first infusion is 
tolerated, the second 
infusion may be 
delivered over 30 
( 10) minutes. If the 
30-minute infusion is 
well tolerated, 
all subsequent 
infusions may be 
delivered over 30 
( 10) minutes. 
Day 1, q3w
21 days
(3 weeks)

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5.2
Pre-Treatment Criteria
Laboratory results must be reviewed prior to dosing. If screening assessments were completed 
within 1 week of Cycle 1 Day 1, these assessments do not need to repeated. 
5.2.1
All Cycles, Day 1 

absolute neutrophil count
≥1,000/mcL

platelets
≥75,000/mcL

AST(SGOT)/ALT(SGPT)
≤ 2.5 × institutional ULN or ≤ 5 × institutional ULN for 
participants with documented liver metastases
-
creatinine
≤1.5 × institutional ULN
5.2.2
Atezolizumab Administration
 will provide atezolizumab. Atezolizumab will be administered by trained 
medical personnel at the investigational site. Treatment compliance will be monitored through 
documentation of study treatment administration in the subject’s medical record.
Atezolizumab will be administered in clinic on day 1 (+/- 3 days) of each cycle. Patients 
will receive the first dose of Atezolizumab 2-7 days before the beginning of stereotactic 
radiation. The initial dose of atezolizumab will be delivered over 60 ( 15) minutes. If the 
first infusion is tolerated without infusion-associated AEs, the second infusion may be delivered 
over 30 ( 10) minutes. If the 30-minute infusion is well tolerated, all subsequent infusions may 
be delivered over 30 ( 10) minutes. No premedication will be allowed for the first dose of 
Atezolizumab. Premedication may be administered for Cycles  2 at the discretion of the treating 
physician. The management of infusion-related reactions (IRRs) will be according to severity as 
follows:

In the event that a patient experiences a mild (NCI CTCAE Grade 1) IRR, the infusion rate 
should be reduced to half the rate being given at the time of event onset. Once the event has 
resolved, the investigator should wait for 30 minutes while delivering the infusion at the 
reduced rate. If tolerated, the infusion rate may then be increased to the original rate.

In the event that a patient experiences a moderate IRR (NCI CTCAE Grade 2) or flushing, 
fever, or throat pain, the infusion should be immediately interrupted and the patient should 
receive aggressive symptomatic treatment. The infusion should be restarted only after the 
symptoms have adequately resolved to baseline grade. The infusion rate at restart should be 
half of the infusion rate that was in progress at the time of the onset of the IRR.

For severe or life-threatening IRRs (NCI CTCAE Grade 3 or 4), the infusion should be 
stopped immediately, and aggressive resuscitation and supportive measures should be 
initiated. Patients experiencing severe or life-threatening IRRs will not receive further 
infusion and will be further managed as clinically indicated until the event resolves.
For anaphylaxis precautions, see APPENDIX B.

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5.2.3
Other Modality(ies) or Procedures
5.2.3.1
Stereotactic radiation
 
5.2.4.1.1 Timing of Radiation
Radiation must begin within 14 days after brain MRI obtained with T1 post contrast sequences, 
with a maximum slice thickness of 1.5mm. Radiation must be delivered at Brigham and 
Women’s Hospital or Dana-Farber Cancer Institute.
5.2.4.1.2 Dose
Lesions <2 cm in maximum diameter will be treated with stereotactic radiosurgery, generally 20 
Gy in 1 fraction. Lesions between 2.0 and 2.5 cm in maximum diameter will generally be treated 
to 18 Gy in 1 fraction. Lesions between 2.5-3.0 cm in maximal diameter will generally be treated 
with stereotactic radiotherapy to 30 Gy in 5 fractions given on consecutive weekdays The 
volume receiving 12 Gy (V12) should be limited to <8-10cc; dose reductions are acceptable if 
the V12 constraint cannot be met via replanning, with a minimum dose of 16 Gy. Patients with 
simultaneous metastases that require 1 fraction and 5 fractions can be treated concurrently. If a 
metastasis that would be treated normally with stereotactic radiosurgery is adjacent to a 
metastasis that must receive stereotactic radiotherapy (so that a significant degree of scatter dose 
from the latter field will include the potential former field) it is acceptable for the treating 
investigator to treat both metastases with stereotactic radiotherapy. 
The treating radiation oncologist may use their discretion in the best interest of the patient in the 
treating participants on study. 
5.2.4.1.3 Physical Factors
Treatment will be delivered using megavoltage machines with 6MV photon beams using a linear 
accelerator equipped with stereotactic capabilities.
5.2.4.1.4 Simulation, Immobilization, and Localization
The patient will be treated in the supine position. A tightly fitting thermoplastic mask will be 
employed for immobilization.
5.2.4.1.5 Treatment Planning and patient setup
The gross tumor volume (GTV) will cover the metastasis as identified by contrast enhanced MRI 
and CT (contrast optional) obtained within 14 days of the treatment initiation date. The MRI 
must be obtained with a T1 post contrast sequence with a maximal slice thickness of 1.5 mm. No 
clinical target volume (CTV) is to be used. The planning target volume (PTV) will be 1 mm. For 
patients who have rapidly growing gross disease an extra 0.1-1mm of PTV margin can be added 
at the discretion of the treating clinician to account for growth between planning and treatment; 
in such cases the time between planning and treatment should be minimized to the greatest extent 

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possible. Treatments will be delivered through volumetric modulated arc therapy (VMAT) using 
a single isocenter for PTV volumes >1.5 cm in maximum diameter. For PTV volumes with a 
maximum dimension of 0-1.5 cm in diameter either VMAT, circular collimators, or multiple 
static fields will be acceptable. The prescription will generally be normalized to the 60-95% 
isodose line. The maximum allowed hot spot will be 170%. 100% of the GTV should be covered 
by the prescription dose. At least 99% (ideal) / 98% (at minimum) of the PTV should be covered 
by the prescription isodose line. The entire PTV should be covered by 90% (ideal) / 85% (at 
minimum) of the prescription dose. Daily set up with cone beam CT or stereoscopic KV imaging 
is mandated.
5.2.4.1.6 Dose to Critical Structures
Dose constraints for stereotactic radiation to critical structures will be as follows:
Dose constraints for stereotactic radiation 
Organ at Risk
Tolerance
Dose Modification Regimen
Eyes, Optic Nerves, Optic 
Chiasm
 Point dose ≤8 Gy
If point dose >8 Gy, undercover PTV while 
maintaining 100% GTV coverage. If not 
achievable, dose reduce GTV to highest dose 
which meets optic constraint, through 16 Gy 
(15 Gy for cavity in which gross total 
resection has been achieved). If 100% of 
GTV cannot be safely covered by 16 Gy (15 
Gy for cavity in which gross total resection 
has been achieved), then an acceptable 
variation will be to convert to stereotactic 
radiotherapy – see Table 2
Brainstem (defined as 
brainstem volume minus 
GTV)
Dose to 0.035cc 
≤12 Gy
If dose to 0.035cc >12 Gy, undercover PTV 
while maintaining 100% GTV coverage. If 
not achievable, dose reduce GTV to highest 
dose which meets brainstem constraint, 
through 16 Gy (15 Gy for cavity in which 
gross total resection has been achieved). If 
100% of GTV cannot be safely covered by 
16 Gy (15 Gy for cavity in which gross total 
resection has been achieved), then an 
acceptable variation will be to convert to 
stereotactic radiotherapy – see Table 2
Volume of normal brain 
(less the GTV) receiving 
>12 Gy (per individual 
lesion, called the V12)
≤10cc
If the V12 is >10cc, undercover PTV while 
maintaining 100% GTV coverage. If not 
achievable, dose reduce GTV to highest dose 
which meets constraint, through 16 Gy (15 
Gy for cavity in which gross total resection 
has been achieved). If 100% of GTV cannot 
be safely covered by 16 Gy (15 Gy for cavity 
in which gross total resection has been 

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achieved), then an acceptable variation will 
be to convert to stereotactic radiotherapy – 
see Table 2
Normal brain less the GTV 
(for entire brain)
Mean <5 Gy
Administer stereotactic radiation on two or 
more consecutive weekdays rather than a 
single day
Dose constraints for stereotactic radiotherapy to critical structures will be as follows:
Dose constraints for stereotactic radiotherapy (5 fractions)
Organ at Risk
Tolerance
Dose Modification Regimen
Eyes, Optic Nerves, Optic 
Chiasm
 Point dose of 25-
27 Gy
If point dose >25-27 Gy undercover PTV 
while maintaining 100% GTV (30 Gy in 5 
fractions if gross disease; 25 Gy in 5 
fractions if gross total resection has been 
achieved) coverage. If not achievable, dose 
reduce GTV to highest dose which meets 
constraint, through 23 Gy in 5 fractions. 
100% of GTV should always receive at least 
23 Gy in such a scenario.
Brainstem (defined as 
brainstem volume minus 
GTV)
Dose to 0.035cc 
≤28 Gy
If dose to 0.035cc >28 Gy, undercover PTV 
while maintaining 100% GTV coverage (30 
Gy in 5 fractions if gross disease; 25 Gy in 5 
fractions if gross total resection has been 
achieved). If not achievable, dose reduce 
GTV to highest dose which meets brainstem 
constraint, through 23 Gy in 5 fractions. 
100% of GTV should always receive at least 
23 Gy in such a scenario.
5.2.4.1.7
Stereotactic Radiation Documentation Requirements
The institution will archive treatment prescription and verification images for later review by the 
study chair if requested. At least one port film or pretreatment alignment film/CT along with the 
digitally reconstructed radiographs (DRRs) from the treatment planning program or, 
alternatively, a simulation verification radiograph shall be acquired and kept for evaluation if 
requested except where geometrically impractical.
5.2.4.1.8 Stereotactic Radiation Radionecrosis Assessment
To assess participants for potential delayed radiation toxicity, a radiation follow-up visit will be 
performed approximately 6 months after completion of stereotactic radiation treatment. This visit 
should be done no earlier than 5 months and no later than 8 months post-stereotactic radiation. 
Another visit should occur, if possible, around 12 months after completion of radiation treatment. 
This visit should be performed no earlier than 11 months and no later than 14 months post-
radiation. At these timepoints, brain imaging will be correlated with a clinical assessment, 

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performed by the radiation oncology team. All potential radiation necrosis events will be 
adjudicated by the PI, Nancy Lin, MD, in collaboration with the trial radiation oncologist, Ayal 
Aizer, MD.A diagnosis of radiation necrosis will be ascribed if:
1.Surgery on an enlarging lesion after radiation reveals a specimen showing 
predominantly necrosis 
2. Changes consistent with necrosis on dual-phase PETCT are seen
3. Changes consistent with necrosis on serial MRI studies of the brain are seen. 
Changes consistent with necrosis on serial MRIs of the brain included lack of 
sustained growth over time in patients who did not receive central nervous system-
active systemic therapy after initial enlargement, development of a non-distinct 
margin of enhancement on T1 post contrast sequences, development of a hypointense 
center on T1 post contrast images, and a large edema to enhancement ratio.
If a diagnosis of radiation necrosis is made for any patient in this cohort, we will distinguish 
radiographic necrosis from radiographic and symptomatic necrosis based upon the presence 
versus absence of associated neurologic symptoms or administration of dexamethasone / 
bevacizumab for neurologic symptomatology correlating with the anatomic location of the lesion 
in question.
Every attempt should be made for these assessments to occur in person. Due to the nature of this 
patient population, some participants may be on hospice or otherwise not able to travel to the 
study site to complete these endpoints. In these cases, the study team will check to see if any 
brain imaging has been completed at local facilities and will obtain those images for review. The 
radiation team may reach out to the patient to perform the radiation necrosis assessment over the 
phone. Not completing these visits in person will not constitute protocol violations. 
5.3
General Concomitant Medication and Supportive Care Guidelines
5.3.1
Concomitant Medication Guidelines
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial. If there is a clinical indication for one of these or other medications or 
vaccinations specifically prohibited during the trial, discontinuation from trial therapy or 
vaccination may be required. The investigator should discuss any questions regarding this with 
the overall PI. 
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 and documented in the medical record. Selected medications of interest received 
within 28 days before the first dose of trial treatment and 30 days after the last dose of trial 
treatment, including dosage, frequency, route, and dates of administration will be recorded in the 
CRF. 
Prohibited Concomitant Medications
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase of this trial:

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
Antineoplastic systemic chemotherapy or biological therapy 

Immunotherapy not specified in this protocol

Investigational agents other than atezolizumab 

Radiation therapy not specified in this protocol

Any systemically active oral, injected, or implanted hormonal method of contraception 
except for progesterone coated intrauterine devices (IUDs) that had been previously 
implanted.

Estrogen replacement therapy.

Live vaccines within 28 days prior to the first dose of trial treatment and while 
participating in the trial. Examples of live vaccines include, but are not limited to, the 
following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and 
typhoid vaccine. 

Systemic glucocorticoids should be avoided for any purpose other than to modulate 
symptoms from radiation, an event of clinical interest of suspected immunologic 
etiology, or emergent symptoms from brain metastasis. If corticosteroids are required for 
this purpose, the minimum effective dose should be used. 

Subjects may receive other medications that the investigator deems to be medically 
necessary.
There are no prohibited therapies during the Post-Treatment Follow-up Phase.
5.3.2
Supportive Care Guidelines – general medications
The following treatments are permitted throughout the duration of the study treatment phase and 
during follow-up:

Standard therapies for pre-existing medical conditions unless listed as prohibited therapy. 
Any medication intended solely for supportive care (e.g., analgesics, anti-diarrheal, anti-
depressants) may be used at the investigator’s discretion. Antiemetics and anti-diarrheal 
medications should not be administered prophylactically before initial treatment with 
study drugs. At the discretion of the investigator, prophylactic antiemetic and 
anti-diarrheal medication(s) may be used as per standard clinical practice before 
subsequent doses of study drugs or before, during or after radiation treatment.

Bisphosphonate or denosumab therapy to be used in accordance with the approved 
labeled indication and/or nationally recognized treatment guidelines. Participants already 
receiving bisphosphonate/denosumab at the time of study entry can continue the 
treatment.

Anticoagulants - Anticoagulation with heparin, heparin derivatives, and/or warfarin may 
be given at the discretion of the treating physician. Coagulation parameters should be 
checked at least once monthly, or more frequently at discretion of treating physician. 

Pain medications administered per standard clinical practice are acceptable while the 

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patient is enrolled in the study.
Patients who experience toxicities should be treated symptomatically as clinically indicated. 
Medications that are considered necessary for the subject’s welfare and that are not expected to 
interfere with the evaluation of study treatment or be restricted may be given at the discretion of 
the investigator. Ancillary treatments will be given as medically indicated.
5.4
Definition of Dose-Limiting Toxicity
Dose-limiting toxicity is defined as any of the following events occurring from first dose of 
Atezolizumab until Cycle 3 Day 1 if judged by the investigator to be possibly, probably, or 
definitely related to study drug and/or radiation administration:

Death

≥ Grade 3 treatment-emergent neurological toxicity

Asymptomatic grade 4 hematologic toxicity lasting ≥14 days unless deemed by the 
investigator to be clinically insignificant

≥Grade 4 thrombocytopenia of any duration

≥ Grade 3 Febrile neutropenia 

≥ Grade 3 Thrombocytopenia if associated with bleeding

≥ Grade 3 elevation in AST or ALT associated with a grade 2 elevation in bilirubin that is 
at least possibly related to study drug (Hy’s Law) 

≥ Grade 3 non-hematologic laboratory value if:
o
Medical intervention is required to treat the patient, or
o
The abnormality leads to hospitalization, or
o
The abnormality persists >7 days
Excluding:

Alkaline phosphatase <10.0x ULN in a patient with ≥ grade 2 alkaline 
phosphatase elevation at baseline as a result of bone metastasis 

Any laboratory values deemed by the investigator to be clinically 
insignificant

≥ Grade 3 pneumonitis of any duration

≥ Grade 3 Fatigue lasting >5 days

> Grade 3 other non-laboratory toxicity lasting >3 days despite optimal supportive care, 
excluding Alopecia (of any grade).
5.5
Criteria for Taking a Participant Off Protocol Therapy
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue for 
an indefinite number of cycles, or until one of the following criteria applies:

Disease progression by iRANO and/or irRC criteria. 

Please note that although the primary endpoint is bi-compartmental PFS as 

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defined by standard RANO-BM (for CNS) and RECIST 1.1 (for non-CNS), 
patients may remain on protocol therapy until the time of disease progression by 
iRANO and/or irRC criteria. The immune criteria allow treatment beyond initial 
radiographic 
worsening 
of 
disease 
in 
order 
to 
distinguish 
between 
pseudoprogression and true disease progression. 

Intercurrent illness that prevents further administration of treatment

Unacceptable adverse event(s)

Participant demonstrates an inability or unwillingness to comply with the medication 
regimen and/or documentation requirements

Participant decides to withdraw from the protocol therapy

General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator
Participants will be removed from the protocol therapy when any of these criteria apply. The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF) and in the CTMS system (OnCore). Alternative care 
options will be discussed with the participant.
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify the Overall PI, Nancy Lin, MD at 
Participants with a documented complete response (CR) may elect to stop Atezolizumab. 
Subjects who stop atezolizumab with a CR may be eligible for additional atezolizumab therapy if 
they progress after stopping study treatment. This retreatment is termed the Second Course Phase 
of this study and is only available if the study remains open and the subject meets the following 
conditions:
o
Stopped initial treatment with atezolizumab after attaining a confirmed and 
documented CR according to RECIST 1.1, was treated for at least 24 weeks with 
atezolizumab before discontinuing therapy, and received at least two treatments with 
atezolizumab beyond the date when the initial CR was declared.
Subjects who restart treatment will be retreated at the same dose and dose interval as when they 
last received atezolizumab. Visit requirements are as outlined for subjects on the initial treatment 
phase of the trial. Patients must meet cycle 1 day 1 pre-treatment criteria to reinitiate therapy.
5.6
Duration of Follow Up
Participants removed from protocol therapy for unacceptable adverse event(s) will be 
followed until resolution or stabilization of the adverse event. Participants who are taken off 
protocol therapy for extracranial progression in the setting of intracranial response or stable 
disease will be followed for CNS progression and survival after removal from protocol therapy. 
It is understood that it may not always be feasible for patients to return for restaging evaluation 
after coming off protocol therapy, though a strong effort should be made to encourage restaging 
every 6-12 weeks. In this specific setting, lack of restaging scans at the interval will not 

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constitute a protocol deviation or violation. Participants who are removed from protocol therapy 
for intracranial disease progression will be followed for survival until death.
 
Participants who are removed from protocol therapy before the 6-month post-radiation follow-up 
visit will be contacted by phone by a member of the study team to be assessed for possible latent 
radiation toxicities.
5.7
Criteria for Taking a Participant Off Study
Participants will be removed from study when any of the following criteria apply:

Lost to follow-up

Withdrawal of consent for data submission

Death

Study closure
The reason for taking a participant off study, and the date the participant was removed, must be 
documented in the case report form (CRF) and CTMS (OnCore).
6.
DOSING DELAYS/DOSE MODIFICATIONS
Dose delays and modifications will be made as indicated in the following table(s). The 
descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 will be utilized for dose delays and dose modifications. A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP website
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
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). Participants held for these reasons are required to resume therapy within 3 
weeks of the scheduled interruption. The reason for interruption must be documented in the 
participant's medical record.
If there are dosing delays for any reason, all study assessments are to be delayed in the same 
fashion, such that that scans and other assessments occur in conjunction with cycles of treatment.
No dose reductions are allowed for atezolizumab.
 
6.1
Management of toxicities attributable to atezolizumab
Toxicities associated or possibly associated with atezolizumab treatment should be 
managed according to standard medical practice. Additional tests, such as autoimmune serology 
or biopsies, may be used to determine a possible immunogenic etiology.
Although most immune-related adverse events (irAEs) observed with immunomodulatory 
agents have been mild and self-limiting, such events should be recognized early and treated 
promptly to avoid potential major complications. Discontinuation of atezolizumab may not have 
an immediate therapeutic effect and, in severe cases, immune-related toxicities may require acute 

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management with topical corticosteroids, systemic corticosteroids, mycophenolate, or TNF 
inhibitors.
The primary approach to Grade 1 to 2 irAEs is supportive and symptomatic care with 
continued treatment with atezolizumab; for higher-grade irAEs, atezolizumab should be withheld 
and oral and/or parenteral steroids administered. Recurrent Grade 2 irAEs may also mandate 
withholding atezolizumab or the use of steroids. Assessment of the risk-benefit ratio should be 
made by the investigator, with consideration of the totality of information as it pertains to the 
nature of the toxicity and the degree of clinical benefit a given patient may be experiencing prior 
to further administration of atezolizumab. Atezolizumab should be permanently discontinued in 
patients with life-threatening irAEs.
6.1.1
Guidelines for Dosage Modification and Treatment Interruption or Discontinuation
There will be no dose reduction for atezolizumab in this study. Patients may temporarily 
suspend study treatment for up to 84 days beyond the scheduled date of delayed infusion if study 
drug-related toxicity requiring dose suspension is experienced. If atezolizumab is held because of 
AEs for  84 days beyond the scheduled date of infusion, the patient will be discontinued from 
atezolizumab and will be followed for safety and efficacy as specified in Section 5.5.
Patients should be assessed clinically for toxicity prior to, during, and after each infusion. 
Any toxicity associated or possibly associated with atezolizumab treatment should be managed 
according to standard medical practice. Additional tests, such as autoimmune serology or 
biopsies, may be used to determine a possible immunogenic etiology. Although most irAEs 
observed with immunomodulatory agents have been mild and self-limiting, such events should 
be recognized early and treated promptly to avoid potential major complications. Discontinuation 
of atezolizumab may not have an immediate therapeutic effect, and there is no available antidote 
for atezolizumab. In severe cases, immune-related toxicities may be acutely managed with 
topical corticosteroids, systemic corticosteroids, mycophenolate, or TNF inhibitors.
Management of hepatitis/transaminitis, colitis, rash, and hypothyroidism are presented in 
this section as they have been observed in this study and are potentially immune related. 
Dose interruptions for reasons other than toxicity, such as planned surgical procedures, 
may be allowed, with prior PI approval. The interruption should not be greater than 84 days.
6.1.1.1
Gastrointestinal Toxicity
Immune-mediated colitis has been associated with the administration of atezolizumab.
Patients should be advised to inform the investigator if any diarrhea occurs, even if it is 
mild.
If the event is of significant duration or magnitude, or is associated with signs of systemic 
inflammation or acute phase reactants (e.g., increased CRP or platelet count or bandemia), it is 
recommended that sigmoidoscopy (or colonoscopy, if appropriate) with colonic biopsy with 
three to five specimens for standard paraffin block be performed. If possible, one or two biopsy 
specimens should be snap frozen and stored.  
Treatment may be restarted following the resolution of colitis. In addition, if the patient is 
being managed with corticosteroids, treatment should not be restarted until the steroids have 
been tapered down to a prednisone dose  10 mg/day. Patients who resume treatment should be 
monitored closely for signs of renewed diarrhea. Table 1 provides a summary of dose 
modification guidelines for gastrointestinal toxicities.

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Table 1
Dose Modification Guidelines for Gastrointestinal Toxicity
Toxicity
Description
Management
Grade 1
Continue atezolizumab.
Initiate symptomatic treatment
Endoscopy is recommended if symptoms 
persist for > 7 days
Close monitoring.
Grade 2 
Hold atezolizumab 
Initiate symptomatic treatment
For recurrent events or events that persist > 5 
days: start Prednisone 60 mg/day or 
equivalent. 
When symptoms improve Grade ≤1, resume 
atezolizumab
o
Corticosteroids must be 
tapered over ≥1 month to <10 
mg/day oral prednisone or 
equivalent before resuming. 
Atezolizumab may be resumed if the event 
improves to Grade ≤ 1 within 12 weeks, and 
corticosteroids have been reduced to the 
equivalent of prednisone ≤ 10 mg/day.
o
Atezolizumab may be 
withheld for a longer period of 
time (i.e., >12 weeks after 
event onset) to allow for 
corticosteroids (if initiated) to 
be reduced to ≤10 mg/day oral 
prednisone or equivalent. The 
acceptable length of the 
extended period of time must 
be determined by the PI
Diarrhea and/or Colitis 
Grade 3 

Hold atezolizumab.

Treat with IV steroids (1-2 mg/kg/day 
methylprednisolone or equivalent) and 
convert to oral steroids (prednisone 60 
mg/day or equivalent) after 
improvement. When symptoms 
improve to Grade ≤ 1, taper steroids 
over ≥ 1 month
o
If event resolves to > Grade 1, 
restart atezolizumab 

If event does not resolve to > grade 1 
within 12 weeks of holding, 
permanently discontinue
o
If the subject was 
unequivocally deriving 
clinical benefit, the subject 
may be rechallenged as 

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determined by the PI.

Gastroenterology referral and 
confirmation biopsy
Grade 4

Permanently discontinue atezolizumab 
and inform PI 
o
If event resolves to Grade 1 or 
better within 12 weeks from 
last dose of atezolizumab, and 
if the subject was 
unequivocally deriving 
clinical benefit, the subject 
may be able to resume 
Atezolizumab as determined 
by the PI.

Gastroenterology referral and 
confirmation biopsy

Treat with IV steroids (1−2 mg/kg/day 
methylprednisolone or equivalent) and 
convert to oral steroids (prednisone 60 
mg/day or equivalent) after 
improvement. When symptoms 
improve to Grade ≤ 1, taper steroids 
over ≥ 1 month

If symptoms are not improving after 48 
hours of initiating steroids or are 
worsening, addition of an alternative 
immunosuppressive agent (e.g., 
mycophenolate or TNF-α antagonist) 
may be considered.
IV = intravenous; TNF-α = tumor necrosis factor alpha.

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6.1.1.2
Hepatotoxicity
Immune-mediated hepatitis has been associated with the administration of atezolizumab.
While in this study, patients presenting with right upper-quadrant abdominal pain and/or 
unexplained nausea or vomiting should have LFTs performed immediately, and LFTs should be 
reviewed before administration of the next dose of study drug.
If LFTs increase, neoplastic, concurrent medications, viral hepatitis, and toxic etiologies 
should be considered and addressed, as appropriate. Imaging of the liver, gall bladder, and biliary 
tree should be performed to rule out neoplastic or other causes of increased LFTs. Anti-nuclear 
antibody, perinuclear anti-neutrophil cytoplasmic antibody, anti-liver kidney microsomal, and 
anti-smooth muscle antibody tests should be performed if an autoimmune etiology is considered.
Patients with LFT abnormalities should be managed according to the guidelines in 
Table 2. For patients with elevated LFTs at baseline (between 3-5 x ULN) due to documented 
liver metastases, further elevation of LFTs may not require dose interruptions if the ALT and/or 
AST have risen < 3 x baseline value and if the total bilirubin elevation remains < 2x ULN with 
normal PT/INR. Such cases should be also discussed with the principal investigator.
Table 2
Dose Modification Guidelines for Hepatotoxicity
Toxicity
Description
Management
Grade 1
Continue Atezolizumab and monitor labs according to study calendar
Grade 2
Continue Atezolizumab and monitor LFTs more frequently until return 
to baseline or Grade ≤1
If persistent > 5 days, hold atezolizumab, and start prednisone 60 
mg/day or equivalent. When LFTs improve to Grade ≤1 taper steroids 
over ≥1 month 
When LFTs improve to Grade ≤1 and the steroid dose is prednisone ≤ 
10 mg/day or equivalent (if initiated), restart atezolizumab
LFT and/or total 
bilirubin 
abnormalities
Grade 3 or 4

Permanently discontinue atezolizumab, start prednisone 60 mg/day 
or equivalent and inform the PI 
o
If the subject was unequivocally deriving clinical benefit, 
the subject may be able to resume Atezolizumab as 
determined by the PI.

If LFT results do not decrease within 48 hours after initiation of 
systemic steroids, consider addition of an alternative 
immunosuppressive agent (e.g., mycophenolate) to the corticosteroid 
regimen

Consider obtaining a hepatology consult and liver biopsy.
When LFTs improve to Grade ≤1 taper steroids over ≥1 month
IV  intravenous; LFT  liver function test; TNF  tumor necrosis factor alpha; ULN  upper limit of normal.
6.1.1.3
Dermatologic Toxicity
Treatment-emergent rash has been associated with atezolizumab. The majority of cases of 
rash were mild in severity, self-limited, both with and without pruritus. Low-grade rash and 
pruritus irAEs have been treated with symptomatic therapy (e.g., antihistamines). Topical or 
parenteral corticosteroids may be required for more severe symptoms. A dermatologist should 
evaluate persistent and/or severe rash or pruritus and consider biopsying the site. 

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Dermatologic toxicity and rash should be managed according to the guidelines in Table 3.
Table 3
Dose Modification Guidelines for Dermatologic Toxicity
Toxicity
Description
Management
Grade 1: 
Mild
 10% BSA
Continue atezolizumab 
Consider topical steroids and/or other symptomatic therapy (e.g., 
antihistamines).
Grade 2: 
Moderate 
10%30% 
BSA
Continue atezolizumab. 
Administer topical steroids and consider higher potency topical steroids 
if events do not improve
Consider dermatologist referral.
Dermatologic 
toxicity/rash 
(e.g., maculopapular 
or purpura)
Grade 3: 
Severe 
 30% BSA
Hold atezolizumab and administer oral prednisone 10 mg or equivalent.
If the rash is not improved after 4872 hours, increase oral dose of 
prednisone to 60 mg or equivalent.
Refer for dermatology consult. 
Restart atezolizumab if rash is resolved to grade 1 or better and systemic 
dose is  10 mg oral prednisone equivalent per day (taper over 1 month).
If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab and contact PI

If the subject was unequivocally deriving clinical benefit, the 
subject may be able to resume atezolizumab as determined by the 
PI.
Grade 4
Permanently discontinue atezolizumab and inform the PI 
If the subject was unequivocally deriving clinical benefit, the subject 
may be able to resume atezolizumab as determined by the PI
BSA  body surface area; PRN  as needed.
6.1.1.4
Endocrine Toxicity
Hypothyroidism has been associated with the administration of atezolizumab.
Patients with unexplained symptoms such as fatigue, myalgias, impotence, mental status 
changes, or constipation should be investigated for the presence of hyponatremia, hypokaelmia 
and thyroid, pituitary and adrenal endocrinopathies.  An endocrinologist should be consulted if 
an endocrinopathy is suspected. 
Hypophysitis is a rare condition, characterized by the development of hypopituitarism 
with multiple anterior pituitary hormone deficiencies (e.g., low levels of adrenocorticotropic 
hormone (ACTH), thyroid-stimulating hormone (TSH).) MRI typically reveals a diffuse 
enlargement of the pituitary gland. 
Cases of hypophysitis have been reported in patients receiving Atezolizumab. Among 2, 
616 patients treated with single agent Atezolizumab in clinical trials, hypophysitis occurred in 2 
patients. It is recommended that Atezolizumab be withheld for grade 2 or grade 3 hypophysitis 

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and permanently discontinued for grade 4 events. Corticosteroids and hormone replacement 
therapy should be administered at the discretion of the treating physician. 
Table 4
Dose Modification Guidelines for Endocrine Toxicity
Toxicity
Management
Asymptomatic
Hypothyroidism

Continue atezolizumab 

Start treatment with thyroid replacement hormone

Monitor thyroid-stimulating hormone (TSH) weekly
Symptomatic
Hypothyroidism

Hold atezolizumab 

Start treatment with thyroid replacement hormone

Monitor TSH weekly

Consider referral to an endocrinologist

Restart atezolizumab when symptoms are controlled
Asymptomatic
Hyperthyroidism

If serum TSH < 0.5 mU/L and >0.1 mU/L, continue atezolizumab and monitor 
TSH every 4 weeks. 

If serum TSH < 0.1 mU/L, follow guidelines for symptomatic hyperthyroidism.
Symptomatic
Hyperthyroidism

Hold atezolizumab 

Initiate treatment with anti-thyroid drug such as methimazole as needed

Consider referral to an endocrinologist

If symptoms are controlled and thyroid function is improving, resume 
atezolizumab 

Permanently discontinue atezolizumab for life-threatening immune-related 
hyperthyroidism. Inform PI and CRC.
Hyperglycemia, grade 
1-2

Continue atezolizumab.

Initiate treatment if clinically indicated

Monitor for glucose control.
Hyperglycemia, grade 
3-4

Hold Atezolizumab

Initiate treatment for hyperglycemia 

Monitor for glucose control.

Resume atezolizumab when symptoms resolve and glucose levels are stable.
Hypophysitis any 
grade 2 or 3 events

Hold atezolizumab until toxicity improve to Grade ≤ 1

Corticosteroids and hormone replacement therapy should be administered as 
clinically indicated. 

Consult an endocrinologist

If 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, permanently discontinue atezolizumab. Inform PI and study team.

For recurrent hypophysitis, treat as Grade 4. 

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Hypophysitis grade 4

Permanently discontinue atezolizumab and treat with an initial dose of 
methylprednisolone 1 to 2 mg/kg per day intravenously followed by oral 
prednisone 1 to 2 mg/kg per day upon improvement. Inform PI 

When symptoms improve to Grade ≤ 1, start steroid taper and taper over ≥ 1 
month, resume atezolizumab

Consult an endocrinologist

Perform appropriate imaging

Initiate hormone replacement therapy, if clinically indicated
If event does not resolve to Grade 1 or better while withholding atezolizumab, 
permanently discontinue atezolizumab and contact PI

If the subject was unequivocally deriving clinical benefit, the subject may 
be able to resume Atezolizumab as determined by the PI.
6.1.1.5
Pulmonary Toxicity
Dyspnea, cough, fatigue, hypoxia, pneumonitis, and pulmonary infiltrates have been 
associated with the administration of atezolizumab and have primarily been observed in patients 
with underlying NSCLC.
Mild-to-moderate events of pneumonitis have been reported with atezolizumab. All 
pulmonary events should be thoroughly evaluated for other commonly reported etiologies such 
as pneumonia/infection, lymphangitic carcinomatosis, pulmonary embolism, heart failure, 
chronic obstructive pulmonary disease (COPD), or pulmonary hypertension. Recommended 
management for pulmonary events are listed in table 5 and may include the following exams:

Measurement of oxygen saturation (i.e., arterial blood gas)

High-resolution CT scan of the chest

Bronchoscopy with bronchoalveolar lavage and biopsy

Pulmonary function tests (with diffusion capacity of the lung for carbon monoxide 
[DLCO])
As a precaution, patients will be assessed for pulmonary signs and symptoms throughout the 
study. 

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Table 5
Dose Modification Guidelines for Pulmonary Toxicity (Pneumonitis)
Toxicity
Description
Management
Grade 1
Continue atezolizumab with close monitoring
Re-evaluate on serial imaging
Consider pulmonary consultation
Grade 2
Hold and atezolizumab and start prednisone 60 
mg/day or equivalent
Consult pulmonary and infectious disease 
specialists with consideration for 
bronchoscopy/BAL
When symptoms improve to Grade ≤ 1, taper 
steroids over ≥ 1 month to < 10 mg/day
First occurrence: 
o Atezolizumab may be resumed if the 
event improves to Grade ≤ 1 within 12 
weeks and if corticosteroids have been 
reduced to the equivalent of oral 
prednisone ≤ 10 mg/day
o Permanently discontinue atezolizumab if 
event does not resolve to Grade 1 or better 
within 12 weeks from last dose of 
Atezolizumab and contact the PI. If the 
subject was unequivocally deriving clinical 
benefit, the subject may be able to resume as 
determined by the PI
For recurrent events:
o Treat as Grade 3−4 (see below)
Pulmonary toxicity 
(Pneumonitis)
Grade 3-4
Permanently discontinue atezolizumab, start 
prednisone 60 mg/day or equivalent and notify 
PI and study team.
If symptoms are not improving after 48 hours or 
is worsening, add additional alternative 
immunosuppression (e.g., infliximab, 
cyclophosphamide, IVIG, or mycophenolate 
mofetil) to the corticosteroid regimen
Consult pulmonary and infectious diseases as 
bronchoscopy/BAL is recommended
 When symptoms improve to Grade ≤ 1, taper 
steroids over ≥ 1 month
If event resolves to Grade 1 or better within 12 
weeks from last dose of atezolizumab, and if the 
subject was unequivocally deriving clinical 
benefit, the subject may be able to resume as 
determined by the PI
6.1.1.6
Potential Pancreatic Toxicity
Symptoms of abdominal pain associated with elevations of amylase and lipase, 
suggestive of pancreatitis, have been associated with administration of other immunomodulatory 

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agents. The differential diagnosis of acute abdominal pain should include pancreatitis. 
Appropriate workup should include an evaluation for obstruction, as well as serum amylase and 
lipase tests.
6.1.1.7
Potential Eye Toxicity
An ophthalmologist should evaluate visual complaints. Uveitis or episcleritis may be 
treated with topical corticosteroid eye drops. Atezolizumab should be permanently discontinued 
for immune-mediated ocular disease that is unresponsive to local immunosuppressive therapy.
Ocular toxicity should be managed according to the guidelines in Table 6.
Table 6
Dose Modification Guidelines for Eye Toxicity
Toxicity
Description
Management
Eye toxicity (autoimmune 
uveitis, iritis, or 
episcleritis)
Symptomatic

Hold atezolizumab. 

Consult ophthalmologist and start topical 
corticosteroid eye drops. 

Atezolizumab may be restarted following 
resolution of the events.

Permanently discontinue Atezolizumab for 
immune-mediated ocular disease that is 
unresponsive to local immunosuppressive 
therapy.
Grade 1

Continue atezolizumab

Referral to ophthalmologist strongly 
recommended

Initiate treatment with topical corticosteroid eye 
drops/ topical immunosuppressive therapy

If symptoms persist, treat as a Grade 2 event.
Grade 2

Withhold atezolizumab for up to 12 weeks

Referral to ophthalmologist strongly 
recommended

Initiate treatment with topical corticosteroid eye 
drops/ topical immunosuppressive therapy

Resume atezolizumab if event resolves to Grade 
1 or better within 12 weeks from last dose of 
atezolizumab

Permanently discontinue atezolizumab if event 
does not resolve to Grade 1 or better within from 
12 weeks from last dose of atezolizumab.
o
If the subject was unequivocally deriving 
clinical benefit, the subject may be able to 
resume Atezolizumab as determined by the 
PI.
Grade 3-4
Permanently discontinue Atezolizumab and contact 
PI
o
If the subject was unequivocally deriving 
clinical benefit, the subject may be able to 

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Toxicity
Description
Management
resume Atezolizumab as determined by the 
PI.Refer to ophthalmologist
Initiate treatment with 1-2 mg/kg/day oral 
prednisone or equivalent
If event resolves to grade 1 or better, taper 
corticosteroids over > 1 month.
6.1.1.8
Potential Cardiac Toxicity
Myocarditis refers to a diverse group of heart-specific immune processes classified by a 
spectrum of clinical and histopathological manifestations. It may present as mild dyspnea or 
chest pain, or more severe cardiogenic short or sudden death. In the absence of an infectious 
etiology, immune-related myocarditis is confirmed by histological evidence of inflammatory 
infiltrates within the myocardium, together with cardiac myocytes degenerations and necrosis of 
non-ischemic origin.
A cumulative analysis of the company safety database which includes data from clinical trials 
and post-marketing setting (data cut-off 20 February 2017), identified 2 non-fatal cases of 
myocarditis, including one with biopsy confirmation. Approximately 8, 000 clinical trial patients 
and 5, 000 post-marketing patients have been treated with Atezolizumab to date. 
Atezolizumab should be permanently discontinued for all grades of myocarditis. Corticosteroids 
and/or additional immunosuppressive agents should be administered as clinically indicated.
Toxicity
Description
Management
Myocarditis
Symptomatic
Permanently discontinue 
Atezolizumab for any grade and 
notify PI and study team.
Corticosteroids and/or 
immunosuppressive agents 
should be administered as 
clinically indicated.
Consult a cardiologist.
7.
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. The 
following list of reported and/or potential AEs (Section 7.1) and the characteristics of an 
observed AE (Section 7.2) will determine whether the event requires expedited reporting in 
addition to routine reporting.
7.1
Adverse Events Lists
7.1.1
Expected adverse events for atezolizumab
The PD-L1/PD-1 pathway is involved in peripheral tolerance; therefore, such therapy 
may increase the risk of immune-related AEs, specifically the induction or enhancement of 

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autoimmune conditions. AEs with potential immune-related causes, including rash, 
hypothyroidism, hepatitis/transaminitis, colitis, myositis, and myasthenia gravis, have been 
observed with Atezolizumab in Study PCD4989g. 
Although most immune-related AEs observed with immunomodulatory agents have been 
mild and self-limiting, such events should be recognized early and treated promptly to avoid 
potential major complications[Champiat et al., 2016]. 
A more detailed safety profile of Atezolizumab is provided in the Atezolizumab 
Investigator’s Brochure.
7.1.2
Safety Parameters and Definitions
Specification of Safety Variables 
Safety assessments will consist of monitoring and reporting adverse events (AEs) and serious 
adverse events (SAEs) per protocol. This includes all events of death, and any study specific 
issue of concern.
Adverse Events
An AE is any unfavorable and unintended sign, symptom, or disease temporally associated with 
the use of an investigational medicinal product (IMP) or other protocol-imposed intervention, 
regardless of attribution.
This includes the following:

AEs not previously observed in the patient that emerge during the protocol-specified AE 
reporting period, including signs or symptoms that were not present prior to the AE reporting 
period

Complications that occur as a result of protocol-mandated interventions (e.g., invasive 
procedures such as cardiac catheterizations).

If applicable, AEs that occur prior to assignment of study treatment associated with 
medication washout, no treatment run-in, or other protocol-mandated intervention.

Preexisting medical conditions (other than the condition being studied) judged by the 
investigator to have worsened in severity or frequency or changed in character during the 
protocol-specified AE reporting period. 

Serious Adverse Events
An AE should be classified as an SAE if the following criteria are met:

It results in death (i.e., the AE causes or leads to death).

It is life threatening (i.e., the AE, in the view of the investigator, places the subject at 
immediate risk of death. It does not include an AE that, had it occurred in a more severe 
form, might have caused death.).

It requires or prolongs inpatient hospitalization.

It results in persistent or significant disability/incapacity (i.e., the AE results in 
substantial disruption of the subject’s ability to conduct normal life functions).

It results in a congenital anomaly/birth defect in a neonate/infant born to a mother 
exposed to the IMP.

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
It is considered a significant medical event by the investigator based on medical 
judgment (e.g., may jeopardize the subject or may require medical/surgical intervention 
to prevent one of the outcomes listed above).
7.1.3
Adverse Event Characteristics
CTCAE term (AE description) and grade: The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will 
be utilized for AE reporting. All appropriate treatment areas should have access to a copy of the 
CTCAE version 4.0. A copy of the CTCAE version 4.0 can be downloaded from the CTEP web 
site http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.
For expedited reporting purposes only: 
AEs for the agent(s) that are listed above should be reported only if the adverse event 
varies in nature, intensity or frequency from the expected toxicity information which is provided.
Attribution of the AE:
Definite – The AE is clearly related to the study treatment.
Probable – The AE is likely related to the study treatment.
Possible – The AE may be related to the study treatment.
Unlikely – The AE is doubtfully related to the study treatment.
Unrelated – The AE is clearly NOT related to the study treatment.
7.1.3.1
Adverse Events of Special Interest 
The following AEs are considered of special interest and must be reported to the 
Drug Safety expeditiously, irrespective of regulatory seriousness criteria: 

Cases of potential drug-induced liver injury that include an elevated ALT or AST in 
combination with either an elevated bilirubin or clinical jaundice, as defined by Hy's Law 
and based on the following observations: 
o
 Treatment-emergent ALT or AST > 3 x baseline value in combination with total 
bilirubin > 2 x ULN (of which > 35% is direct bilirubin) 
o
Treatment-emergent ALT or AST > 3 x baseline value in combination with 
clinical jaundice Suspected transmission of an infectious agent by the study 
treatment, as defined below: 

Any organism, virus, or infectious particle (e.g., prion protein transmitting 
transmissible spongiform encephalopathy), pathogenic or non-pathogenic, 
is considered an infectious agent. A transmission of an infectious agent 
may be suspected from clinical symptoms or laboratory findings that 
indicate an infection in a patient exposed to a medicinal product. This term 
applies only when a contamination of study treatment is suspected. 

Pneumonitis 

Colitis 

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
Endocrinopathies: diabetes mellitus, pancreatitis, adrenal insufficiency, hyperthyroidism, 
and hypophysitis 

Hepatitis, including AST or ALT > 10xULN 

Systemic lupus erythematosus 

Neurological disorders: Guillain-Barré syndrome, myasthenic syndrome or myasthenia 
gravis, and meningoencephalitis 

Events suggestive of hypersensitivity, infusion-related reactions, cytokine release 
syndrome, influenza-like illness, systemic inflammatory response syndrome, and 
systemic immune activation 

Nephritis 

Ocular toxicities (e.g., uveitis, retinitis) Myositis Myopathies, including rhabdomyolysis 

Grade > 2 cardiac disorders (e.g., atrial fibrillation, myocarditis, pericarditis)
7.2
Methods and Timing for Assessing AND Recording Safety variables
The investigator is responsible for ensuring that all AEs and SAEs that are observed or reported 
during the study, are collected and reported to the FDA, appropriate IRB(s), and 
 
in accordance with CFR 312.32 (IND Safety Reports). 
7.2.1
Adverse Event Reporting Period
The study period during which all AEs and SAEs must be reported begins after informed consent 
is obtained- and initiation of study treatment and ends 30 days following the last administration 
of study treatment or study discontinuation/termination, whichever is earlier. After this period, 
investigators should only report SAEs that are attributed to prior study treatment.
7.2.2
Assessment of Adverse Events
All AEs and SAEs whether volunteered by the subject, discovered by study personnel during 
questioning, or detected through physical examination, laboratory test, or other means will be 
reported appropriately. Each reported AE or SAE will be described by its duration (i.e., start and 
end dates), regulatory seriousness criteria if applicable, suspected relationship to the 
atezolizumab (see following guidance), and actions taken.
To ensure consistency of AE and SAE causality assessments, investigators should apply the 
following general guideline:
Yes
There is a plausible temporal relationship between the onset of the AE and administration of 
atezolizumab, and the AE cannot be readily explained by the subject’s clinical state, intercurrent 
illness, or concomitant therapies; and/or the AE follows a known pattern of response to 
atezolizumab; and/or the AE abates or resolves upon discontinuation of atezolizumab or dose 
reduction and, if applicable, reappears upon re-challenge.

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No
Evidence exists that the AE has an etiology other than atezolizumab (e.g., preexisting medical 
condition, underlying disease, intercurrent illness, or concomitant medication); and/or the AE has 
no plausible temporal relationship to atezolizumab administration (e.g., cancer diagnosed 2 days 
after first dose of study drug).
Expected adverse events are those adverse events that are listed or characterized in the Package 
Insert (P.I) or current Investigator Brochure (I.B). 
Unexpected adverse events are those not listed in the P.I or current I.B or not identified. This 
includes adverse events for which the specificity or severity is not consistent with the description 
in the P.I. or I.B. For example, under this definition, hepatic necrosis would be unexpected if the 
P.I. or I.B. only referred to elevated hepatic enzymes or hepatitis.
7.3
Procedures for Eliciting, Recording, and Reporting Adverse Events
7.3.1
Eliciting Adverse Events
A consistent methodology for eliciting AEs at all subject evaluation time points should be 
adopted. Examples of non-directive questions include: 

“How have you felt since your last clinical visit?”

“Have you had any new or changed health problems since you were last here?” 
7.3.2
Specific Instructions for Recording Adverse Events
Investigators should use correct medical terminology/concepts when reporting AEs or SAEs. 
Avoid colloquialisms and abbreviations.
7.3.2.1
Diagnosis vs. Signs and Symptoms
If known at the time of reporting, a diagnosis should be reported rather than individual signs and 
symptoms (e.g., record only liver failure or hepatitis rather than jaundice, asterixis, and elevated 
transaminases). However, if a constellation of signs and/or symptoms cannot be medically 
characterized as a single diagnosis or syndrome at the time of reporting, it is acceptable to report 
the information that is currently available. If a diagnosis is subsequently established, it should be 
reported as follow-up information.
7.3.2.2
Deaths
All deaths that occur during the protocol-specified AE reporting period (see Section 7.2.1), 
regardless of attribution, will be reported to the appropriate parties. When recording a death, the 
event or condition that caused or contributed to the fatal outcome should be reported as the single 
medical concept. If the cause of death is unknown and cannot be ascertained at the time of 
reporting, report “Unexplained Death”.
7.3.2.3
Preexisting Medical Conditions
A preexisting medical condition is one that is present at the start of the study. Such conditions 
should be reported as medical and surgical history. A preexisting medical condition should be re-
assessed throughout the trial and reported as an AE or SAE only if the frequency, severity, or 
character of the condition worsens during the study. When reporting such events, it is important 

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to convey the concept that the preexisting condition has changed by including applicable 
descriptors (e.g., “more frequent headaches”).
7.3.2.4
Hospitalizations for Medical or Surgical Procedures
Any AE that results in hospitalization or prolonged hospitalization should be documented and 
reported as an SAE. If a subject is hospitalized to undergo a medical or surgical procedure as a 
result of an AE, the event responsible for the procedure, not the procedure itself, should be 
reported as the SAE. For example, if a subject is hospitalized to undergo coronary bypass 
surgery, record the heart condition that necessitated the bypass as the SAE.
Hospitalizations for the following reasons do not require reporting:

Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures 
for preexisting conditions

Hospitalization or prolonged hospitalization required to allow efficacy measurement for 
the study or

Hospitalization or prolonged hospitalization for scheduled therapy of the target disease of 
the study.
7.3.2.5
Pregnancy
If a female subject becomes pregnant while receiving the study drug or within 90 days after the 
last dose of study drug, a report should be completed and expeditiously submitted to 
 
. Follow-up to obtain the outcome of the pregnancy should also occur. Abortion, whether 
accidental, therapeutic, or spontaneous, should always be classified as serious, and expeditiously 
reported as an SAE. Similarly, any congenital anomaly/birth defect in a child born to a female 
subject exposed to the study drug should be reported as an SAE.
7.3.2.6
Post-Study Adverse Events
The investigator should expeditiously report any SAE occurring after a subject has completed or 
discontinued study participation if attributed to prior study drug exposure. If the investigator 
should become aware of the development of cancer or a congenital anomaly in a subsequently 
conceived offspring of a female subject who participated in the study, this should be reported as 
an SAE. 
7.3.2.7
 Reconciliation
The Sponsor agrees to conduct reconciliation for the product. 
 and the Sponsor will 
agree to the reconciliation periodicity and format, but agree at minimum to exchange quarterly 
line listings of cases received by the other party. 
If discrepancies are identified, the Sponsor and 
 will cooperate in resolving the 
discrepancies. The responsible individuals for each party shall handle the matter on a case-by-
case basis until satisfactory resolution. The sponsor shall receive reconciliation guidance 
documents within the ‘Activation Package’.

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7.6
Reporting to the Institutional Review Board (IRB)
Investigative sites within DF/HCC will report AEs directly to the DFCI Office for Human 
Research Studies (OHRS) per the DFCI IRB reporting policy. 
7.7
Expedited Reporting to the Food and Drug Administration (FDA)
The overall PI Investigator is required to notify the FDA of any fatal or life-threatening adverse 
event that is unexpected and assessed by the Investigator to be possibly related to the use of 
atezolizumab. An unexpected adverse event is one that is not already described in the 
atezolizumab Investigator Brochure. Such reports are to be telephoned or faxed to the FDA and 
within 7 calendar days of first learning of the event.
The overall PI will also notify the FDA and all participating investigators, in a written IND 
Safety Report, of any serious, unexpected AE that is considered reasonably or possibly related to 
the use of atezolizumab. An unexpected adverse event is one that is not already described in the 
atezolizumab investigator brochure.
7.8
Expedited Reporting to Hospital Risk Management
Participating investigators will report to their local Risk Management office any participant 
safety reports or sentinel events that require reporting according to institutional policy. 
Immediate Reporting of Adverse Events and Events of Clinical Interest to 
7.9
Routine Adverse Event Reporting
All Grade 2 or higher Adverse Events must be reported in routine study data submissions to the 
Overall PI on the toxicity case report forms. AEs reported through expedited processes (e.g., 
reported to the IRB, FDA, etc.) must also be reported in routine study data submissions.
8.
PHARMACEUTICAL INFORMATION
A list of the adverse events and potential risks associated with the investigational and other 
agents administered in this study can be found in Section 7.1.
8.1
ATEZOLIZUMAB
8.1.1
Description
Atezolizumab is a human immunoglobulin (Ig) G1 monoclonal antibody consisting of two heavy 
chains (448 amino acids) and two light chains (214 amino acids) and is produced in Chinese 
hamster ovary cells (Other name: MPDL3280A). Atezolizumab targets human programmed 
death-ligand 1 (PD-L1) and inhibits its interaction with its receptor, programmed death-1 (PD-1). 

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Atezolizumab also blocks the binding of PD-L1 to B7.1, an interaction that is reported to provide 
additional inhibitory signals to T cells.
8.1.2
Form
The atezolizumab drug product is provided in a single-use, 20-cc USP/Ph. Eur. Type 1 glass vial 
as a colorless-to-slightly-yellow, sterile, preservative-free clear liquid solution intended for IV 
administration. 
The vial is designed to deliver 20 mL (1200 mg) of Atezolizumab solution but may contain more 
than the stated volume to enable delivery of the entire 20 mL volume. The Atezolizumab drug 
product is formulated as 60 mg/mL atezolizumab in 20 mM histidine acetate, 120 mM sucrose, 
0.04% polysorbate 20, pH 5.8.
8.1.3
Storage and Stability
Atezolizumab must be refrigerated at 2°C  8°C (36°F  46°F) upon receipt until use. 
Atezolizumab vials should not be used beyond the expiration date provided by the manufacturer. 
No preservative is used in the atezolizumab drug product; therefore, each vial is intended for 
single use only. Discard any unused portion of drug left in a vial. Vial contents should not be 
frozen or shaken and should be protected from direct sunlight.
For further details, see the atezolizumab Investigator’s Brochure.
8.1.4
Compatibility
Atezolizumab will be delivered in infusion bags with IV infusion lines that have product 
contacting surfaces of polyvinyl chloride (PVC) or polyolefin and 0.2 m in-line filters (filter 
membrane of polyethersulfone [PES]). No incompatibilities have been observed between 
Atezolizumab and PVC or polyolefin infusion materials (bags or infusion lines). 
8.1.5
Handling
Qualified personnel, familiar with procedures that minimize undue exposure to themselves and 
the environment, should undertake the preparation, handling, and safe disposal of the 
chemotherapeutic agent in a self-contained and protective environment. 
8.1.6
Availability
Atezolizumab is an investigational agent and will be supplied free of charge from 
8.1.7
Preparation
Atezolizumab can be diluted to concentrations between 2.4 mg/mL and 9.6 mg/mL in IV bags 
containing 0.9% NaCl. Atezolizumab vials should not be used beyond the expiration date 
provided by the manufacturer. No preservative is used in the atezolizumab drug product; 

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therefore, each vial is intended for single use only. Discard any unused portion of drug left in a 
vial. Vial contents should not be frozen or shaken and should be protected from direct sunlight.
8.1.8
Administration
Atezolizumab will be delivered in infusion bags with IV infusion lines that have product 
contacting surfaces of polyvinyl chloride (PVC) or polyolefin and 0.2 m in-line filters (filter 
membrane of polyethersulfone [PES]). No incompatibilities have been observed between 
atezolizumab and PVC or polyolefin infusion materials (bags or infusion lines). 
Administration of atezolizumab will be performed in a setting with emergency medical facilities 
and staff who are trained to monitor for and respond to medical emergencies.
The initial dose of atezolizumab will be delivered over 60 ( 15) minutes. If the first infusion is 
tolerated without infusion-associated AEs, the second infusion may be delivered over 30 ( 10) 
minutes. If the 30-minute infusion is well tolerated, all subsequent infusions may be delivered 
over 30 ( 10) minutes Patients will be informed about the possibility of delayed post-infusion 
symptoms and instructed to contact their study physician if they develop such symptoms.
8.1.9
Ordering
Atezolizumab will be obtained directly from 
8.1.10 Accountability
The investigator, or a responsible party designated by the investigator, should maintain a careful 
record of the inventory and disposition of the agent using the NCI Drug Accountability Record 
Form (DARF) or another comparable drug accountability form. (See the NCI Investigator’s 
Handbook for Procedures for Drug Accountability and Storage.)
8.1.11 Destruction and Return
At the end of the study, unused supplies of atezolizumab should be destroyed according to 
institutional policies. Destruction will be documented in the Drug Accountability Record Form.
9.
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES
All patients will be asked to provide archival tumor tissue (both primary and metastatic tissue 
will be requested if available; either paraffin blocks or 15 unstained slides, ideally 4-micron 
thickness). However, if archival tissue is not available or not evaluable, that will not be a basis to 
exclude the patient from any portion of the trial or the planned analysis.
In all patients in whom a tumor outside the field of radiation is accessible, a baseline tumor 
biopsy is required. We plan to use baseline biopsy tissue to perform a number of immune 
profiling assays, detailed below. On baseline tumor biopsies, we will perform characterization 

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based on histology (TILs), protein expression, and mRNA expression. Additionally, we will 
bank specimens for possible future DNA analysis, and other further testing.
Serial blood draws for correlative science are required on this trial; blood draws will be obtained 
according to the schedule in Table 9-1. We will perform flow cytometry on each blood draw to 
characterize protein expression of immune mediators, as detailed below, and additional blood 
will be banked for future testing.
Table 9-1 Summary of Research Tissue and Blood Specimen Collection
Research 
Sampling
Time point
Contents
Cycle 1 Day 1
1-10 mL Streck Tube
5- 10mL green top tubes* 
Start day of stereotactic radiation
1-10 mL Streck Tube
5- 10mL green top tubes*
Cycle 3 Day 1
1-10 mL Streck Tube
5- 10mL green top tubes*
Cycle 5 Day 1
1-10 mL Streck Tube
5- 10mL green top tubes*
Cycle 9 Day 1
1-10 mL Streck Tube
5- 10mL green top tubes*
Blood 
At progression or off protocol therapy
1-10 mL Streck Tube
5- 10mL green top tubes*
Pre-treatment (2-7 days prior to 
stereotactic radiation)
5-7 cores 
Cycle 2 Day 1 to day 21 
5-7 cores 
Fresh Tissue 
Optional at progression for patients who 
achieved an objective response and/or a 
prolonged stable disease (≥ 24 weeks)
5-7 cores
Archival Tissue 
Anytime 
1 block or 15, 4 micron 
thick unstained slides
Screening
3-10 mL in sterile 
collection tubes
Cycle 2 Day 15 to day 21
3-10 mL in sterile 
collection tubes
CSF
At progression or off protocol therapy
3-10 mL in sterile 
collection tubes
* EDTA (purple top) tubes or CPT tubes may be used interchangeably with green top tubes.
9.1
Archival Tissue Collection
1 block or 15, 4-micron unstained, charged slides will be collected for future research.
 

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isolation. The samples will be banked in the DFCI breast tissue repository for these and future 
research purposes. These specimens will become the property of the DF/HCC. 
Blood draws should not be performed on Friday afternoons, as there may not be time for 
processing of the blood. If a blood draw must be performed on Friday morning, the lab of 
must be notified ahead of time to ensure that there will be adequate time for 
processing the blood, since it cannot be stored over the weekend. 
The following research blood samples are required: 
Cycle 1 Day 1: 

1-10 mL Streck Tube for whole blood

5- 10mL green top tubes for whole blood
Day 1 of Stereotactic Radiation: 

1-10 mL Streck Tube for whole blood

5- 10mL green top tubes for whole blood
Cycles 3, 5, and 9 Day 1: 

1-10 mL Streck Tube for whole blood

5- 10mL green top tubes for whole blood
Off Treatment (at progression or off protocol therapy, whichever comes first):

1-10 mL Streck Tube for whole blood

5- 10mL green top tubes for whole blood
The following Time of Progression research blood samples are optional for patients who came 
off treatment for a reason other than progressive disease:

1-10 mL Streck Tube for whole blood

5- 10mL green top tubes for whole blood
If green top tubes are unavailable, purple top tubes or CPT tubes may be substituted.
9.3.2
Handling and Shipping 
All samples should be de-identified and labeled with the Participant initials, Participant Study ID 
number and date of collection and time point (e.g., “Baseline” or “Cycle 1” or “Progressive 
Disease”). 

Green Top tubes:
Must be processed within 3-4hrs of its being drawn at ambient temperature 
immediately after being drawn to
 at:

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explore potential prognostic or predictive candidate markers/panels or markers related to 
treatment benefit and/or safety, to improve diagnostic tests, or to understand breast cancer 
biology.
9.5.1
Tumor infiltrating lymphocyte (TIL) percentage and determination of lymphocyte 
predominant breast cancer (LPBC)
Paraffinized, hematoxylin and eosin-stained slides taken from two tissue planes will be derived 
from each biopsy and will be reviewed by certified pathologists. The extent of lymphocytic 
infiltrate in tumor tissue will be assessed, and stromal TIL percentage will be determined. More 
detailed guidelines for the quantification of stromal TILs in breast cancer can be found in the 
recommendations from the International TILs Working Group 2014.[Salgado et al., 2015]
After assessment of the TIL percentage, the specimen may be categorized as lymphocyte 
predominant breast cancer (LPBC), defined as a tumor that contains >60% stromal lymphocytes, 
or non-LPBC.
9.5.2
Immunohistochemistry
Tissue will be collected and fixed by 10% neutral buffered formalin overnight, dehydrated, and 
paraffin embedded. Four micrometer-thick sections will be cut. The paraffin blocks and 
unstained slides will be stored at room temperature. All immunohistochemical staining will be 
performed in the Center for Immuno-Oncology Pathology Core at Dana-Farber/Harvard Cancer 
Center (DF/HCC) Specialized Histopathology Core.
Formalin fixed-paraffin embedded (FFPE) tumor slides will be prepared and H&E stained for 
assessment of TIL in pre- and post-treatment tumor samples. To identify subsets of different 
immune populations (effector/memory CD8 cells, T regulatory cells, dendritic cells, tumor 
associated macrophages, and Tie-2 expressing monocytes (TEM)), immunohistochemical (IHC) 
staining will be performed on FFPE tumor slices using some or all of the following antibodies:
Core set: CD8, PD-1, PD-L1, PD-L2
Others: CD3, CD4, CD25, FoxP3, Indoleamine 2,3 deoxygenase-1 (IDO1), CD11c, CD83, 
CD86, CD56, CD14, CD16, Tie2
Chen et al[Chen et al., 2013] describe a semi-quantitative scoring method, which is in 
accordance with typical biomarker scoring in anatomic and surgical pathology. Briefly, staining 
is scored according to intensity (0=no staining, 1=weak staining, 2=moderate staining, 3=strong 
staining), staining patter (M=predominantly cell membrane; C=predominantly cell cytoplasm), 
and the percentage of cells showing positive staining (0-100%). The semi-quantitative scoring is 
performed for: 1) the neoplastic tumor cells and 2) the non-neoplastic infiltrating immune cells. 
Significant discordant results have been rare during case evaluations.[Chen et al., 2013]
It should be noted that the above staining protocols are based on standard methods used at the 
time of protocol writing. It is possible that at the time protein expression assays are conducted, 
novel and improved methods for staining will exist. In this case, we plan to use the best 
available, best validated experimental method available at the time.

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9.5.3
Flow cytometry, genomic analysis of biopsy tissue
TILs will be isolated from the biopsy specimen and assessed by surface staining as described in 
the lab manual for this protocol. 
Messenger RNA (mRNA) expression within tumor biopsy specimens will be assessed using the 
most current and informative methodologies at the time that correlative science is performed on 
all specimens. NanoString signatures and comprehensive RNA sequencing may be used. 
Potential genes of interest, based on prior immune profiling of breast tumors,[Denkert et al., 
2015] include CXCL9, CCL5, CD8ACD80, CXCL13, IGKC, CD21, IDO1, PD-1, PD-L1, PD-
L2, CTLA4, and FOXP3. Additional DNA analysis, for example to assess mutational load and 
neoantigen burden, may also be performed.
9.5.4
Analysis of PBMCs
PBMCs will be generated as described in the lab manual for this protocol, and used to assess 
immune cell populations by flow cytometry.
9.5.5
Analysis of cell-free DNA
Blood will be collected at baseline, restaging visits and at time of progression for evaluation of 
cell-free DNA (cfDNA). The cfDNA will be banked in the DF/HCC Clinical Trials Core 
laboratory for future research purposes. The banked samples will be used to analyze DNA, RNA 
and protein in future studies. 
9.6
Additional analysis
The above-mentioned analyses may be altered based on novel developments in the field of 
cancer immune profiling at the time of correlative science. Additional markers or alternative 
technologies (based on scientific developments and/or novel technologies) may also be used, to 
explore potential prognostic or predictive candidate markers/panels or markers related to 
treatment benefit and/or safety, to improve diagnostic tests, or to understand breast cancer 
biology.
10. STUDY CALENDAR
Screening evaluations are to be conducted within 28 days prior to initiating protocol therapy 
unless otherwise specified. Screening assessments occurring within 1 week prior to initiating 
study treatment do not need to be repeated on Cycle 1 Day 1. 
Screening laboratory assessments must be done within 8 days prior to initiating protocol therapy. 
For women of childbearing potential, as defined in the eligibility criteria, a pregnancy test must 
be completed within 8 days prior to initiating protocol therapy. If a urine pregnancy test is 
positive or cannot be confirmed as negative, a serum pregnancy test will be required. 

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If the participant’s condition is deteriorating, laboratory evaluations should be repeated within 48 
hours prior to initiation of the next cycle of therapy.
Assessments must be performed prior to administration of any study agent. Study assessments 
and agents should be administered within + 3 days of the protocol-specified date, unless 
otherwise noted.
Screenin
g
Cycle 1
Cycle 2
Cycle 3
Cycle 4+
Cycle 5
Cycle 6
Day 
Day -28 
to day -
1
Day 1
RT 
Day 1 
10 
days 
after 
RT
Day 1
Day 15-
21
Day 1
Day 1
Da
y 
15-
21
Day 1
Da
y 1
Day 
15-
21
Off-Treatments
Follow-Up
Informed consent
X
SRS Planning 
Appointmenta
X
Medical historyb
X
Physical examc
X
X
X
X
X
X
X
X
Radiation Oncologist 
Visitd
Xd
Xd
Adverse event 
evaluation
X
X
X
X
X
X
X
X
Vital signse
X
X
X
X
X
X
X
X
Weight
X
X
X
X
X
X
X
Concurrent 
medicationsf
X
X
X
X
X
ECOG Performance 
status
X
X
X
X
X
X
X
X
Neurological 
Assessment
X
X
X
X
X
Brain MRIg
X
X
X
X
X
X
CAP CT and/or MRIh
X
X
X
X
X
X
Hematology paneli
X
X
X
X
X
Chemistry panelj
X
X
X
X
X
TSH k
X
X
X
X
X
X
X
Pregnancy testl
X
Research Blood - 
cfDNAm
X
X
X
Xm
Xm
Xm
X
X

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Research Blood - 
Immune Markersn
X
X
X
X
Xn
Xn
Xn
X
Research Biopsyo
X
X
X
Cerebrospinal Fluid 
Collectionp
X
X
X
Questionnaireq
X
X
X
X
X
X
X
General Impression 
Worksheett
X
X
X
X
X
X
Archival Tissue 
Collection 
X
Atezolizumab
X
X
X
X
X
X
Post RT Follow-up 
Visitu
Xu
Survival Statusr
X
Atezolizumab: 1200mg given IV q3 weeks on Day 1 of each cycle + Stereotactic Radiation: radiation will start 2-7 days after the first dose of atezolizumab
a. Stereotactic radiation planning appointment must occur at least 7 days prior to initiating radiation
b. Medical history includes clinically significant disease, surgeries, and cancer history (including prior cancer therapies and procedures). 
c. A complete physical examination, including neurological examination, will be performed at screening. A limited physical exam, to include a neurological exam, will be 
performed at subsequent Day 1 visits. 
d. Participants will be seen by a radiation oncologist on day 1 of stereotactic radiation and 10 days after radiation completion (+/- 4 days). 
e. Vital signs to include: heart rate, systolic and diastolic blood pressures while the patient is in a seated position, respiratory rate, and temperature. 
f. Selected medications of interest received within 28 days before the first dose of trial treatment and 30 days after the last dose of trial treatment, including dosage, frequency, 
route, and dates of administration will be documented
g. T-1 weighted perfusion MRI will be used. Screening MRI must be done within 14 days of the radiation initiation. Subsequent assessments should be done during the last 15-21 
days of a cycle, q6weeks for the first 24 weeks (i.e. C2, 4, 6, 8) and then can be reduced to q9 weeks (i.e. C11, 14, 17, etc). If progression is suspected, an unscheduled assessment 
is permitted. An objective response (CR, PR should be confirmed by repeat assessments 4-6 weeks after initial finding. Patients with CNS PD are allowed to continue on study 
for 4-6 weeks to confirm PD on MRI. For those taken off-study for reasons other than progressive disease in the CNS, assessments should continue to be repeated every 6-12 
weeks until progression or beginning a new cancer therapy regimen. It is understood that it may not always be feasible for patients to return for restaging evaluation after coming 
off protocol therapy; however, it strongly encouraged. Failure to complete CNS restaging after a patient has been taken off protocol therapy will not constitute a protocol 
violation.
h. CT and/or MRI should be of the chest, abdomen and pelvis. Additional imaging studies (CT neck, plain films, etc.) are permitted as clinically indicated. The same radiographic 
procedures and technique must be used throughout the study for each patient. Assessments should be done during the last 15-21 days of a cycle, q6weeks for the first 24 weeks 
(i.e. C2, 4, 6, 8) and then can be reduced to q9 weeks (i.e. C11, 14, 17, etc.) until progression.  For those taken off-study for reasons other than progressive disease, tumor 
measurements should continue to be repeated every 6-12 weeks until progression or beginning a new cancer therapy regimen. Failure to complete restaging after a patient has 
been taken off protocol therapy will not constitute a protocol violation.
i.
Hematology: hemoglobin, hematocrit, platelet count, RBC count, WBC count, percent and absolute differential count. 
j.
Chemistry: sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, calcium, total bilirubin, total protein, albumin, ALT, AST, alkaline phosphatase, and LDH. 
k. Beginning with cycle 4, TSH will be done every other cycle on Day 1 (i.e. cycles 4, 6, 8, etc.). 
l.
In female subjects of child-bearing potential as defined in the eligibility criteria, serum or urine pregnancy test must be performed within 8 days prior to initiating protocol 
therapy
m. cfDNA is required to be drawn on C1D1, Day 1 of RT, C3D1, C5D1, C9D1, at each restaging visit, and at disease progression or discontinuation of protocol therapy, whichever 
comes first.  
n. Immune markers will be drawn on C1D1, Day 1 of RT, C3D1, C5D1, C9D1, and at disease progression or discontinuation of protocol treatment, whichever comes first.
o. Baseline tumor biopsy should be obtained within 28 days of the first dose of Atezolizumab. The C2D1 biopsy should be performed as close to C2D1 as possible but may be 
collected between C2D1 and C2D21. Both the baseline and C2 biopsy are required for participants with accessible disease outside of the field of radiotherapy. A biopsy at the 
time of disease progression is optional for subjects who have accessible disease and have achieved an objective response (CR or PR) and/or experienced prolonged stable disease 
for ≥ 24 weeks.
p. CSF collection will be performed at baseline, C2 day 15 to day 21, and at disease progression or discontinuation of protocol therapy, whichever comes first (±3 days) in at least 
10 participants. 
q. NANO Scale, MDASI0BT and EQ-5D to be administered at baseline, C3D1, C5D1, C7D1, C9D1, and Off-Treatment. For those taken off treatment for reasons other than 
progressive disease, questionnaires should continue to be repeated every 6-12 weeks at the time of tumor assessments until progression or beginning a new cancer therapy 
regimen when possible. Failure to complete questionnaires after a patient has been taken off protocol therapy will not constitute a protocol violation.
r. Participants will be followed for overall survival every 6 months or until death. This can be a visit to the clinic or a phone call to the participant or the participant’s local provider.
s. Off-Treatment visit should occur within 30 days of the last dose of study treatment. Tumor assessments (including brain MRI and CAP CT/MRI do not need to be repeated if 
done within 28 days of the off-treatment visit).
t.
General Impression Worksheet to be completed at baseline and the end of each 3-week cycle of treatment.
u. To assess participants for potential delayed radiation toxicity, a stereotactic radiation follow-up visit will be performed approximately 6 months and 12 months after completion 
of stereotactic radiation treatment. This visit may occur any time post 6 months (as early as 5 months/as late as 8 months) or post 12 months (as early as 11 months/as late as 14 
months) after completion of stereotactic radiation treatment. Please see section5.2.4.1.8 for more information surrounding these visit requirements. 

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11. MEASUREMENT OF EFFECT
In this study, response and progression in the CNS and in non-CNS sites will be 
evaluated and recorded separately in this trial. For the purposes of this study, participants should 
be re-evaluated for response every 6 weeks for the first 24 weeks and then every 9 weeks 
thereafter. For participants who achieve a sustainable response after 1 year on protocol therapy, 
re-evaluation can be performed every 12 weeks.
11.1
Antitumor Effect – CNS disease 
Tumor response and progression for CNS disease will be assessed centrally by the DF/HCC Tumor 
Imaging Metrics Core according to RANO-BM criteria and according to iRANO criteria. Please refer to 
the full publications for additional details.
11.1.1 Response Assessment in Neuro-Oncology-Brain Metastases(RANO-BM) Criteria: 
11.1.1.1
Definitions

Definition of Measurable Disease: Measurable disease is defined as a contrast 
enhancing lesion that can be accurately measured in at least one dimension with a 
minimum size of 10 mm, visible on two or more axial slices that are preferably ≤ 5 
mm apart with 0-mm skip (and ideally ≤ 1.5 mm apart with 0-mm skip). In addition, 
although the longest diameter in the plane of measurement is to be recorded, the 
diameter perpendicular to the longest diameter in the plane of measurement should be 
at least 5 mm for the lesion to be considered measurable. In the event the MRI is 
performed with thicker slices, the size of the measurable lesion at baseline should be 
at least two times the slice thickness. If there are interslice gaps, this also needs to be 
considered in determining the minimum size of measurable lesions at baseline. 
Measurement of tumor around a cyst or surgical cavity represents a particularly 
difficult challenge. In general, such lesions should be considered non-measurable 
unless there is a nodular component measuring ≥ 10 mm in longest diameter and ≥ 5 
mm in the perpendicular plane. The cystic or surgical cavity should not be measured 
in determining response (Figure 1 in the original publication).

Definition of Non-measurable Disease: All other lesions, including lesions with 
longest dimension < 10 mm, lesions with borders that cannot be reproducibly 
measured, dural metastases, bony skull metastases, cystic-only lesions, and 
leptomeningeal disease.
11.1.1.2
Specifications of Methods of Measurement

Method of Assessment: The same method of assessment and the same technique 
should be used to characterize each identified and reported lesion at baseline and 
during follow-up. It is important to use imaging techniques that are consistent across 
all imaging time points in order to ensure that the assessment of interval appearance 
or disappearance of lesions or of change in size is not affected by scan parameters 
such as slice thickness. Use of thin section imaging (for example, Appendix A of the 
original publication) is particularly important when evaluating lesions < 10 mm in LD 
and/or small changes in lesion size.

Imaging Modality: Gadolinium-enhanced MRI is the best currently available, 
sensitive, and reproducible method to measure CNS lesions selected for response 
assessment. Suggested brain MRI specifications are detailed in Appendix A of the 
original publication. A sum of the diameters for all target lesions will be calculated 
and reported as the baseline sum of longest diameters (sum LD). All other CNS 

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lesions should be identified as non-target lesions and should also be recorded at 
baseline. Measurements are not required and these lesions should be followed as 
‘present’, ‘absent’, or ‘unequivocal progression’.
11.1.1.3
Definition of Best Overall CNS Response
Best overall CNS response represents a composite of radiographic CNS target and non-
target response (see definitions above), corticosteroid use, and clinical status. In non-randomized 
trials where CNS response is the primary endpoint, confirmation of PR or CR at least 4 weeks 
later is required to deem either one the best overall response. At each protocol-specified time 
point, a response assessment should occur and CNS assessments should be coincident with extra-
CNS assessment. Table 1 shows the additional corticosteroid and clinical status requirements to 
deem a PR or CR.
11.1.1.4
Evaluation of Target Lesions

Complete response (CR): Disappearance of all CNS target lesions sustained for at 
least 4 weeks; no new lesions; no corticosteroids; stable or improved clinically. 

Partial response (PR): At least a 30% decrease in the sum LD of CNS target lesions, 
taking as reference the baseline sum LD sustained for at least 4 weeks; no new 
lesions; stable to decreased corticosteroid dose; stable or improved clinically. 

Progressive disease (PD): At least a 20% increase in the sum LD of CNS target 
lesions, taking as reference the smallest sum on study (this includes the baseline sum 
if that is the smallest on study). In addition to the elative increase of 20%, at least one 
lesion must increase by an absolute value of ≥ 5 mm to be considered progression. 

Stable disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum LD while on study.
11.1.1.5
Evaluation of Non-Target Lesions
Non-target lesions should be assessed qualitatively at each of the time points specified in 
the protocol.

CR: Requires all of the following: disappearance of all enhancing CNS non-target 
lesions, no new CNS lesions.

Non-CR/Non-PD: Persistence of one or more non-target CNS lesion(s).

PD: Any of the following: unequivocal progression of existing enhancing non-target 
CNS lesions, new lesion(s) (except while on immunotherapy-based treatment), or 
unequivocal progression of existing tumor-related non-enhancing (T2/FLAIR) CNS 
lesions. In the case of immunotherapy-based treatment, new lesions alone may not 
constitute progressive disease (see “Guidance in the case of new lesion(s) while on 
immunotherapy” below).
Special Notes on the Assessment of Target and Non-Target CNS Lesions:
a) Target lesions that become too small to measure: While on study, all CNS target 
lesions should have their actual measurement recorded, even when very small (e.g., 2 
mm). If the lesion disappears, the value should be recorded as 0 mm. However, if the 

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lesion is sufficiently small (but still present) that the radiologist does not feel 
comfortable assigning an exact measure, a default value of 5 mm should be recorded 
on the case report form.
b) Lesions that coalesce on treatment: As lesions coalesce, a plane between them may 
be maintained that would aid in obtaining maximum LD of each individual lesion. If 
the lesions have truly coalesced such that they are no longer separable, the vector of 
the longest diameter in this instance should be the maximum LD for the ‘coalesced’ 
lesion.
c) Definition of new lesion(s): The finding of a new CNS lesion should be unequivocal 
and not due to technique or slice variation. A new lesion is one that was not present 
on prior scans. If the MRI is obtained with ≤ 1.5 mm slice thickness, then the new 
lesion should also be visible in axial, coronal, and sagittal reconstructions of ≤ 1.5 
mm projections. If a new lesion is equivocal, for example because of its small size 
(i.e., ≤ 5 mm), continued therapy may be considered, and follow up evaluation will 
clarify if it represents truly new disease. If repeat scans confirm there is definitely a 
new lesion, then progression should be declared using the date of the initial scan 
showing the new lesion. In the case of immunotherapy, new lesions alone may not 
constitute progressive disease (see “Guidance in the case of new lesion(s) while on 
immunotherapy” below).
d) Definition of Unequivocal Progression of Non-Target Lesion(s): When the patient 
also has measurable disease, to achieve ‘unequivocal progression’ on the basis of 
non-target disease alone, there must be an overall level of substantial worsening in 
non-target disease such that, even in the presence of SD or PR in target disease, the 
overall tumor burden has increased sufficiently to merit discontinuation of therapy. 
When the patient has only non-measurable disease, there must be an overall level of 
substantial worsening to merit discontinuation of therapy. 
e) Guidance in the Case of Uncertain Attribution of Radiographic Findings and/or 
Equivocal Cases: The RANO-BM group acknowledges that in the case of patients 
followed after SRS or during immunotherapy-based approaches, there may be 
radiographic evidence of enlargement of target and non-target lesions which may not 
necessarily represent tumor progression. If there is evidence of radiographic 
progression but there is clinical evidence supporting the possibility that the 
radiological changes are due to treatment effect (and not to progression of cancer), 
additional evidence is required to distinguish true progression versus treatment effect 
as standard MRI alone is not sufficient. The methods used to distinguish between the 
two entities should be specified prospectively in the clinical protocol. one or more of 
the following options: (1) Repeat the scan at the next protocol scheduled evaluation 
or sooner, and generally within ~6 weeks. An investigator may choose a shorter time 
interval in the case of progressive symptoms or other clinically concerning findings. 
If there is continued increase in enhancement concerning for tumor growth, then this 
may be consistent with radiographic progression and the patient should be taken off 
study (Figure 2 in the original publication). If the lesion is stable or decreased in size, 
then this may be consistent with treatment effect and the patient may remain on study 
(Figure 3 in the original publication). For patients with equivocal results even on the 
next restaging scan, the scan may be repeated again at a subsequent protocol 
scheduled evaluation or sooner although surgery and/or use of an advanced imaging 

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modality (in the case of SRS/SRT) are strongly encouraged. (2) Surgical pathology 
obtained via biopsy or resection. (3) For SRS/SRT treated lesions, an advanced 
imaging modality such as perfusion MR imaging, MR spectroscopy, or 18FLT or 
18FDG positron emission tomography (PET) may be used as additional evidence of 
tumor progression or treatment effect/radionecrosis. Upon review of the literature and 
extensive discussions by the Working Group, we were not able to conclude that any 
one modality or approach can be recommended across all patients to distinguish 
between radiation necrosis versus true progression, as the literature is not sufficiently 
robust, and recommend clinical judgment and involvement of a multidisciplinary 
team. We recognize this is less than satisfactory and agree that developing more 
sensitive and specific methods for distinguishing between treatment effect and tumor 
progression are needed. We should also note that these advanced imaging modalities 
have not been extensively studied with regards to immunotherapy-based approaches 
and therefore are cannot be recommended for distinguishing tumor progression versus 
immune-related changes at this time. Regardless of the additional testing obtained, if 
subsequent testing demonstrates that progression has occurred, the date of 
progression should be recorded as the date of the scan at which this issue was first 
raised. Patients may also have an equivocal finding on a scan (for example, a small 
lesion that is not clearly new). It is permissible to continue treatment until the next 
protocol scheduled evaluation. If the subsequent evaluation demonstrates that 
progression has indeed occurred, the date of progression should be recorded as the 
date of the initial scan where progression was suspected.
 
Notes Regarding Corticosteroid Use and Clinical Deterioration:
a) An increase in corticosteroid dose alone, in the absence of clinical deterioration 
related to tumor, will not be used as a sole determinant of progression. Patients with 
stable imaging studies whose corticosteroid dose was increased for reasons other than 
clinical deterioration related to tumor do not qualify for stable disease or progression. 
They should be observed closely. If their corticosteroid dose can be reduced back to 
baseline, they will be considered as having stable disease; if further clinical 
deterioration related to tumor becomes apparent, they will be considered to have 
progression.
b) The definition of clinical deterioration is left to the discretion of the treating 
physician, but it is recommended that a decline in the KPS from 100 or 90 to 70 or 
less, a decline in KPS of at least 20 points from 80 or less, or a decline in KPS from 
any baseline to 50 or less, for at least 7 days, be considered neurologic deterioration 
unless attributable to comorbid events, treatment-related toxicity, or changes in 
corticosteroid dose.

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Table 1
Summary of the Proposed RANO Response Criteria for CNS Metastases
Abbreviations: CNS = central nervous system; CR = complete response; LD= longest 
dimension; NA = not applicable; PD = progressive disease; PR= partial response; RANO= 
Response Assessment in Neuro-Oncology; SD = stable disease. 
*Progression occurs when this criterion is met. 
**New lesion = new lesion not present on prior scans and visible in at least 2 projections. 
If a new lesion is equivocal, for example because of its small size, continued therapy may be 
considered, and follow up evaluation will clarify if it represents truly new disease. If repeat scans 
confirm there is definitely a new lesion, then progression should be declared using the date of the 
initial scan showing the new lesion. For immunotherapy based approaches, new lesions alone to 
do not define progression (See “Guidance in the Case of New Lesion(s) while on 
Immunotherapy”). 
+Increase in corticosteroids alone will not be taken into account in determining 
progression in the absence of persistent clinical deterioration.

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11.2
Antitumor Effect – non-CNS disease 
Response and progression in extracranial sites of metastases will be evaluated in this 
study using the international criteria proposed by the RECIST 1.1 criteria [Eisenhauer et al., 
2009]. Changes in the largest diameter (unidimensional measurement) of the tumor lesions and 
the shortest diameter in the case of malignant lymph nodes are used in the RECIST criteria. 
11.2.1 RECIST 1.1 Definitions
Evaluable for Target Disease response. Only those participants who have measurable 
disease outside the field of radiation present at baseline, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for target 
disease response. These participants will have their response classified according to the 
definitions stated below. (Note: Participants who exhibit objective disease progression 
prior to the end of cycle 1 will also be considered evaluable.)
Evaluable Non-Target Disease Response. Participants who have lesions present at 
baseline that are evaluable but do not meet the definitions of measurable disease, have 
received at least one cycle of therapy, and have had their disease re-evaluated will be 
considered evaluable for non-target disease. The response assessment is based on the 
presence, absence, or unequivocal progression of the lesions. 
11.2.2 Disease Parameters
Measurable disease. Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as ≥ 20 mm by 
chest x-ray or ≥10 mm with CT scan, MRI, or calipers by clinical exam. All tumor 
measurements must be recorded in millimeters (or decimal fractions of centimeters).
Note: Tumor lesions that are situated in a previously irradiated area are not considered 
measurable.
Malignant lymph nodes. To be considered pathologically enlarged and measurable, a 
lymph node must be ≥15 mm in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm). At baseline and in follow-up, only 
the short axis will be measured and followed.
Non-measurable disease. All other lesions (or sites of disease), including small lesions 
(longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), 
are considered non-measurable disease. Bone lesions, leptomeningeal disease, ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
abdominal masses (not followed by CT or MRI), and cystic lesions are all considered 
non-measurable.
Note: Cystic lesions that meet the criteria for radiographically defined simple cysts 
should not be considered as malignant lesions (neither measurable nor non-measurable) 

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since they are, by definition, simple cysts.
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable 
lesions, if they meet the definition of measurability described above. However, if non-
cystic lesions are present in the same participant, these are preferred for selection as 
target lesions.
Target lesions. All measurable lesions up to a maximum of 2 lesions per organ and 5 
lesions in total, representative of all involved organs, should be identified as target 
lesions and recorded and measured at baseline. Target lesions should be selected on the 
basis of their size (lesions with the longest diameter), be representative of all involved 
organs, but in addition should be those that lend themselves to reproducible repeated 
measurements. It may be the case that, on occasion, the largest lesion does not lend itself 
to reproducible measurement in which circumstance the next largest lesion which can be 
measured reproducibly should be selected. A sum of the diameters (longest for non-nodal 
lesions, short axis for nodal lesions) for all target lesions will be calculated and reported 
as the baseline sum diameters. If lymph nodes are to be included in the sum, then only the 
short axis is added into the sum. The baseline sum diameters will be used as reference to 
further characterize any objective tumor regression in the measurable dimension of the 
disease. 
Non-target lesions. All other lesions (or sites of disease) including any measurable 
lesions over and above the 5 target lesions should be identified as non-target lesions and 
should also be recorded at baseline. Measurements of these lesions are not required, but 
the presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow up. 
11.2.3 Methods for Evaluation of Disease
All measurements should be taken and recorded in metric notation using a ruler, calipers, 
or a digital measurement tool. All baseline evaluations should be performed as closely as 
possible to the beginning of treatment and never more than 4 weeks before the beginning 
of the treatment.
The same method of assessment and the same technique should be used to characterize 
each identified and reported lesion at baseline and during follow-up. Imaging-based 
evaluation is preferred to evaluation by clinical examination unless the lesion(s) being 
followed cannot be imaged but are assessable by clinical exam. 
Clinical lesions. Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and ≥10 mm in diameter as 
assessed using calipers (e.g., skin nodules). In the case of skin lesions, documentation by 
color photography, including a ruler to estimate the size of the lesion, is recommended. 
Chest x-ray. Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung; however, CT is preferable. 

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Conventional CT and MRI. This guideline has defined measurability of lesions on CT 
scan based on the assumption that CT thickness is 5mm or less. If CT scans have slice 
thickness greater than 5 mm, the minimum size of a measurable lesion should be twice 
the slice thickness. MRI is also acceptable in certain situations (e.g. for body scans). 
Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which 
greatly impact image quality, lesion conspicuity, and measurement. Furthermore, the 
availability of MRI is variable globally. As with CT, if an MRI is performed, the 
technical specifications of the scanning sequences used should be optimized for the 
evaluation of the type and site of disease. Furthermore, as with CT, the modality used at 
follow-up should be the same as was used at baseline and the lesions should be 
measured/assessed on the same pulse sequence. It is beyond the scope of the RECIST 
guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases. Ideally, the same type of scanner should be used and the image 
acquisition protocol should be followed as closely as possible to prior scans. Body scans 
should be performed with breath-hold scanning techniques, if possible.
FDG-PET. While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease). New lesions on the basis 
of FDG-PET imaging can be identified according to the following algorithm: 
(a) Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of 
PD based on a new lesion.
(b) No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive 
FDG-PET at follow-up corresponds to a new site of disease confirmed by CT, this is 
PD. If the positive FDG-PET at follow-up is not confirmed as a new site of disease 
on CT, additional follow-up CT scans are needed to determine if there is truly 
progression occurring at that site (if so, the date of PD will be the date of the initial 
abnormal FDG-PET scan). If the positive FDG-PET at follow-up corresponds to a 
pre-existing site of disease on CT that is not progressing on the basis of the anatomic 
images, this is not PD.
(c) FDG-PET may be used to upgrade a response to a CR in a manner similar to a 
biopsy in cases where a residual radiographic abnormality is thought to represent 
fibrosis or scarring. The use of FDG-PET in this circumstance should be 
prospectively described in the protocol and supported by disease-specific medical 
literature for the indication. However, it must be acknowledged that both approaches 
may lead to false positive CR due to limitations of FDG-PET and biopsy 
resolution/sensitivity.
Note: A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake 
greater than twice that of the surrounding tissue on the attenuation corrected image.
PET-CT. At present, the low dose or attenuation correction CT portion of a combined 
PET-CT is not always of optimal diagnostic CT quality for use with RECIST 

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measurements. However, if the site can document that the CT performed as part of a 
PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), 
then the CT portion of the PET-CT can be used for RECIST measurements and can be 
used interchangeably with conventional CT in accurately measuring cancer lesions over 
time. Note, however, that the PET portion of the CT introduces additional data which 
may bias an investigator if it is not routinely or serially performed. 
Ultrasound. Ultrasound is not useful in assessment of lesion size and should not be used 
as a method of measurement. Ultrasound examinations cannot be reproduced in their 
entirety for independent review at a later data and, because they are operator dependent, it 
cannot be guaranteed that the same technique and measurements will be taken from one 
assessment to the next. If new lesions are identified by ultrasound in the course of the 
study, confirmation by CT or MRI is advised. If there is concern about radiation exposure 
from CT, MRI may be used instead of CT in selected instances. 
Endoscopy, Laparoscopy. The utilization of these techniques for objective tumor 
evaluation is not advised. However, such techniques may be useful to confirm complete 
pathological response when biopsies are obtained or to determine relapse in trials where 
recurrence following complete response (CR) or surgical resection is an endpoint.
Tumor markers. Tumor markers alone cannot be used to assess response. If markers are 
initially above the upper normal limit, they must normalize for a participant to be 
considered in complete clinical response. Specific guidelines for both CA-125 response 
(in recurrent ovarian cancer) and PSA response (in recurrent prostate cancer) have been 
published [JNCI 96:487-488, 2004; J Clin Oncol 17, 3461-3467, 1999; J Clin Oncol 
26:1148-1159, 2008]. In addition, the Gynecologic Cancer Intergroup has developed CA-
125 progression criteria which are to be integrated with objective tumor assessment for 
use in first-line trials in ovarian cancer [JNCI 92:1534-1535, 2000].
Cytology, Histology. These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor 
types, such as germ cell tumors, where known residual benign tumors can remain).
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or 
stable disease is mandatory to differentiate between response or stable disease (an 
effusion may be a side effect of the treatment) and progressive disease.
11.2.3.1
Evaluation of Target Lesions
Complete Response (CR): Disappearance of all target lesions. Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm.
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum diameters.

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Progressive Disease (PD): At least a 20% increase in the sum of the diameters of 
target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study). In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm. (Note: the 
appearance of one or more new lesions is also considered progressions).
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while on 
study.
11.2.3.2
Evaluation of Non-Target Lesions
Complete Response (CR): Disappearance of all non-target lesions and normalization 
of tumor marker level. All lymph nodes must be non-pathological in size (<10 mm 
short axis).
Note: If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response.
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance 
of tumor marker level above the normal limits.
Progressive Disease (PD): Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions. Unequivocal progression 
should not normally trump target lesion status. It must be representative of overall 
disease status change, not a single lesion increase.  
Although a clear progression of “non-target” lesions only is exceptional, the opinion 
of the treating physician should prevail in such circumstances, and the progression 
status should be confirmed at a later time by the review panel (or Principal 
Investigator).
11.2.3.3
Evaluation of New Lesions
The finding of a new lesion should be unequivocal (i.e. not due to difference in 
scanning technique, imaging modality, or findings thought to represent something 
other than tumor (for example, some ‘new’ bone lesions may be simply healing or 
flare of pre-existing lesions). However, a lesion identified on a follow-up scan in an 
anatomical location that was not scanned at baseline is considered new and will 
indicate PD. If a new lesion is equivocal (because of small size etc.), follow-up 
evaluation will clarify if it truly represents new disease and if PD is confirmed, 
progression should be declared using the date of the initial scan on which the lesion 
was discovered.

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11.2.3.4
Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started). The patient's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria.
For Participants with Measurable Disease (i.e., Target Disease)
Target 
Lesions
Non-Target 
Lesions
New 
Lesions
Overall 
Response
Best Overall Response when 
Confirmation is Required*
CR
CR
No
CR
4 wks Confirmation**
CR
Non-CR/Non-
PD
No
PR
CR
Not evaluated
No
PR
PR
Non-CR/Non-
PD/not 
evaluated
No
PR
4 wks Confirmation**
SD
Non-CR/Non-
PD/not 
evaluated
No
SD
PD
Any
Yes or No
PD
Any
PD***
Yes or No
PD
Any
Any
Yes
PD
no prior SD, PR or CR

See RECIST 1.1 manuscript for further details on what is evidence of a new lesion.
**    Only for non-randomized trials with response as primary endpoint.
***   In exceptional circumstances, unequivocal progression in non-target lesions may be
      accepted as disease progression.
Note: Participants with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.” Every effort should be made to document the 
objective progression even after discontinuation of treatment.
For Participants with Non-Measurable Disease (i.e., Non-Target Disease)
Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD

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
‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign 
this category when no lesions can be measured is not advised
11.2.4 Duration of Response
Duration of overall response: The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first 
date that recurrent or progressive disease is objectively documented (taking as reference 
for progressive disease the smallest measurements recorded since the treatment started, or 
death due to any cause. Participants without events reported are censored at the last 
disease evaluation).
Duration of overall complete response: The duration of overall CR is measured from the 
time measurement criteria are first met for CR until the first date that progressive disease 
is objectively documented, or death due to any cause. Participants without events 
reported are censored at the last disease evaluation.
Duration of stable disease: Stable disease is measured from the start of the treatment until 
the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started, including the baseline measurements. 
11.2.5 Clinical Benefit rate 
Clinical benefit rate: defined as CR, PR and stable disease (SD) ≥ 24 weeks.
11.3
Antitumor Effect – Hematologic Tumors
N/A
11.4
Other Response Parameters
11.4.1 Definition of Tumor Response Using Immune-Related Response Criteria (irRC)
The sum of the longest diameter of lesions (SPD) at tumor assessment using the immune-
related response criteria (irRC) for progressive disease incorporate the contribution of 
new measurable lesions. Each net Percentage Change in Tumor Burden per assessment 
using irRC criteria accounts for the size and growth kinetics of both old and new lesions 
as they appear.
11.4.1.1
Impact of New Lesions on irRC
New lesions in and of themselves do not qualify as progressive disease. However, their 
contribution to total tumor burden is included in the SPD which in turn feeds into the 

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irRC criteria for tumor response. Therefore, new non-measurable lesions will not 
discontinue any subject from the study.
11.4.1.2
Definition of Target Lesions Response Using irRC

irComplete Response (irCR): Complete disappearance of all target lesions. This 
category encompasses exactly the same subjects as “CR” by the mWHO criteria.

irPartial Response (irPR): Decrease, relative to baseline, or 50% or greater in the sum 
of the products of the two largest perpendicular diameters of all target and all new 
measurable target lesions (i.e., Percentage Change in Tumor Burden). Note: the 
appearance of new measurable lesions is factored into the overall tumor burden, but does 
not automatically qualify as progressive disease until the SBD increases by >25% when 
compared to SPD at nadir.

irStable Disease (irSD): Does not meet criteria for irRC or irPR, in the absence of 
progressive disease.

irProgressive Disease (irPD): At least 25% increase Percentage Change in Tumor 
Burden (i.e. taking SPD of all target lesions and any new lesions) when compared to SPD 
at nadir.
11.4.1.3
Definition of Non-Target Lesions Response Using irRC

irComplete Response (irCR): Complete disappearance of all non-target lesions. This 
category encompasses exactly the same subjects as “CR” by the mWHO criteria.

irPartial Response (irPR) or irStable Disease (irSD): Non-target lesion(s) are not 
considered in the definition of PR; these terms do not apply.

irProgressive Disease (irPD): Increases in number or size of non-target lesion(s) does 
not constitute progressive disease unless/until the Percentage Change in Tumor Burden 
increases by 25% (i.e. the SPD at nadir of the target lesions increases by the required 
amount).
11.4.1.4
Definition of Overall Response Using irRC
Overall response using irRC will be based on these criteria:

Immune-Related Complete Response (irCR): Complete disappearance of all tumor 
lesions (target and non-target) together with no new measurable/unmeasurable lesions for 
at least 4 weeks from the date of documentation of complete response.

Immune-Related Partial Response (irPR): The sum of the products of the two largest 
perpendicular diameters of all target lesions is measured and captured as the SPD 
baseline. At each subsequent tumor assessment, the SPD of the two largest perpendicular 
diameters of all target lesions and of new measurable lesions are added together to 
provide the Immune Response Sum of Product Diameters (irSPD). A decrease, relative to 
baseline, of the irSPD compared to the previously SPD baseline of 50% or greater is 
considered an irPR.

Immune-Related Stable Disease (irSD): irSD is defined as the failure to meet criteria 

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for immune complete response or immune partial response, in the absence of progressive 
disease

Immune-Related Progressive Disease (irPD): It is recommended in difficult cases to 
confirm PD by serial imaging. Any of the following will constitute PD:

At least 25% increase in the SPD of all target lesions over baseline SPD calculated 
for the target lesions.

At least 25% increase in the SPD of all target lesions and new measurable lesions 
(irSPD) over the baseline SPD calculated for the target lesions.
Criteria for determining overall response by irRC are summarized as follows:
11.4.1.5
Immune-Related Best Overall Response Using irRC (irBOR)
irBOR is the best confirmed overall response over the study as a whole, recorded 
between the date of first dose until the last tumor assessment before subsequent therapy 
(except for local palliative radiotherapy for painful bone lesions) for the individual 
subject in the study. For the assessment of irBOR, all available assessments per subject 
are considered.
irCR or irPR determinations included in the irBOR assessment must be confirmed by a 
second (confirmatory) evaluation meeting the criteria for response and performed no less 
than 4 weeks after the criteria for response are first met.
11.4.2 Definition of immunotherapy Response Assessment in Neuro-Oncology (iRANO)
Standard RANO criteria differ according to whether the target population is high-grade 

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glioma, low-grade brain tumors, or solid tumor brain metastases[Lin et al., 2015] [Wen et al., 
2010, Van Den Bent et al., 2011]Given the clinical success of modern immunothery trials, 
iRANO was designed to integrate seamlessly into these different “backbone” RANO criteria 
(Okada et al, 2015). iRANO takes an algorithmic approach as to whether a patient may remain 
on protocol therapy following the first “disease progression” event after beginning protocol 
threapy, and provides the ability for patients to remain on protocol therapy through this initial 
event. The key component of the iRANO criteria is specific additional guidance for the 
determination of progressive disease in patients with neuro-oncological malignancies undergoing 
immunotherapy (Figure 1). Specifically, the iRANO criteria advocate for the confirmation of 
radiographic progression in appropriate patients defined by clinical status and time from 
initiation of immunotherapy.
If disease progression is confirmed on subsequent scan(s), then the date of progression is 
backdated to the original date of radiographic worsening.
Figure 1: iRANO treatment algorithm for the assessment of progressive imaging findings in patients with
neuro-oncological malignancies undergoing immunotherapy [Okada et al., 2015].

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iRANO=immunotherapy Response Assessment in Neuro-Oncology.
In patients who have imaging findings that meet RANO criteria for progressive disease 
within 6 months of starting immunotherapy including the development of new lesions, 
confirmation of radiographic progression on follow-up imaging before defining the patient as 
nonresponsive to treatment might be needed provided that the patient does not have new or 

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substantially worse neurological deficits. Such patients might be allowed a window of up 3 
months before confirming disease progression with the scan that first showed initial progressive 
changes as the new reference scan for comparison with subsequent imaging studies. 
If RANO criteria for progressive disease are met on the follow-up scan 3 months later, non-
responsiveness to treatment should be assumed, and the date of progressive disease should be 
back-dated to the initial date when it was first identified (table 1). Patients who develop 
substantial new or worsened neurological deficits not due to comorbid events or a change in co-
administered medication at any time within the 3-month follow-up window should be designated 
as non-responsive to treatment and should discontinue immunotherapy. For these patients, the 
date of actual tumor progression should also be back-dated to the date when radiographic 
progressive disease was initially identified.
If radiographic findings at the 3-month follow-up meet RANO criteria for stable disease, 
partial response, or complete response compared with the original scan meeting criteria for 
progression, and no new or worsened neurological deficits are identified, such patients should be 
deemed as deriving clinical benefit from therapy and allowed to continue treatment. Patients who 
develop worsening radiographic findings compared with the pretreatment baseline scan more 
than 6 months from starting immunotherapy are expected to have a low likelihood of ultimately 
deriving clinical benefit and should be regarded as non-responsive to treatment with a 
recommendation to discontinue therapy.
11.4.3Progression-free Survival
RANO-BM proposes evaluating of progression-free survival according to a bi-compartmental 
model, i.e. each compartment (CNS and non-CNS) is evaluated separately, CNS according to 
RANO-BM and non-CNS according to RECIST 1.1. Progression in either compartment is 
deemed an overall progression event and site of first progression (CNS or non-CNS) is captured 
as a unique data element in the CRFs.
RECIST 1.1 uses instead a summation approach. With RECIST 1.1, up to 2 target lesions per 
organ may be assessed and the longest dimension of all target lesions (i.e. CNS and non-CNS) 
are summed for evaluation of response and progression. As with RANO-BM, unequivocal 
worsening of target lesions in either CNS or non-CNS compartments also constitutes a 
progression event. Unlike RANO-BM, RECIST 1.1 relies primarily on radiographic findings and 
does not include neurological status or corticosteroid use.
It is unknown what the correlation between RANO-BM and RECIST 1.1 is with respect to PFS 
and with respect to any relationships between PFS and OS. In this study, data will be collected 
prospectively to allow calculation of PFS according to both methods. 

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11.4.3 Definition of Abscopal response
As described previously, abscopal response is defined as a decrease in the longest 
diameter of at least 30% in any measurable (≥1 cm) non-irradiated lesion from 
baseline[Golden et al., 2015]. In patients with more than three lesions, the non-irradiated 
lesions will be measured individually for response to treatment. The best abscopal 
responding lesion will be reported.
11.4.3.1
Definition of overall response according abscopal response definition

Complete abscopal response is defined as the complete disappearance of a measurable 
non-irradiated lesion.

Partial abscopal response is defined as at least a 30% decrease in the longest diameter.

Progressive disease is defined as at least a 20% increase in the longest diameter of the 
best measurable non-irradiated lesion. 

Stable disease is defined as insufficient shrinkage or growth to qualify for a partial 
abscopal or complete abscopal response or progressive disease.
11.4.4 Patient-Reported Outcome Measure
11.4.4.1
The PRO outcome measure for this study is as follows: Scores from the MDASI-BT 
assessment 
11.4.5 Investigator-Assessed Neurological Evaluation
In order to standardize the evaluation of key neurological exam components, this study will use 
the Neurological Assessment in Neuro-Oncology (NANO) scale[Nayak et al., 2014]. The scale 
was developed by an international group of neuro-oncologists convened bi-weekly between June 
2012 and July 2013 as an objective and quantifiable metric of neurologic function evaluable 
during a routine office examination that will integrate into the existing RANO criteria[Lin et al., 
2015]. The NANO scale is intended to serve as a quick, oncology-friendly, quantifiable, 
evaluation of eight relevant neurologic domains based on direct examination by clinicians during 
routine office visits.The scale defines criteria for domain-specific and overall scores of response, 
progression and stable disease. In addition, a given domain is scored non-assessed if the clinician 
neglects to examine the domain or non-evaluable if the domain cannot be accurately assessed 
due to pre-existing conditions, co-morbid events, and/or concurrent medications.
11.4.6 EQ-5D evaluation
In order to evaluate the impact of the study treatment, on general health status we will have 
participants complete the EQ-5D questionnaire (APPENDICES E or F).
12. DATA REPORTING / REGULATORY REQUIREMENTS
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements).

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12.4
Collaborative Agreements Language
N/A
13. STATISTICAL CONSIDERATIONS
13.1
Study Design/Endpoints
This is an open-label, single arm phase II study to assess PFS in patients with TNBC and brain 
metastasis who will receive stereotactic radiation in combination with atezolizumab. The target 
enrollment is 45 participants.
Primary endpoint
The primary endpoint is PFS defined as time from first dose of atezolizumab (day 1 cycle 1) to 
progression or death due to any cause. Progression will be defined according to the bi-
compartmental model proposed in the RANO-BM publication and is defined as the first 
detection of radiologic progression of intracranial (per RANO-BM criteria; Section 11.1), 
extracranial (per RECIST 1.1 criteria; Section 11.2), or both or unequivocal progression of non-
measurable disease in the opinion of the treating physician (an explanation must be provided); 
with each compartment (CNS and non-CNS) assessed separately. 
Key secondary endpoints
Secondary endpoints include extracranial objective response rate (ORR), defined as an 
extracranial complete (CR) or partial (PR) response according to RECIST 1.1, and OS, defined 
as the time from the first dose of atezolizumab to death due to any cause. 
13.2
Sample Size, Accrual Rate and Study Duration
The primary endpoint is bi-compartmental PFS according to RANO-BM criteria. A sample size 
of 45 was chosen to achieve 80 % power to detect a difference between the null hypothesis 
median PFS of 2 months and alternative of 3.5 months at a one-sided type I error of 0.05. 
The null hypothesis was derived from two sources: First, a prospective trial testing the 
combination of irinotecan and iniparib in patients with metastatic triple-negative breast cancer 
and new/progressive brain metastases reported a median time to progression (which included 
both intracranial and extracranial progression) of 2.14 months[Anders et al., 2014]. Next, in a 
retrospective study describing outcomes of breast cancer patients after initial stereotactic 
radiation, time to intracranial progression was significantly shorter in patients with triple-
negative breast cancer, relative to the luminal A subtype (HR 28.0 in multivariable model, 
p=0.003[Dyer et al., 2012]. Although the numbers are small, the point estimate for the time to 
intracranial progression in the triple-negative subset was 2.5 months [Dyer et al., 2012]. 
Anticipated accrual of approximately 2 patients per month, it will require approximately 24 
months of patient accession to reach 45 patients. The primary analysis of PFS and OS will be 

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time-driven and performed after 6 months of additional follow-up.
13.3
Stratification Factors
N/A 
13.4
Interim Monitoring Plan
A safety run-in analysis will be performed after the first 6 patients are enrolled and have 
completed the assessment period for dose-limiting toxicity (DLT). The DLT assessment period 
encompasses the period from first dose of atezolizumab until Cycle 3 Day 1, to allow sufficient 
from stereotactic radiation treatment to assess for DLT. If there are 3 or more dose-limiting 
toxicity (DLTs) in the first 6 patients included, the study will be closed to further enrollment. If 
this occurs, then any plans to re-open the study with a modified treatment plan will need to be 
formally reviewed and approved by the sponsor and by the DF/HCC SRC/IRB prior to 
activation. If there are less than 3 DLT within the first 6 patients enrolled, then the study will 
proceed to full accrual. All patients who receive at least one dose of study drug will be included 
in the efficacy analysis.
Table: Probability of continuing enrollment with <2 DLTs out of 6 subjects. 
Safety run-in using 6 subjects
True DLT rate
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Probability of 
continuing 
enrollment
98%
90%
74%
54%
34%
18%
7%
To assess for potential delayed radiation toxicities, a 6-month safety visit will be performed. 
Patients who stop protocol therapy before the 6 months post stereotactic radiation treatment 
visit will be evaluated by phone by a member of the study team. If at any point during the 
trial the risk of delayed radiation toxicity is deemed to be excessive, the trial will be terminated. 
In addition to the safety run-in in the first 6 patients treated, a continual assessment of 
symptomatic necrosis at 6 months and at 1 year will be conducted, using the method of Ivanova, 
et al (25) that applies Pocock-style boundaries for the maximum-tolerated rates of toxicity. 
Specifically, rates of necrosis at 6 months that are 25% or greater or at 1 year that are 50% or 
greater are considered unacceptable. For each toxicity rule, the upper limit of the probability of 
early stopping, φ, is set at 0.1 and the proportion with maximum-tolerated toxicity, θ, is defined 
as half the unacceptable rate.  The following gives the sequential stopping rules tabulated 
according to the number of events. For instance, if 3 events of symptomatic necrosis at 6 months 
are observed in the first 6 patients enrolled, or if 8 events are observed in the first 30 patients, the 
study would be terminated for excessive toxicity.  

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Boundary for necrosis at 
6 months
3
4
5
6
7
8
9
10
11
Maximum number 
enrolled
≤6
≤10
≤14
≤19
≤25
≤30
≤36
≤41
≤47
Boundary for necrosis at 
1 year
5
6
7
8
9
10
11
12
13
Maximum number 
enrolled
≤8
≤10
≤13
≤16
≤19
≤21
≤24
≤27
≤30
Boundary for necrosis at 
1 year
14
15
16
17
18
19
Maximum number 
enrolled
≤34
≤37
≤40
≤43
≤46
≤47
The probabilities of stopping the trial early for vary true rates of each classification of toxicity 
are presented below:
True rate of 
necrosis
at 6 months
Prob of 
stopping
early, φ
E[N]
True rate of 
necrosis
at 1 year
Prob of 
stopping
early, φ
E[N]
0.125
0.0994
43.91
0.25
0.1000
43.93
0.20
0.4708
34.48
0.30
0.2529
40.06
0.30
0.9169
18.94
0.40
0.7254
27.13
0.40
0.9966
10.40
0.50
0.9692
15.43
0.50
1.0000
6.64
0.60
0.9993
9.32
13.5
Analysis of Primary Endpoint
The primary endpoint is bi-compartmental PFS defined as time from first dose of atezolizumab 
(day 1 cycle 1) to progression or death due to any cause. Progression is defined as the first 
detection of radiologic progression of intracranial (per RANO-BM criteria; Section 11.1), 
extracranial (per RECIST 1.1 criteria; Section 11.2), or both or unequivocal progression of non-
measurable disease in the opinion of the treating physician (an explanation must be provided). 
The PFS will be analyzed using Kaplan–Meier product-limit estimates and will be plotted with 
two-sided 90% confidence bands using Greenwood’s formula for the variance. For evaluating 
median survival, a Brookmeyer-Crowley like test will be conducted using the one-sided alpha = 
0.05. 

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13.6
Analysis of Key Secondary Endpoints
13.6.1 Extracranial Objective Response:
The design of this study, which involves radiation to CNS metastases in the setting of evaluable 
extracranial disease, provides a unique opportunity to test whether there is a signal consistent 
with an abscopal effect with the addition of stereotactic radiation to atezolizumab. Extracranial 
response will be assessed according to RECIST 1.1, and will be evaluated as a key secondary 
objective using a one-sample exact binomial test (one-sided type I error ≤ 0.05). 
In prior studies evaluating immune checkpoint inhibitors in metastatic triple negative breast 
cancer (which excluded patients with active CNS metastases), the extracranial response rate has 
ranged from 8.6% in an unselected population[Dirix et al., 2015] (Dirix et al, 2015), to 18-19% 
in patients selected for tumor PD-L1 expression[Emens et al., 2015, Nanda et al., 2016]. Based 
on these prior studies of single agent PD1/PDL1 blockade in unselected triple negative breast 
cancer, the null hypothesis is that the extra-CNS response rate is 10% or lower. 
With a sample size of 45 defined by the primary endpoint of PFS, there will be 82% power to 
reject the null hypothesis if the true extra-CNS response rate is 25% with stereotactic radiation 
given in combination with atezolizumab.
 
The observed extra-CNS response rate will be reported with a two-sided 90% confidence level 
which given the sample size will have a maximum width of 26%. In addition, we intend to 
evaluate extracranial objective according abscopal response as by Golden et al [Golden et al., 
2015]. 
13.6.2 Overall survival 
Overall survival is defined as the time from first dose of atezolizumab (day 1 cycle 1) to death 
from any cause. Patients who are alive at the end of the study will be censored at the date of last 
known alive. OS will be analyzed using Kaplan–Meier product-limit estimates and will be 
plotted with two-sided 90% confidence bands using Greenwood’s formula for the variance. For 
evaluating median survival, a Brookmeyer-Crowley like test will be conducted using the one-
sided alpha = 0.05. Based on prior studies[Eichler et al., 2008, Lin et al., 2008, Nam et al., 2008, 
Niwinska et al., 2010, Anders et al., 2011], the null hypothesis is that median overall survival is 
5 months or less. 
With a sample size of 45 defined by the primary endpoint of PFS, there will be 90% power to 
reject the null hypothesis if the true median OS is 10 months when patients are given stereotactic 
radiation in combination with atezolizumab. The Approximate Upper Critical Value to the 
hypothesis test is a median OS of 7.4 months, under the assumption of nonparametric 
exponential family of density function for the distribution of failure times.  The following table 
shows the level of power if smaller levels of improvement in survival are true which may be 
clinically relevant.

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Alternative Hypothesis:
Median OS (HR versus null)
Power
10 months (HR = 0.5)
90%
8.33 months (HR = 0.6)
75%
8 months (HR = 0.625)
70%
7.5 months (HR = 0.667)
61%
13.7
Analysis of Exploratory and Correlative Endpoints
Efficacy Endpoints 
Intracranial Objective Response:
There is debate in the field as to the best criteria to use for assessment of response and 
progression in patients with brain metastases and in patients receiving immunotherapy, and this 
study provides an opportunity to evaluate efficacy using multiple published criteria in the setting 
of stereotactic radiation and to compare and contrast these. 
All patients who initiate protocol therapy will be evaluated for CNS response according RECIST 
1.1, RANO-BM and iRANO-BM criteria. 
Lesions treated with stereotactic radiation as part of this protocol will be specifically designated 
in the case report forms. Based on prior literature, the response rate for stereotactic radiation-
treated lesions should be high[Dyer et al., 2012]. 
In this study, stereotactic radiation-treated lesions can be designated as target lesions, as long as 
they are reproducibly measurable, and at least 1 cm in longest dimension. It is anticipated that 
some patients may enter the study with previously treated and stable CNS lesions that are not re-
treated as part of the study. These lesions should generally be designated as non-target lesions for 
the purpose of this study.
Based on a high CNS response rate previously reported with stereotactic radiation alone, we do 
not necessarily anticipate a detectable increase in the response rate when stereotactic radiation is 
given in combination with immune checkpoint therapy. 
  
Clinical benefit:
The proportion of patients with stable or responsive disease in both CNS and non-CNS (each 
compartment assessed separately; CNS by RANO-BM and non-CNS by RECIST 1.1) at 16 and 
24 weeks will be calculated. 
Progression free survival
Historically, PFS has been assessed using RECIST 1.1, which assumes a “single-compartment” 
summation model. Using RECIST 1.1, up to 2 target lesions may be chosen from each organ site, 

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with up to 5 total lesions overall. Although the brain can be included as an organ site in RECIST 
1.1, frequently, investigators have designated brain metastases as non-target lesions. If brain 
metastases are instead designated as target lesions, then using RECIST 1.1 as currently written 
would require that up to 2 lesions in the brain are summed with other target lesions outside of the 
brain, and progression only deemed when the sum of all longest dimensions exceeds 20% of the 
sum of nadir on study, and there is an absolute increase of at least 5 mm in at least one lesion.
RANO-BM proposes a bi-compartmental PFS model, such that the CNS and extracranial 
compartments are evaluated separately, and in this study, bi-compartmental PFS is the primary 
endpoint. However, there are little to no data comparing the RECIST 1.1 single-compartment 
model and RANO-BM bi-compartmental model. 
In addition, the use of immunotherapy further complicates the assessment of progression. Both 
irRC and iRANO allow patients to be treated beyond the first demonstration of radiologic 
progression in order to distinguish between true progression and pseudoprogression. In addition, 
new lesions do not automatically constitute progressive disease. If true progression is 
subsequently documented, the date of progression is backdated to the original demonstration of 
radiographic worsening. 
This study will provide a unique opportunity to compare and contrast:
-PFS according to RECIST 1.1, single compartment model, with first progression 
event deemed an event
-PFS according to RANO-BM, two-compartment model, with first progression event 
deemed an event
-PFS according to irRC, single compartment model
-PFS according to iRANO, two-compartment model
Safety and tolerability 
All patients will be evaluable for toxicity from the time of their first treatment with any study 
agent. Toxicity will be graded according to NCI CTCAE, Version 4.0. Toxicities will be 
summarized by maximum grade.
Radiation Necrosis
Brain metastases treated with stereotactic radiation which enlarge post treatment will be 
evaluated for radiation necrosis by the treating radiation oncologist, via neuroradiology 
assessment, and/or through the use of dual-phase PET-CT studies (Horky et al., 2011), as 
clinically indicated, according to standard of care. The cumulative incidence of necrosis will be 
evaluated as the time from first dose of atezolizumab (day 1 cycle 1) to detected necrosis. 
Patients without detected necrosis will be censored at the end of the study, whether due to death 
or other reason. Cumulative incidence will be analyzed using Kaplan–Meier product-limit 
estimates and will be plotted with two-sided 90% confidence bands using Greenwood’s formula 
for the variance.

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Patient-reported outcomes
The PRO measure for this study will be the scores from the MDASI-BT assessment. 
Neurological examination
In order to standardize the evaluation of key neurological exam components, this study will use 
the Neurological Assessment in Neuro-Oncology (NANO) scale.
Correlative endpoints
Previous studies demonstrated that, in addition to its direct cytoreductive effect, RT-induced cell 
death can be immunogenic, facilitating the recruitment and activation of antigen presenting cells 
(APCs) and priming of tumor antigen-specific T-cells[Shahabi et al., 2015]. Recently, different 
groups demonstrated that RT to the tumor bed led to upregulation of PD-L1 on tumor cells, 
dendritic cells, and on myeloid-derived suppressive cells (MDSCs), which may contribute to 
impairment of T-cell function in the tumor[Liang et al., 2013, Deng et al., 2014, Sharabi et al., 
2014]. Furthermore, these groups also demonstrated that the combination of RT plus blockade of 
the PD-1/PD-L1 axis improved outcomes in different preclinical models compared with RT or 
anti-PD1/PD-L1 alone, including breast cancer models. 
Recently, Herbst et al have demonstrated that patients who presented an increase of at least 5% 
in expression of PD-L1 in tumor microenvironment experienced a bigger likelihood to respond 
to treatment with the anti-PD-L1 Atezolizumab[Herbst et al., 2014]. Also, modifications in 
molecular signature of tumor microenvironment also correlated with response rate to this drug. 
Because of this rationale, we plan to perform two research tumor biopsies: one at baseline and 
the other one just before the begging of cycle 3 of atezolizumab. Biopsies will be performed in 
the case of accessible extracranial disease (which will be outside of the field of radiation). 
With a sample size of 45 and assuming that there will be patients without accessible lesions, the 
table below indicates the power available to detect 20%, 30%, or 40% increases of PD-L1 
positivity rate. The power calculation is based on McNemar’s test with 1-sided alpha of 0.05 and 
assuming 2% of patients unexpectedly show PD-L1 positivity only in the baseline assessment,
 
Increase of PD-L1 positivity 
rate at C3D1
# of paired biopsies (baseline 
and at cycle 3)
Power
20%
20
64%
30
79%
40
88%
30%
20
85%
30
95%
40
98%
40%
20
96%
30
99%
40
99%

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PD-L1 positivity seen at baseline and C3D1 samples will be summarized using contingency 
tables. An exploratory analysis is planned to evaluate PD-L1 change in continuous scale.
To explore the relationship between correlative endpoints obtained from cerebrospinal fluid 
(CSF) to genetic alterations detected in the tumor and plasma, patient and disease characteristics, 
and clinical outcomes, the following analyses are planned: cell-free DNA (cfDNA) from serial 
CSF samples will be quantified using ultra-low pass whole genome sequencing, evaluated as 
both a continuous factor, and using the pre-defined threshold of TFx > 10% as a dichotomous 
variable; whole exome sequencing (WES) will be performed to determine copy number and 
mutation calls. 
For paired assessments of WES of tumoral DNA and CSF at baseline and at time of progression, 
concordance will be assessed as the proportion of overall agreement using bootstrapped standard 
error estimates and confidence intervals, and kappa statistics to assess non-zero agreement. The 
following table shows the true Cohen’s Kappa statistic there will be 80% power to detect given 
the prevalence of the phenotype, number of paired samples, and using a two-sided alpha = 0.05 
Prevalence of 
# of paired samples (tumor 
and CSF)
True 
Cohen’s 
kappa
20%
20
0.63
30
0.53
40
0.46
30%
20
0.61
30
0.51
40
0.44
40%
20
0.60
30
0.50
40
0.43
The association of baseline CSF assessments to PFS and OS will be explored using Kaplan-
Meier estimation and Cox proportional hazard models, and the association to ORR and CBR will 
be assessed using logistic models. Serial assessments will be characterized using descriptive 
statistics, and the association to clinical outcome will be modeled as post-baseline time-varying 
covariates (PFS and OS) and longitudinal mixed effects models (ORR and CBR). All analyses 
will be exploratory and hypothesis generating and point estimates will be reported with 95% 
confidence intervals.  
13.8
Reporting and Exclusions
13.8.1 Evaluation of Efficacy
For this Phase II trial, the efficacy evaluable population is a modified intent-to-treat (ITT) 
population. The modified ITT population consists of all patients who initiate protocol 
therapy, even if there are major protocol therapy deviations. 
Subanalyses may then be performed on the basis of a subset of participants, excluding 

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those for whom major protocol deviations have been identified (e.g., early death due to 
other reasons, early discontinuation of treatment, major protocol violations, etc.). 
However, these subanalyses may not serve as the basis for drawing conclusions 
concerning treatment efficacy, and the reasons for excluding participants from the 
analysis should be clearly reported. If applicable to the endpoint, the 95% confidence 
intervals should also be provided. 
13.8.2 Evaluation of Safety
The safety population will be used in the safety data summaries. The safety population 
consists of all patients who took at least one dose of any randomized treatment and who 
have at least one post-baseline safety assessment. Note that a patient who had no adverse 
events constitutes a safety assessment. Patients who have received at least one dose of 
study drug but have no post-treatment safety data of any kind would be excluded. 
14. PUBLICATION PLAN
The results should be made public within 24 months of reaching the end of the study. The end of 
the study is the time point at which the last data items are to be reported, or after the outcome 
data are sufficiently mature for analysis, as defined in the section on Sample Size, Accrual Rate 
and Study Duration. If a report is planned to be published in a peer-reviewed journal, then that 
initial release may be an abstract that meets the requirements of the International Committee of 
Medical Journal Editors. A full report of the outcomes should be made public no later than three 
(3) years after the end of the study. 

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Engl J Med: 

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APPENDIX A
PERFORMANCE STATUS CRITERIA
ECOG Performance Status Scale
Karnofsky Performance Scale
Grade
Descriptions
Percent
Description
100
Normal, no complaints, no evidence 
of disease.
0
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction.
90
Able to carry on normal activity; 
minor signs or symptoms of disease.
80
Normal activity with effort; some 
signs or symptoms of disease.
1
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work).
70
Cares for self, unable to carry on 
normal activity or to do active work.
60
Requires occasional assistance, but 
is able to care for most of his/her 
needs.
2
In bed <50% of the time. 
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities. Up and about 
more than 50% of waking hours.
50
Requires considerable assistance and 
frequent medical care.
40
Disabled, requires special care and 
assistance.
3
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours.
30
Severely disabled, hospitalization 
indicated. Death not imminent.
20
Very sick, hospitalization indicated. 
Death not imminent.
4
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair.
10
Moribund, fatal processes 
progressing rapidly.
5
Dead.
0
Dead.

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APPENDIX B
ANAPHYLAXIS PRECAUTIONS
EQUIPMENT NEEDED

Tourniquet

Oxygen

Epinephrine for subcutaneous, intravenous, and/or endotracheal use in accordance with 
standard practice 

Antihistamines

Corticosteroids

Intravenous infusion solutions, tubing, catheters, and tape
PROCEDURES
In the event of a suspected anaphylactic reaction during study drug infusion, the following 
procedures should be performed:
1.
Stop the study drug infusion.
2.
Apply a tourniquet proximal to the injection site to slow systemic absorption of study drug. 
Do not obstruct arterial flow in the limb.
3.
Maintain an adequate airway.
4.
Administer antihistamines, epinephrine, or other medications as required by patient status 
and directed by the physician in charge.
5.
Continue to observe the patient and document observation.

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APPENDIX C     M.D. ANDERSON SYMPTOM INVENTORY-BRAIN TUMOR 
(MDASI-BT)
The MDASI-BT consists of 28 items and is a multi-symptom measure of cancer-related 
symptoms that are sensitive to disease and treatment changes. The MDASI-BT is composed of 
the symptom severity scale and the symptom interference scale. In the symptom severity scale, 
patients rate the severity of their symptoms in the last 24 hours on 0 −10 numeric scales, ranging 
from “not present” to “as bad as you can imagine.” In the symptom interference scale, patients 
rate interference with daily activities caused by their symptoms on 0 −10 numeric scales ranging 
from “did not interfere” to “interfered completely.” This instrument is brief, takes less than five 
minutes to complete, is easily understood and validated in the cancer population [Armstrong et 
al., 2006].
The English and Spanish versions of the MDASI-BT are below.

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NANO response criteria:
Definition of Neurologic Response: An overall NANO score will be determined following 
assessment of each domain and will include one of five possible outcomes: neurologic response; 
neurologic progression; neurologic stability; not assessed; and non-evaluable. 
Neurologic response: ≥ 2 level improvement in at least 1 domain without worsening in other 
domains from baseline or best level of function.
Neurologic progression: 1) ≥ 2 level worsening from baseline or best level of function within ≥ 1 
domain; or 2) worsening to the highest score within ≥ 1 domain. 
Neurologic stability: a score of neurologic function that does not meet criteria for neurologic 
response, neurologic progression, non-evaluable or not assessed. 
Non-evaluable (NE): if it is more likely than not that a factor other than underlying tumor 
activity contributed to an observed change in neurologic function. Such factors may include 
changes in concurrent medications or a co-morbid event. 
Not assessed (NA): if the clinician omits evaluation of that particular domain during their 
examination. If a particular domain is marked NA at baseline, then that domain cannot be 
considered for progression or response. 
In general, the assessment and scoring of all domains is encouraged.

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APPENDIX E EQ-5D ENGLIGH QUESTIONARIE 
Health Questionnaire
English version for the USA

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Under each heading, please check the ONE box that best describes your health TODAY.
MOBILITY
I have no problems walking

I have slight problems walking

I have moderate problems walking

I have severe problems walking

I am unable to walk

SELF-CARE
I have no problems washing or dressing myself

I have slight problems washing or dressing myself

I have moderate problems washing or dressing myself

I have severe problems washing or dressing myself

I am unable to wash or dress myself

USUAL ACTIVITIES (e.g. work, study, housework, family or 
leisure activities)
I have no problems doing my usual activities

I have slight problems doing my usual activities

I have moderate problems doing my usual activities

I have severe problems doing my usual activities

I am unable to do my usual activities

PAIN / DISCOMFORT
I have no pain or discomfort

I have slight pain or discomfort

I have moderate pain or discomfort

I have severe pain or discomfort

I have extreme pain or discomfort


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ANXIETY / DEPRESSION
I am not anxious or depressed

I am slightly anxious or depressed

I am moderately anxious or depressed

I am severely anxious or depressed

I am extremely anxious or depressed


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The worst health 
you can imagine
We would like to know how good or bad your health is TODAY.
This scale is numbered from 0 to 100.
100 means the best health you can imagine.
0 means the worst health you can imagine.
Mark an X on the scale to indicate how your health is TODAY.
Now, please write the number you marked on the scale in the box below.
 
The best health you 
can imagine
YOUR HEALTH TODAY =
10
0
20
30
40
50
60
80
70
90
100
5
15
25
35
45
55
75
65
85
95

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APPENDIX F EQ-5D SPANISH QUESTIONNAIRE
Cuestionario de Salud
Versión en español para los EE. UU.
(Spanish version for the USA)

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Debajo de cada encabezamiento, marque UNA casilla, la que mejor describe su 
salud HOY.
MOVILIDAD
No tengo problemas para caminar

Tengo problemas leves para caminar

Tengo problemas moderados para caminar

Tengo problemas graves para caminar

No puedo caminar

CUIDADO PERSONAL
No tengo problemas para lavarme o vestirme solo/a

Tengo problemas leves para lavarme o vestirme solo/a

Tengo problemas moderados para lavarme o vestirme solo/a

Tengo problemas graves para lavarme o vestirme solo/a

No puedo lavarme o vestirme solo/a

ACTIVIDADES DE TODOS LOS DÍAS (Ej.: trabajar, estudiar, hacer las 
tareas domésticas, actividades familiares o actividades de ocio)
No tengo problemas para realizar mis actividades de todos los días

Tengo problemas leves para realizar mis actividades de todos los días

Tengo problemas moderados para realizar mis actividades de todos los días

Tengo problemas graves para realizar mis actividades de todos los días

No puedo realizar mis actividades de todos los días

DOLOR / MALESTAR
No tengo dolor ni malestar

Tengo dolor o malestar leve

Tengo dolor o malestar moderado

Tengo dolor o malestar intenso

Tengo dolor o malestar extremo


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ANSIEDAD / DEPRESIÓN
No estoy ansioso/a ni deprimido/a

Estoy levemente ansioso/a o deprimido/a

Estoy moderadamente ansioso/a o deprimido/a

Estoy muy ansioso/a o deprimido/a

Estoy extremadamente ansioso/a o deprimido/a


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La peor salud que 
se pueda imaginar
 
Nos gustaría saber lo buena o mala que es su salud HOY.
La escala está numerada de 0 a 100.
100 representa la mejor salud que se pueda imaginar.
0 representa la peor salud que se pueda imaginar.
Por favor haga una X en la escala para indicar cuál es su estado 
de salud HOY.
Ahora, por favor escriba en la casilla que encontrará a 
continuación el número que ha marcado en la escala.
La mejor salud que 
se pueda imaginar
SU SALUD HOY =
10
0
20
30
40
50
60
80
70
90
100
5
15
25
35
45
55
75
65
85
95

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APPENDIX G: GENERAL IMPRESSION WORKSHEET
(to be completed at baseline and at the end of each 3-week cycle)
Patient_____________________Examiner______________________Date_________
In the opinion of the treating physician, overall, has the patient had clinical 
deterioration since baseline?
(   ) YES
(   ) NO
In the opinion of the treating physician, overall, has the patient had clinical 
deterioration since his/her last visit
(   ) YES
(   ) NO
Is the patient currently taking corticosteroids?
(   ) YES
(   ) NO
If yes, please list name of medication and dose (e.g. decadron, 4 mg QD): 
__________________________________________________________
Please indicate the patient’s ECOG or Karnofsky Performance Status 
(see Appendix A for definitions): ________

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APPENDIX H
GUIDELINES FOR COLLECTING RESEARCH BIOPSY TISSUE 
Tissue specimens will be collected from metastatic lesions using standard institutional 
procedures. The amount of tissue collected may follow the guidelines listed below:
Skin/chest wall: Because the yield of malignant tissue from skin/chest wall biopsies tends to be 
relatively low, if a patient has another accessible site of disease (i.e. lymph node, liver), that site 
should be biopsied preferentially. If skin/chest wall is the only biopsy-accessible site, then a goal 
of 2 5-mm punch biopsies will be obtained. 
Lymph node: A goal of 5-7 core biopsy specimens will be obtained using an 18-gauge needle.
Liver: A goal of 5-7 core biopsy specimens will be obtained using an 18-gauge needle.
Lung: Because of the risk of pneumothorax associated with core needle biopsies of lung nodules,
no core biopsies of lung nodules are mandated on this protocol, unless they are clinically
indicated.
Bone: Because the yield of malignant tissue from bone biopsies tends to be relatively low, if a
patient has another accessible site of disease (i.e. lymph node, liver), that site should be
biopsied preferentially. If bone is the only biopsy-accessible site, then a goal of 5-7 core biopsy
specimens will be obtained using an 11-13 gauge needle.
Please note that the above are guidelines for the amount of tissue to be obtained, and are
not meant to replace clinical judgment at the time the procedure is performed. Less than the
goal quantity of tissue is accepted for each type of biopsy, and will be left to the clinical
judgment of the physician performing the procedure.
Coded laboratory specimens will be stored in the Tumor Bank of the DFCI. These specimens 
will become the property of DFCI. Patients will be informed that their specimens may be used 
for research by investigators at DF/HCC and other approved collaborators. Shared specimens 
will be identified with a sample ID number; all patient identifying material will be removed.
Risks of Research Biopsy and Procedures for Minimizing Risk
Potential risks according to site are:
Skin/chest wall (punch biopsy):

Likely: local discomfort and minor bleeding

Less likely: moderate or major bleeding, or infection
Lymph node, liver, or bone (core needle biopsy):

Likely: local discomfort and minor bleeding

Less likely: moderate or major bleeding, need for blood transfusion, hospitalization 
due
to bleeding or other complications, infection, damage to adjacent organs. Additional risks may be 

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present if intravenous conscious sedation is required
Breast (core biopsy):

Likely: local discomfort and minor bleeding.

Less likely: moderate or major bleeding, need for blood transfusion, hospitalization 
due 
to bleeding or other complications, infection, pneumothorax, damage to adjacent organs.
Pleural fluid (thoracentesis):

Likely: local discomfort and minor bleeding

Less likely: moderate or major bleeding, need for blood transfusion, hospitalization 
due to bleeding or other complications, infection, pneumothorax, damage to adjacent 
organs
Ascites fluid (paracentesis):

Likely: local discomfort and minor bleeding

Less likely: moderate or major bleeding, need for blood transfusion, hospitalization 
due to bleeding or other complications, infection, bowel perforation or damage to 
adjacent organs. In order to minimize the risk of a biopsy, only qualified personnel 
will perform these procedures. 
Prior to the procedure, the physician performing the procedure will discuss the risks with each 
study participant, answer any questions, and obtain separate procedure consent. Patients will be 
evaluated for comorbidities or concomitant medications that may increase the risk of potential 
complications. For biopsies of lesions that are not superficial and clearly palpable, imaging 
studies such as CT or ultrasound will be used to guide the biopsy in order to minimize the risk of 
damage to adjacent structures. After lymph node biopsies, patients will be observed after the 
procedure, or according to standard institutional guidelines. After liver biopsies, patients will be 
observed a minimum of 4 hours (range 4-6 hours) after the procedure, or according to standard 
institutional guidelines. Less than the goal quantity of tissue is accepted for each type of biopsy, 
and will be left to the clinical judgment of the physician performing the procedure.
Risks of Anesthesia
Local Anesthesia
All biopsy procedures require local anesthesia using lidocaine, xylocaine, or related
compounds. There is a small risk of an allergic reaction associated with these drugs.
In order to minimize the risk of local anesthesia, only qualified personnel will perform
the biopsy procedure. Patients will be queried if they have had previous allergic
reactions to local anesthetics.
Intravenous Conscious Sedation
Certain biopsy procedures, such as lymph node, liver, or bone biopsies, may require
intravenous conscious sedation (IVCS). IVCS is a minimally depressed level of consciousness 
that retains the patient’s ability to maintain a patent airway independently and continuously and 

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respond appropriately to physical stimulation and verbal commands.
The risks of intravenous conscious sedation include: inhibition of the gag reflex and concomitant 
risk of aspiration, cardiopulmonary complications (myocardial infarction, cardiac arrhythmias, 
hypoxemia), and allergic reactions to the sedative or analgesic medications. These risks are small 
but real; for example, in a prospective study of 14,149 patients undergoing IVCS during upper 
gastrointestinal endoscopies, the rate of immediate cardiopulmonary events was 2 in 
1000.[Quine et al., 1995] The 30-day mortality was 1 per 2,000 cases. In this study, there was a 
strong association between lack of monitoring and use of high-dose benzodiazepines with 
adverse outcomes. There was also an association between the use of local anesthetic sprays to the 
oropharynx and the development of pneumonia. In order to minimize the risk of intravenous 
conscious sedation, only qualified personnel will be responsible for conscious sedation. A 
minimum of two individuals will be involved in the care of patients undergoing conscious 
sedation—the physician performing the biopsy procedure, and the individual (M.D. or R.N.) who 
monitors the patients and his/her response to both the sedation and the procedure, and who is 
capable of assisting with any supportive or resuscitative measures. The room where the 
procedure utilizing IVCS takes place will have adequate equipment to provide supplemental 
oxygen, monitor vital signs, and maintain an airway should this be necessary. An emergency cart 
will also be immediately accessible to the room where the procedure is to take place, and 
emergency support services will be available on page. Patients will be screened and evaluated for 
their fitness to undergo conscious sedation by a trained physician. Patients with active cardiac 
disease are excluded from this study. No local anesthetic spray to the oropharynx will be 
necessary, given that endoscopy is not a planned procedure. Following the procedure, patients 
will be observed closely in the recovery room for a minimum of 2 hours.
General Anesthesia
Because of the higher risk of general anesthesia compared with local anesthesia or intravenous 
conscious sedation, biopsies that would require general anesthesia in order to be performed are 
not permitted on this protocol.

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For Effusions and Ascites
1. Fluid sample should be split into two equal aliquots
2. One aliquot should be spun down into a pellet and snap frozen in an ETOH/dry ice bath
or in liquid N2
3. One aliquot should be fixed and processed as a standard cell block.
Note: if the sample preparation is done by a clinical cytopathology laboratory, it is important to
explain that the sample is for research purposes only and that no thin prep should be performed
as this uses up a significant portion of the sample.
For Fine Needle Aspiration Samples
A goal of 3 passes:
1. One pass should be evacuated and rinsed directly into 2mL of room temperature Trizol for
RNA analysis.
2. One pass should be evacuated and rinsed directly into 2mL of room temperature Trizol for
DNA analysis.
3. One pass should be evacuated and rinsed directly into 10-20mL of RPMI to prepare a cell
block.