A Phase II Study of Atezolizumab in Combination With Pertuzumab Plus High-dose Trastuzumab for the Treatment of Central Nervous System Metastases in Patients With Her2-positive Breast Cancer
Phase: PHASE2
Conditions: HER2-positive Metastatic Breast Cancer, Central Nervous System Metastases
Sponsor: Nancy Lin, MD

 
DF/HCC Protocol #: 17-546 
Protocol Version Date: 1/21/2020 
 
 
 DF/HCC Protocol #: 
17-546 
 
 
TITLE:   A phase II study of atezolizumab in combination with pertuzumab plus high-dose 
trastuzumab for the treatment of central nervous system metastases in patients with Her2-
positive breast cancer 
 
 
Coordinating Center: 
 
 
Dana-Farber Cancer Institute 
 
Principal Investigator (PI): 
Nancy U. Lin, MD 
 
Dana-Farber Cancer Institute  
 
450 Brookline Avenue  
 
Boston, MA 02215  
 
 
nlin@partners.org  
Statisticians: 
 
 
Lorenzo Trippa, PhD 
Dana-Farber Cancer Institute  
450 Brookline Ave., CLS 11007 
Boston, MA 02215 
Tel: 617-582-9133 
Email: Lorenzo_trippa@dfci.harvard.edu   
 
Project Manager: 
Dana-Farber Cancer Institute  
450 Brookline Ave. 
Boston, MA 02215 
Tel: 617-632-5313 
Fax: 617-632-5152 
Email: ctopm@dfci.harvard.edu  
 
IND #:  137053 
IND Sponsor:  Nancy Lin, MD  
Agent(s): Atezolizumab, Trastuzumab and Pertuzumab, supplied by Genentech 
 
 
 
Protocol Type / Version # / Version Date: Amendment / Version 4 / January 21, 2020  
 
 

 
DF/HCC Protocol #: 17-546 
Protocol Version Date: 1/21/2020 
 
 
 
SCHEMA 
 
 N= 33 
 1 cycle = 21 days 
 
 
 
 
 
 
 
                                         
                                              
 
 
 
          
 
               Induction Phase (24 weeks) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility 
• HER2+ 
Metastatic Breast 
Cancer 
• At least 1 
measurable CNS 
Lesion  ≥ 10mm 
 
 
Atezolizumab (q3w) 
+ Pertuzumab (q3w) 
+ Trastuzumab 
(q3w)   
CNS Progression 
 Survival follow-
up q6months 
Off Treatment  
for reasons other 
than PD 
Atezolizumab (q3w) + 
Pertuzumab (q3w) + 
Trastuzumab (weekly)   
Follow for CNS 
progression, then 
survival follow-up 
q6 months 
Off-Tx: 
Optional 
biopsy 
Cycle 2: 
Optional 
biopsy 
Optional 
Biopsy 
CSF 
Collection 
Cycle 2 CSF 
Collection 
CSF 
Collection 
 
Continue  
Treatment 
 
CR, PR, SD 
 
R
E
G
I
S
T
R
A
T
I
O
N 
 
 
 

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TABLE OF CONTENTS 
 
 
SCHEMA .........................................................................................................................................1 
1. 
OBJECTIVES ......................................................................................................................4 
1.1 
Study Design ............................................................................................................4 
1.2 
Primary Objective ....................................................................................................4 
1.3 
Secondary Objectives...............................................................................................4 
1.4 
Correlative Objectives .............................................................................................5 
2. 
BACKGROUND .................................................................................................................6 
2.1 
Study Disease ...........................................................................................................6 
2.2 
The PD-1/PD-L1 pathway in cancer ........................................................................6 
2.3 
Atezolizumab (MPDL3280A) .................................................................................7 
2.4 
Pertuzumab ............................................................................................................12 
2.5 
Trastuzumab ...........................................................................................................13 
2.6 
Rationale ................................................................................................................14 
2.7 
Correlative Studies Background ............................................................................16 
3. 
PARTICIPANT SELECTION ...........................................................................................19 
3.1 
Eligibility Criteria ..................................................................................................19 
• 
IHC 3+ based on circumferential membrane staining that is 
complete, intense........................................................................................19 
-AND/OR-..............................................................................................................19 
• 
FISH positive based on one of the three following criteria: ......................19 
o 
Single-probe average HER2 copy number ≥6.0 signals/cell; OR .............19 
o 
Dual-probe HER2/CEP17 ratio ≥2.0 OR ..................................................19 
o 
Dual-probe HER2/CEP17 ratio <2.0 with an average HER2 copy 
number≥6.0 signals/cell .............................................................................19 
3.2 
Exclusion Criteria ..................................................................................................20 
3.3 
Inclusion of Women and Minorities ......................................................................22 
4. 
REGISTRATION PROCEDURES ...................................................................................22 
4.1 
General Guidelines for DF/HCC Institutions ........................................................22 
4.2 
Registration Process for DF/HCC Institutions .......................................................22 
4.3 
General Guidelines for Other Investigative Sites ..................................................22 
4.4 
Registration Process for Other Investigative Sites.................................................22 
5. 
TREATMENT PLAN ........................................................................................................23 
5.1 
Treatment Regimen ................................................................................................23 
5.2 
Pre-Treatment Criteria ...........................................................................................24 
5.3 
Agent Administration.............................................................................................24 
5.4 
Definition of Dose-Limiting Toxicity ....................................................................25 

 
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5.5 
General Concomitant Medication and Supportive Care Guidelines ......................26 
5.6 
Criteria for Taking a Participant Off Protocol Therapy .........................................27 
5.7 
Duration of Follow Up ...........................................................................................29 
5.8 
Criteria for Taking a Participant Off Study ...........................................................29 
6. 
DOSING DELAYS/DOSE MODIFICATIONS ...............................................................29 
6.1 
Management of toxicities attributable to atezolizumab .........................................30 
6.2 
Management of toxicities attributable to pertuzumab and/or trastuzumab ............44 
7. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................46 
7.1 
Adverse Events Lists..............................................................................................46 
7.2 
Adverse Event Characteristics ...............................................................................47 
7.3 
DF/HCC Expedited Adverse Event Reporting ......................................................48 
7.4 
Expedited Reporting to the Food and Drug Administration (FDA) ......................48 
7.5 
Expedited Reporting to Genentech ........................................................................49 
7.6 
Additional Reporting Requirements for Genentech ..............................................50 
7.7 
Expedited Reporting to Hospital Risk Management .............................................52 
7.8 
Routine Adverse Event Reporting .........................................................................52 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................52 
8.1 
Atezolizumab .........................................................................................................52 
8.2 
Pertuzumab ............................................................................................................54 
8.3 
Trastuzumab ...........................................................................................................56 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................58 
9.1 
Archival Tissue Collection ....................................................................................59 
9.2 
Fresh Tissue Collection..........................................................................................59 
9.3 
Blood Collection ....................................................................................................62 
9.4 
Cerebrospinal fluid (CSF) ......................................................................................65 
9.5 
Planned Assays for Correlative Objectives ............................................................66 
9.6 
Additional analysis.................................................................................................68 
10. 
STUDY CALENDAR .......................................................................................................68 
11. 
MEASUREMENT OF EFFECT........................................................................................72 
11.1 
Antitumor Effect – CNS disease ............................................................................72 
11.2 
Antitumor Effect – non-CNS disease ....................................................................76 
11.3 
Other Response Parameters ...................................................................................83 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS ...........................................88 
12.1 
Data Reporting .......................................................................................................88 
12.2 
Data Safety Monitoring..........................................................................................88 
12.3 
Multicenter Guidelines...........................................................................................89 
12.4 
Collaborative Research and Future Use of Samples ..............................................89 
13. 
STATISTICAL CONSIDERATIONS...............................................................................90 
13.1 
Study Design/Endpoints.........................................................................................90 

 
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13.2 
Sample Size, Accrual Rate and Study Duration ....................................................91 
13.3 
Interim Monitoring Plan ........................................................................................92 
13.4 
Analysis of Primary Endpoint ................................................................................92 
13.5 
Analysis of Secondary Endpoints ..........................................................................92 
13.6 
Reporting and Exclusions ......................................................................................94 
14. 
PUBLICATION PLAN .....................................................................................................95 
REFERENCES ..............................................................................................................................96 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ................................................103 
APPENDIX B 
ANAPHYLAXIS PRECAUTIONS.........................................................104 
APPENDIX C 
M.D. ANDERSON SYMPTOM INVENTORY-BRAIN TUMOR 
(MDASI-BT) 105 
APPENDIX D 
NEUROLOGICAL ASSESSMENT IN NEURO-ONCOLOGY (NANO) 
SCALE 
110 
APPENDIX E 
EQ-5D ENGLISH QUESTIONNARIE ...................................................113 
APPENDIX F 
EQ-5D SPANISH QUESTIONNAIRE ...................................................117 
APPENDIX G SPECIMEN REQUISITION FORM ..................................................................121 
APPENDIX H ASYMPTOMATIC DECLINE IN LVEF...........................................................122 
APPENDIX I 
NEW YORK HEART ASSOCIATION CLASSIFICATION OF 
FUNCTIONAL CARDIAC CAPACITY ........................................................................123 
APPENDIX J 
LEFT VENTRICULAR SYSTOLIC DYSFUNCTION GRADING ......124 
APPENDIX K 
REPORTING CONVENTIONS FOR LEFT VENTICULAR SYSTOLIC 
DYSFUNCTION/HEART FAILURE .............................................................................125 
APPENDIX L: 
GENERAL IMPRESSION WORKSHEET ............................................126 
APPENDIX M 
GUIDELINES FOR COLLECTIING RESEARCH BIOPSY TISSUE ..127 
APPENDIX N 
GENENTECH SAFETY REPORTING FAX COVERSHEET ..............131 
APPENDIX O 
DF/HCC MULTI-CENTER DATA AND SAFETY MONITORING 
PLAN 
132 
 
 
 
 

 
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1. OBJECTIVES 
 
1.1 
Study Design 
 
This is an open-label, multi-center, phase II study designed to evaluate the efficacy of the 
combination of atezolizumab with pertuzumab plus with high-dose trastuzumab for the 
treatment of central nervous system (CNS) metastases in patients with HER2-positive 
metastatic breast cancer (MBC), as measured by objective response rate (ORR) in the CNS.  
 
Up to 33 eligible patients will receive the following treatment: atezolizumab [1200mg 
intravenously (IV) every 3 weeks (q3w)], pertuzumab (loading dose of 840 mg IV, 
followed q3w thereafter by a dose of 420 mg IV), and high-dose trastuzumab (at a dose of 
6 mg/kg weekly for the first 24 weeks, and thereafter trastuzumab 6mg/Kg IV q3w). 
 
1.2 
Primary Objective 
 
To evaluate the efficacy of atezolizumab in combination with pertuzumab and high-dose 
trastuzumab for the treatment of CNS metastases in patients with HER2-positive MBC, as 
measured by ORR in the CNS according to response assessment in neuro-oncology-brain 
metastases (RANO-BM) criteria. 
 
1.3 
Secondary Objectives 
 
1.3.1 Safety Objective 
 
• To evaluate the safety, and tolerability of the combination of atezolizumab, 
pertuzumab and high-dose trastuzumab. 
 
1.3.2 Efficacy Objectives 
 
• To evaluate the duration of response (DOR) in the CNS 
• To evaluate the efficacy of the study combination, as defined by bi-compartmental 
progression-free survival (PFS) according to RANO-BM criteria [Lin et al., 2015] 
(Section 11.1.1). 
• To evaluate the CNS response rates according to response assessment in immunotherapy 
neuro-oncology-brain metastases (iRANO-BM) criteria [Okada et al., 2015]. 
• To evaluate the extracranial ORR according RECIST 1.1 criteria[Eisenhauer et al., 
2009]. 
• To evaluate the extracranial ORR according to immune-related response criteria 
(irRC)[Wolchok et al., 2009]. 
• To evaluate clinical benefit rate at 18 and 24 weeks, defined as the proportion of 
participants with stable or responsive disease in both CNS and non-CNS at 18 and 24   
weeks per RANO-BM criteria. 
• To evaluate PFS according to the RECIST 1.1 single-compartmental model. 
• To describe the site of first progression (CNS vs extracranial vs both)  

 
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• To evaluate the overall survival (OS) among patients included in this trial 
 
1.3.3 Patient-Reported Outcome Objectives 
• To evaluate the impact of the experimental treatment on PROs, as measured by the 
M.D. Anderson Symptom Inventory-Brain Tumor (MDASI-BT) assessment 
1.3.4 Investigator-Assessed Neurological Evaluation 
• To evaluate the impact of the study treatment, for these same patients, on investigator-
assessed neurological evaluation, as measured by the Neurological Assessment in 
Neuro-Oncology (NANO) scale. 
1.3.5 EQ-5D evaluation 
• To evaluate the impact of the study treatment, for these same patients, on general 
health status assessed by EQ-5D questionnarie.   
  
1.4 
Correlative Objectives 
• To explore whether the number and/or type of mutations identified using a next generation 
sequencing (NGS) panel is correlated with patient outcomes (PFS, CNS ORR, CBR, and 
OS). 
• 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, CNS ORR, CBR, and OS). 
• 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. 
• To characterize a broad array of immune markers in metastatic HER-2 positive breast 
cancer (characterization will be based on histology, protein expression, and mRNA 
expression), and their changes with immune checkpoint blockade.  
• To explore how different immunosuppressive and/or immune-stimulating immune marker 
profiles at baseline correlate with patient outcomes (PFS, CNS ORR, CBR and OS). 
• To characterize changes in immune marker profiles on treatment and at time of progression 
• To characterize serial changes in immune marker profile in peripheral blood mononuclear 
cells (PBMCs) and in plasma over the course of the trial treatment. 
• To explore whether induction of changes in the immunosuppressive and/or immune-
stimulating immune marker profile in PBMC correlates with clinical outcomes (PFS, CNS 
ORR, and OS). 
• 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.   
• To explore whether cfDNA load in CSF is associated with clinical outcomes (PFS, CNS 
ORR, CRR, and OS). 
• 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 
 
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%-20% overexpress 
human epidermal growth factor receptor 2 (HER2) and are classified as HER2 positive tumors 
[Slamon et al., 1987, Pathmanathan et al., 2012, Wolff et al., 2013]. Together with triple negative 
breast cancer (TNBC), HER-2 positive tumors have the highest rates of brain metastases (BM), 
with studies reporting up to 50% rate of central nervous system (CNS) involvement among those 
subtypes[Lin et al., 2008, Niwinska et al., 2010, Lin et al., 2012, Olson et al., 2013, Pestalozzi et 
al., 2013].  
 
Initial treatment for patients with BM typically includes surgery or radiotherapy, either whole brain 
radiotherapy (WBRT), sterotactic radiosurgery (SRS), or both, depending on factors such as 
performance status, expected prognosis, as well the localization and the number of CNS 
metastases[Lim et al., 2014]. Although median OS after a diagnosis of brain metastasis now 
exceeds 2 years in patients with good performance status and HER2-positive disease[Sperduto et 
al., 2012], this outcome has resulted in patients who live long enough to have substantial morbidity 
from additional CNS progression post-radiation. At this time point, there are currently no systemic 
therapies approved for use in the treatment of these patients. Clearly, better options for the 
prevention and treatment of brain metastases in patients with HER2-positive breast cancer are 
needed. 
 
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 

 
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an immunoreceptor tyrosine-based switch motif (ITSM).  Following T-cell stimulation, PD-1 
recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif within its cytoplasmic 
tail, leading to the dephosphorylation of effector molecules such as CD3ζ, PKCθ and ZAP70 
which are involved in the CD3 T-cell signaling cascade.  The mechanism by which PD-1 down 
modulates T-cell responses is similar to, but distinct from that of CTLA-4 as both molecules 
regulate an overlapping set of signaling proteins.  PD-1 was shown to be expressed on activated 
lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer 
cells.  Expression has also been shown during thymic development on CD4-CD8- (double 
negative) T-cells as well as subsets of macrophages and dendritic cells.  The ligands for PD-1 
(PD-L1 and PD-L2) are constitutively expressed or can be induced in a variety of cell types, 
including non-hematopoietic tissues as well as in various tumors.  Both ligands are type I 
transmembrane receptors containing both IgV- and IgC-like domains in the extracellular region 
and contain short cytoplasmic regions with no known signaling motifs.  Binding of either PD-1 
ligand to PD-1 inhibits T-cell activation triggered through the T-cell receptor.  PD-L1 is 
expressed at low levels on various non-hematopoietic tissues, most notably on vascular 
endothelium, whereas PD-L2 protein is only detectably expressed on antigen-presenting cells 
found in lymphoid tissue or chronic inflammatory environments.  PD-L2 is thought to control 
immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen unwarranted T-
cell function in peripheral tissues.  Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor.  PD-1 
has been suggested to regulate tumor-specific T-cell expansion in subjects with melanoma 
(MEL).  This suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune 
evasion and should be considered as an attractive target for therapeutic intervention[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 

 
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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 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 with Atezolizumab 
 
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 

 
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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 
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.  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. 

 
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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. 
 
2.3.3 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-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. 
 

 
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2.3.4 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 suggest that 
PD-L1 expression in tumor-infiltrating immune cells is likely to be associated with response to 
Atezolizumab.  
 
In adittion, 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. 
 
2.3.5 Clinical Pharmacokinetics and Immunogenicity 
 
Based on 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. 
 

 
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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 
Pertuzumab 
Pertuzumab (Perjeta®), a humanized monoclonal antibody to the HER2 receptor, blocks ligand-
dependent heterodimerization of HER2 with other HER family members. This results in the 
inhibition of ligand-initiated intracellular signaling. In addition, pertuzumab mediates antibody-
dependent cellular cytotoxicity.  
 
Pertuzumab has been shown in nonclinical settings to have superior anti-tumor effects 
when combined with trastuzumab than when used as monotherapy. Trastuzumab and pertuzumab 
monoclonal antibodies bind to distinct epitopes on the HER2 receptor without competing with 
each other, resulting in distinctive mechanisms for disrupting HER2 signaling. These 
mechanisms are complementary and result in augmented therapeutic efficacy when pertuzumab 
and trastuzumab are given in combination. Pertuzumab binds to an epitope within subdomain 2 
of HER2, whereas the epitope for trastuzumab is localized to subdomain 4 (Cho et al. 2003; 
Franklin et al. 2004).  
 
Pertuzumab acts by blocking dimerization of HER2 with other HER family members, thereby 
inhibiting ligand-initiated intracellular signaling through two major signaling pathways, MAPK 
and PI3K. Inhibition of these pathways can result in growth arrest and apoptosis (Hanahan and 
Weinberg 2000). In comparison, trastuzumab binds to the juxtamembrane epitope (subdomain 4), 
preventing cleavage and ligand independent signal transduction. Both antibodies are also capable 
of activating antibody-dependent, cell-mediated cytotoxicity (Spector and Blackwell 2009). In the 
Phase III, pivotal study WO20698/TOC4129g (CLEOPATRA; N = 808) in patients with 
previously untreated HER2-positive MBC, a statistically significant and clinically meaningful 
improvement in PFS, based on tumor assessments by an independent review facility (IRF), was 
observed in patients treated with pertuzumab, trastuzumab, and docetaxel (n = 406) compared with 
those receiving placebo, trastuzumab, and docetaxel (n = 402). PFS was prolonged at the median 
by 6.1 months, and the risk of disease progression or death was reduced by 38% (hazard ratio 
[HR]: 0.62; 95% confidence interval [CI]: 0.51, 0.75; p < 0.0001) with an improvement in median 
PFS from 12.4 months to 18.5 months. Results of the investigator-assessed PFS analysis (HR: 0.65 
[0.54, 0.78]; p  0.0001; median 12.4 vs. 18.5 months, respectively) were consistent with those 
observed for IRF-assessed PFS. A second interim analysis of OS (performed one year after the 
primary analysis of efficacy) crossed the predefined stopping boundary for statistical significance 
(p = 0.0138), demonstrating that treatment with pertuzumab, trastuzumab, and docetaxel 
significantly improved OS when compared with the placebo arm (HR: 0.66; 95% CI: 0.52, 0.84; 
p = 0.0008). The updated analysis of investigator-assessed PFS demonstrated that the PFS benefit 
observed at the primary analysis was maintained after an additional year of follow-up. The HR of 
0.69 and the increase in median PFS of 6.3 months (from 12.4 months in the placebo arm to 18.7 

 
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months in the treatment arm) were highly consistent with those from the first analysis of 
investigator-assessed PFS and consequently also with the primary IRF analysis (Swain et al. 2013).  
 
Based on these data, pertuzumab was approved by the FDA for use in HER2-overexpressing MBC 
in combination with trastuzumab and docetaxel for first-line treatment metastatic disease. 
Pertuzumab is also currently approved in the early breast cancer setting. See the pertuzumab 
Investigator's Brochure for additional information. 
 
2.5 
Trastuzumab 
Trastuzumab (Herceptin®) is a recombinant monoclonal antibody that binds specifically and with 
high affinity to the extracellular domain of HER2. Trastuzumab has been shown to inhibit the 
proliferation of human tumor cells overexpressing HER2 both in vitro and in vivo. The clinical 
benefit of trastuzumab in women with MBC has been demonstrated in two pivotal studies. 
 
A Phase II trial (H0649g) assessed the activity of single-agent trastuzumab in 222 women with 
HER2-overexpressing MBC with progressive disease after one or more chemotherapy regimens 
(Cobleigh et al. 1999). An independent response evaluation committee identified 8 complete and 
26 partial responses, for an objective response rate of 15% in the intent-to-treat population (95% 
CI: 11% to 21%). The median duration of response was 9.1 months, and the median duration of 
survival was 13 months. The most common adverse events, which occurred in approximately 40% 
of patients, were mild to moderate infusion-associated fever and/or chills. The most clinically 
significant event was cardiac dysfunction, which occurred in 4.7% of patients. An open-label, 
randomized, Phase III study (H0648g) in 469 patients with HER2-positive MBC was conducted 
to evaluate the efficacy of trastuzumab in combination with chemotherapy as first-line treatment. 
Patients who were anthracycline-naïve were randomized to receive either anthracycline plus 
cyclophosphamide (AC) or trastuzumab plus AC. Patients who had received prior anthracyclines 
in the adjuvant setting were randomized to receive either paclitaxel or trastuzumab plus paclitaxel. 
As determined by an independent response evaluation committee, trastuzumab prolonged median 
time to disease progression from 4.6 months to 7.4 months (p  0.001), improved the overall 
response rate (complete and partial responses) from 32% to 50% (p < 0.001), and increased median 
duration of response from 6.1 to 9.1 months (p  0.001). Compared to chemotherapy alone, the 
addition of trastuzumab significantly lowered the incidence of death at one year from 33% to 22% 
(p = 0.008) and increased median overall survival 24% from 20.3 months to 25.1 months (p = 
0.046) (Slamon et al. 2001). The observed survival advantage remained despite crossover of 66% 
of patients initially randomized to chemotherapy alone who elected to receive trastuzumab upon 
disease progression (Tripathy et al. 2000). Fever/chills were observed with the initial trastuzumab 
infusion in approximately 25% of patients. Class III or IV cardiac dysfunction was observed in 
16% of the trastuzumab + AC subgroup; increasing age was an associated risk factor for the 
development of cardiotoxicity in this treatment cohort (Slamon et al. 2001). 
 
Based on these data, trastuzumab was approved by the U.S. Food and Drug Administration (FDA) 
for use in HER2-overexpressing MBC in combination with paclitaxel for first-line treatment and 
as a single agent for patients who have progressed on chemotherapy for metastatic disease.  
Subsequent randomized studies have demonstrated the value of continued trastuzumab in 
combination with chemotherapy or targeted therapy, even after prior progression on trastuzumab 

 
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(von Minckwitz, 2009; Blackwell, 2012). As a result, even after progression on trastuzumab, 
continuing the blockade of HER-2 pathway, usually with a trastuzumab containing regimen, is 
considered standard of care [Giordano et al., 2014]. See the trastuzumab Investigator's Brochure 
for additional information. 
 
2.6 
Rationale  
 
2.6.1 Rationale for choice of high dose trastuzumab and pertuzumab backbone 
 
Unfortunately, CNS response to existing systemic anticancer therapies at standard dosages has 
been disappointing, in part due to the limited capacity of many of these drugs to cross the blood–
brain barrier (BBB) effectively, and due the therapeutic concentration limitations resulting from 
active drug efflux proteins such as P-glycoprotein (Pgp), which are present in high concentrations 
in the luminal membranes of brain endothelium[Regina et al., 2001]. Large monoclonal antibodies 
are not believed to cross an intact BBB. However, the BBB may be subject to increased 
permeability/disruption associated with radiation effects and tumor invasion. A study using 
positron electron tomography imaging demonstrated CNS penetration by 89Zr-trastuzumab in 
patients with MBC with an 18-fold higher uptake in brain tumors than in normal brain 
tissue[Dijkers et al., 2010].  
 
Multiple retrospective and prospective studies have demonstrated that patients treated with 
trastuzumab prior to the development of CNS metastases and/or after CNS metastases have 
improved survival outcomes. Incremental increases in uptake of trastuzumab have been observed 
with standard systemic dosing when the BBB is disrupted by associated radiation effects and/or 
tumor invasion[Dijkers et al., 2010]. Subtherapeutic trastuzumab levels achieved in the CNS may 
be related to insufficient dosing as opposed to the inability of trastuzumab to cross the BBB. Of 
note, Phillips et al. (unpublished Genentech internal data) evaluated the relationship between dose-
response in brain graft experiments in murine models. When evaluated in brain graft experiments, 
4D5 (a murine equivalent of trastuzumab) doses up to three times the effective dose used in 
mammary grafts were required to achieve efficacy in brain grafts. Importantly, higher trastuzumab 
dosages have not been associated with increased cardiotoxicity or adverse events as observed in a 
Phase I study (8 patients received 500 mg intravenously every week for 8 weeks), and in two Phase 
II studies (Vogel et al. 2002; Leyland-Jones et al. 2010) where patients received two (N = 57) and 
three times (N = 47) the standard dose.  
 
The impact of a more comprehensive blockade of cell signaling associated with the addition of 
pertuzumab to trastuzumab has been demonstrated in the nonclinical and clinical settings. The 
combination of pertuzumab and trastuzumab with docetaxel demonstrated statistically significant 
and clinically meaningful improvements in outcomes (PFS and OS) without an observed increase 
in cardiotoxicity compared with trastuzumab and docetaxel in a pivotal, Phase III, randomized, 
controlled trial CLEOPATRA[Swain et al., 2013].  
 
Based on the above data, the PATRICIA trial, an ongoing, Genentech-sponsored, multicenter, 
prospective, single-arm study is evaluating the efficacy of “high dose” trastuzumab (6 mg/kg 
weekly) in combination with standard dose pertuzumab in patients with HER2-positive breast 

 
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cancer and progressive brain metastases.  In this study, patients are also allowed to continue 
concurrent systemic chemotherapy and/or endocrine therapy.  Over 30 patients have been enrolled 
to date. Pre-planned interim analysis of the first 15 patients has demonstrated a CNS ORR of 20% 
(95% CI 4.3%-48.1%).  At four months, 40% (95% CI 16.3%-67.7%) have had no evidence of 
either CNS or systemic progression.  No cardiac toxicity signals of concern have been observed to 
date.  Although preliminary, these results provide proof-of-concept that altering the trastuzumab 
dosing schedule may result in CNS efficacy, and provide a well-tolerated backbone upon which to 
add novel agents of interest. 
 
2.6.2 Rationale for exploration of immunotherapy in HER2-positive breast cancer 
 
There are accumulating preclinical and clinical evidence suggesting that immune system is critical 
for disease outcome in breast cancer, particularly in the triple-negative and HER2-positive 
subtypes [Kroemer et al., 2015]. Different groups have been shown that immune cell infiltration 
differs according BC subtype: while hormonal-positive BC are poorly T cell infiltrated, a 
substantial proportion of HER2-positive tumors can be richly infiltrated [Loi et al., 2014, Salgado 
et al., 2014, Denkert et al., 2015]. Of note, multiple concordant reports indicate that disease 
outcome in patients with HER2-positive breast cancer treated in the neo(adjuvant) setting with 
trastuzumab-based regimes improves when tumor microenvironment either have an abundant 
tumors lymphocyte infiltration or express immune-related signatures[Kroemer et al., 2015]. 
Recently, in a secondary analysis of the phase III CLEOPATRA study, which evaluated the benefit 
of adding pertuzumab or placebo to docetaxel plus trastuzumab in the first line treatment of 
patients with advanced HER2-positive breast cancer, investigators showed that higher stromal 
tumour-infiltrating lymphocytes values are significantly associated with improved overall 
survival, suggesting that the effect of antitumour immunity extends to the advanced setting[Luen 
et al., 2017]. So far, only one trial has reported data evaluating immune checkpoint inhibitors (ICI) 
in patients with HER2-positive breast cancer: a phase I clinical trial has evaluated the safety of the 
PD-L1 inhibitor avelumab in monotherapy[Dirix et al., 2015]. Although the ORR was low, of 
note, patients did not receive concurrent anti-HER2-therapy. 
 
Importantly, it has been demonstrated that trastuzumab induces robust tumor infiltration by 
lymphoid cells in patients with breast cancer[Gennari et al., 2004], and preclinical data has shown that 
trastuzumab loses its efficacy when the gene encoding the common γ chain of activating Fcγ 
receptors is deleted in the host[Clynes et al., 2000]. Therefore, trastuzumab might mediate anticancer 
effects in part via the induction of antibody-dependent cellular cytotoxicity (ADCC). In agreement 
with these data, there are evidence suggesting that components both of the innate and adaptive 
immune system participate in the clinical activity of trastuzumab. The optimal response of mouse 
BCs to various anti-HER2 mAbs (including trastuzumab) requires the presence not only of NK 
cells but also of CD8+ and CD4+ T lymphocytes[Park et al., 2010, Stagg et al., 2011]. Expression of PD-
1, PD-L1 or both, in HER-positive breast tumor has been noted, and this may be an important 
mechanism of immune evasion and contribute to resistance through anti-HER2 agents. 
Furthermore, it has been demonstrated that anti-HER2 mAbs synergize with anti-PD-1, and can 
significantly improve the therapeutic activity of trastuzumab in immunocompetent mice [Stagg et al., 
2011].  
 

 
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2.6.3 Rationale for overall study design 
 
To date, patients with active breast cancer brain metastases have been excluded from virtually all 
trials of immunotherapy.  However, clear CNS activity has been demonstrated with immune 
checkpoint inhibitors in patients with advanced melanoma or non-small cell lung cancer[Weber et 
al., 2011, Konstantinou et al., 2014, Goldberg et al., 2016].  Given the high prevalence of brain 
metastases in patients with HER2-positive breast cancer, evaluating the efficacy of checkpoint 
blockade in this patient population represents an opportunity for a major impact in this area of 
unmet medical need.  Furthermore, preliminary activity from the PATRICIA trial supports the use 
of a high dose trastuzumab/pertuzumab backbone upon which to add checkpoint blockade. 
 
Therefore, we hypothesize that an optimal anti-HER2 regimen, designed to better penetrate the 
BBB, combined with an anti-PD-L1 agent, will synergize to increase efficacy against CNS 
metastases in patients with HER2-positive MBC. We propose a single-arm, multi-center, phase II 
trial to evaluate the efficacy and safety of atezolizumab in combination with pertuzumab and high-
dose trastuzumab for the treatment of CNS metastases in patients with HER2-positive MBC, as 
measured by ORR in the CNS according to RANO-BM criteria. Patients will receive atezolizumab 
[1200mg intravenously (IV) every 3 weeks (q3w)], pertuzumab (loading dose of 840 mg IV, 
followed q3w thereafter by a dose of 420 mg IV), and high-dose trastuzumab (at a dose of 6 mg/kg 
weekly for the first 24 weeks, and thereafter trastuzumab 6mg/Kg IV q3w). 
 
2.7 
Correlative Studies Background 
2.7.1 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 of type 
I IFN transcriptional signature. This tumor phenotype is called non-T-cell-inflamed[Gajewski, 
2015]. 

 
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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, 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. The lack of a significant T-cell infiltrate, and the low expression 
of immune checkpoint molecules, may explain the reason that non-inflamed tumor phenotype are 
associated with de novo resistance to ICI. For this group of patients, therapeutic strategies that 
promote a boost in innate immunity, such as a highly effective anti-HER2 therapy, will be crucial 
to successfully overcoming T-cell exclusion and improve the likelihood of benefit of PD-1 
blockers. Therefore, the bulk of correlative science in this trial highlights our especial interest in 
characterize a broad array of immune markers in metastatic HER2-positive breast cancer, 
investigating whether those markers predict disease response to therapy. 
 
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. 
 
2.7.2 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 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--

 
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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].  
 
2.7.3 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.  In patients with brain 
metastases, in particular, research biopsies of CNS tumors are not feasible—yet given that these 
tumors have often been exposed to additional therapies (for example, WBRT and/or SRS), their 
genetic profile may be distinct from that of other metastatic sites. Although there have been some 
studies describing the genomics of brain metastases, because most resections occur in the setting 
of a new presentation of a single brain metastasis, they do not truly reflect the patient with 
progressive brain metastases after local therapy.  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. 
 
 

 
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3. PARTICIPANT SELECTION 
 
Participants must meet the following criteria on screening examination to be eligible to participate 
in the study. Screening evaluations are to be conducted within 28 days prior to start of protocol 
therapy unless otherwise specified. Screening laboratory assessments must be done within 8 days 
prior to initiating protocol therapy.  
 
3.1 
Eligibility Criteria 
 
3.1.1 Histologically confirmed metastatic breast cancer  
3.1.2 Histologically confirmed HER-2 positive by ASCO CAP 2013 guidelines by local 
laboratory. Central confirmation of HER-2 status is not required.  
• IHC 3+ based on circumferential membrane staining that is complete, intense  
-AND/OR- 
• FISH positive based on one of the three following criteria:  
o Single-probe average HER2 copy number ≥6.0 signals/cell; OR 
o Dual-probe HER2/CEP17 ratio ≥2.0 OR 
o Dual-probe HER2/CEP17 ratio <2.0 with an average HER2 copy number≥6.0 
signals/cell 
3.1.3 At least one measurable CNS lesion, defined as ≥ 10 mm in at least one dimension  
3.1.4 Unequivocal evidence of new and/or progressive brain metastases, and  at least one of the 
following scenarios: 
• Treated with SRS or surgery with residual un-treated lesions remaining. Such participants 
are eligible for immediate enrollment on this study providing that at least one untreated 
lesion is measurable 
• Participants who have had prior WBRT and/or SRS and then whose lesions have 
subsequently progressed are also eligible. In this case, lesions which have been treated 
with SRS may be considered as target lesions if there is unequivocal evidence, in the 
opinion of the treating physician, of progression following SRS.  
• Participants who have not previously been treated with cranial radiation (e.g., WBRT or 
SRS) are eligible to enter the study, but such participants must be asymptomatic from 
their CNS metastases and not requiring corticosteroids for symptom control. 
• Both participants who present with systemic stable/absent or progressive disease are 
eligible to this trial, as long as they fulfill one of the above criteria. 
 

 
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3.1.5 Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 or 1. 
3.1.6 Left ventricular ejection fraction (LVEF) ≥ 50% by echocardiogram (ECHO) or multigated 
acquisition (MUGA) scan  
3.1.7 Stable dose of dexamethasone 2mg or less for at least 7 days prior to initiation of treatment 
3.1.8 Concurrent administration of other anti-cancer therapy during the course of this study is 
not allowed.  Note that concurrent use of supportive care medications (e.g. anti-resorptive 
agents, pain medications) is allowed. 
3.1.9 The subject is 18 years old. 
3.1.10 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 × institutional upper limit of normal except subject with  
documented Gilbert's syndrome (≤5 x ULN) or liver metastasis, who must have a  
baseline total bilirubin ≤3.0 mg/dL; 
• AST(SGOT)/ALT(SGPT) ≤ 2.5 × institutional ULN OR ≤ 5.0 × institutional ULN for 
patients with documented liver metastases. 
• Albumin >2.5mg/dL 
• serum creatinine ≤ 1.5 × ULN (or glomerular filtration rate ≥ 60 ml/min as   determined 
by the Cockcroft-Gault equation) 
 
3.1.11 Female subjects of childbearing potential must have a negative serum or urine pregnancy 
test within 8 days of initiating protocol therapy. Childbearing potential is defined as pre-
menopausal women with inteact uterus and ovaries.   
3.1.12  Women of child-bearing potential and men must agree to use adequate contraception 
(barrier method of birth control; abstinence) prior to study entry, for the duration of study 
participation and 4 months after completion of atezolizumab administration.   
3.1.13 Ability to understand and the willingness to sign a written informed consent document. 
 
3.2 
Exclusion Criteria 
3.2.1 Visceral crisis or impending visceral crisis at time of screening. 
3.2.2 CNS complications for whom urgent neurosurgical intervention is indicated (e.g., 
resection, shunt placement). 
3.2.3 Known leptomeningeal metastases [Defined as positive CSF cytology and/or unequivocal 
radiological evidence of clinically significant leptomeningeal involvement. CSF sampling 
is not required in the absence of suggestive symptoms to exclude leptomeningeal 
involvement]. 
3.2.4 Treatment with high dose systemic corticosteroids defined as dexamethasone > 2mg/day 
or bioequivalent within 7 days of treatment initiation  
3.2.5 Patients unable to undergo gadolinium contrast-enhanced MRI or receive IV contrast for 

 
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any reason (e.g., due to pacemaker, ferromagnetic implants, claustrophobia, extreme 
obesity, hypersensitity). 
3.2.6 Chemotherapy or targeted therapy within 14 days prior to planned treatment start  
3.2.7 Has received prior therapy with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or 
anti-Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) antibody (including 
ipilimumab or any other antibody or drug specifically targeting T-cell co-stimulation or 
checkpoint pathways). 
3.2.8 No washout is required for endocrine therapy.  If a patient has been on endocrine therapy 
within 28 days of study entry, that same endocrine therapy is permitted to be continued 
during protocol therapy, at the investigator’s discretion, as is continuation of ovarian 
suppression in premenopausal women.  Starting a new endocrine therapy during protocol 
therapy is not permitted 
3.2.9 Current use or history of receiving a non-approved, investigational treatment within 14 
days prior to planned treatment start 
3.2.10 Subjects with a history of hypersensitivity to compounds of similar biologic composition 
to atezolizumab or any constituent of the product 
3.2.11 Uncontrolled intercurrent illness, including, but not limited to, ongoing or active infection, 
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, chronic liver or renal disease, or severe malnutrition.   
3.2.12 Pregnant women or women who are lactating/breastfeeding due to the teratogenic potential 
of the study drugs 
3.2.13 Active, second potentially life-threatening cancer 
3.2.14 Major surgery within 21 days of planned treatment start 
3.2.15 Active infection requiring iv antibiotics at treatment initiation  
3.2.16 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. 
3.2.17 Symptomatic intrinsic lung disease or extensive tumor involvement of the lungs, resulting 
in dyspnea at rest  
3.2.18 Known human immunodeficiency virus (HIV), HepBsAg, or HCV RNA. HIV-positive 
participants on combination antiretroviral therapy are ineligible because of the unclear 
effects of immune checkpoint inhibitors in this setting.   
3.2.19 Live vaccines within 28 days of first dose of trial therapy and during trial treatment.  
3.2.20 Known intolerance to trastuzumab or pertuzumab or atezolizumab. 
 

 
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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 
DF/HCC 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. 
 
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 must be taken off-study in the 
CTMS (OnCore) with an appropriate date and reason entered.   
 
4.2 Registration Process for DF/HCC Institutions 
 
Applicable DF/HCC Policy (REGIST-101) must be followed.   
 
4.3 General Guidelines for Other Investigative Sites 
 
Eligible participants will be entered on study centrally at the Dana-Farber Cancer Institute by the 
Project Manager.  All sites should email or call the Project Manager to verify slot availabilities. 
The required forms in Section 4.4 should be emailed or faxed to the Project Manager. 
 
Following registration, participants should begin protocol therapy within 7 days. Issues that 
would cause treatment delays should be discussed with the Overall PI.  If a participant does not 
receive protocol therapy following registration, the participant’s registration on the study must be 
canceled.  The Project Manager should be notified of cancellations as soon as possible. 
 
4.4 Registration Process for Other Investigative Sites 
 
To register a participant, the following documents should be completed by the participating site 
and emailed to the Project Manager at CTOPM@dfci.harvard.edu or faxed to 617-632-5152: 
 
• Clinic visit note including medical history, physical exam, ECOG-PS, and vital signs 
• Copy of required laboratory tests including: Hematology (CBC with differential), 
Chemistry, TSH, and pregnancy test (if applicable) 
• Pathology report and documentation of ER/PR status and HER2 status 

 
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• Tumor assessments by CT or MRI 
• Brain MRI 
• ECHO or MUGA report 
• Signed participant consent form 
• HIPAA authorization form (if separate from the main consent form) 
• Completed DF/HCC Eligibility Checklist 
 
To complete the registration process, the Project Manager will 
• Follow the DF/HCC Standard Operating Procedure for Human Subject Research Titled 
Subject Protocol Registration (SOP #: REGIST-101) and register the participant on the 
protocol 
• email the research nurse or data manager at the participating site with the participant 
study number, and registration confirmation  
 
NOTE: Registration can only be conducted during the business hours of 8:00 AM and 5:00 
PM Eastern Time Monday through Friday. Same day treatment registrations will only be 
accepted with prior notice and discussion with the DF/HCC Project Manager. 
 
5. TREATMENT PLAN 
 
5.1 Treatment Regimen 
Patients will receive the following treatment: atezolizumab [1200mg intravenously (IV) every 3 
weeks (q3w)], pertuzumab (loading dose of 840 mg IV, followed q3w thereafter by a dose of 420 
mg IV), and high-dose trastuzumab (at a dose of 6 mg/kg weekly for the first 24 weeks, and 
thereafter trastuzumab 6mg/Kg IV q3w). Treatments will be administered on an outpatient basis.  
  Regimen Description 
Agent 
Premedication 
Dose 
Route 
Schedule 
Cycle 
Length 
Atezolizumab 
Not routinely 
necessary unless 
prior infusion 
reaction. 
 
1200 mg 
IV over 60 
minutes (+/- 
15 mins) 
Day 1 (q3w) 
 
 
 
 
 
 
21 days 
(3 weeks) 
 
 
Pertuzumab 
Not routinely 
necessary unless 
prior infusion 
reaction. 
 
Loading dose of 
840 mg followed 
by standard dose of 
420 mg*  
IV over 60 
mins with 
60 min obs 
period 
 
Day 1 (q3w) 
Trastuzumab 
Not routinely 
necessary unless 
prior infusion 
reaction. 
6 mg/Kg  
IV over 30-
90 
minutes** 
Weekly for the 
first 24 weeks 
followed by 
q3w 

 
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Atezolizumab, pertuzumab, and trastuzumab may be administered in any order. 
 
Weekly doses of trastuzumab may be administered +4 -2 days (no less than 5 days apart). 
 
If the initial infusion of atezolizumab is well-tolerated, subsequent infusions may be delivered over 30 
minutes (+/- 10 minutes).  
 
If the initial infusion of pertuzumab is well-tolerated, subsequent infusions may be delivered over 30 
minutes, per institutional guidelines.  
 
*No loading dose is required in the case of an interval < 6 weeks between last dose of pertuzumab and the 
first administration of on-study pertuzumab. 
 
**Trastuzumab-naïve patients should receive their first dose over 90 minutes. Patients who are actively 
receiving trastuzumab prior to enrollment will have a dose increase to 6 mg/kg IV weekly. 
 
5.2 Pre-Treatment Criteria 
Laboratory results must be reviewed prior to dosing.  If screening assessments were completed 
within 8 calendar days of Cycle 1 Day 1, these assessments do not need to be repeated.  
 
5.2.1 All cycles, Day 1 
− 
Absolute Neutrophil Count ≥1,000/mcL 
− 
Platelets 
≥50,000/mcL 
− 
AST(SGOT)/ALT(SGPT) 
≤ 2.5 × institutional ULN or ≤ 5 × institutional ULN for 
participants with documented liver metastases 
- 
Creatinine  
≤ 1.5 mg/dL (or glomerular filtration rate >_ 50 ml/min  
 
 
 
as determined by the Cockcroft-Gault equation) 
 
5.2.2 All cycles, Days 8 and 15 
 
Because trastuzumab is not expected to lead to hematologic, renal, or hepatic toxicity, there are 
no laboratory criteria-to-treat for day 8 or day 15 trastuzumab 
 
5.3 Agent Administration 
5.3.1 Atezolizumab Administration  
 
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. 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 

 
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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. 
 
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. 
 
5.3.2 Pertuzumab Administration  
 
The loading dose of pertuzumab will be 840 mg administered as a 60-minute IV infusion, followed 
every 3 weeks thereafter by a dose of 420 mg administered over a period of 30 minutes. For 
patients already receiving pertuzumab as part of their ongoing systemic therapy, no loading dose 
is required in the case of an interval < 6 weeks between last dose of pertuzumab and the first 
administration of on-study pertuzumab. An observation period of 30 to 60 minutes is 
recommended after each pertuzumab infusion, according to each participating site’s institutional 
guidelines. 
 
5.3.3 Trastuzumab Administration  
 
High-dose trastuzumab will be administered at a dose of 6 mg/kg weekly, infused intravenously 
over 30 -90 minutes.  No loading dose is required. Trastuzumab-naïve patients should receive 
their first dose over 90 minutes. Patients who are actively receiving trastuzumab prior to 
enrollment will have a dose increase to 6 mg/kg IV weekly. The dose of trastuzumab should be 
based on institutional guidelines.  Weekly doses may be administered +4 -2 days (no less than 5 
days apart). 
  
5.4 Definition of Dose-Limiting Toxicity  
 
The first six participants will be assessed for dose-limiting toxicities (DLTs). After the first six 
patients are enrolled, accrual must pause until the DLT window passes. If there are ≥ 2 DLTs in 
these patients, the regimen will be declared unsafe for further study. If there are ≤ 1 DLTs 
observed, the study may continue with enrollment. 
 
Dose-limiting toxicity is defined as any of the following events occurring within 21 days of 
Cycle 1 Day 1 treatment, if judged by the investigator to be possibly, probably, or definitely 

 
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related to study drug: 
 
1) Death 
2) ≥ Grade 3 treatment-emergent neurological toxicity 
3) Asymptomatic grade 4 neutropenia or thrombocytopenia lasting ≥7 days  
4) Grade 4 thrombocytopenia of any duration 
5) ≥ Grade 3 Febrile neutropenia  
6) ≥ Grade 3 Thrombocytopenia if associated with bleeding 
7) ≥ 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)  
8) ≥ Grade 3 non-hematologic laboratory value if: 
a. Medical intervention is required to treat the patient, or 
b. The abnormality leads to hospitalization, or 
c. The abnormality persists >7 days 
d. Excluding: 
i. Alkaline phosphatase <10.0x ULN in a patient with grade 2 alkaline 
phosphatase elevation at baseline as a result of bone metastasis  
9) ≥ Grade 3 pneumonitis of any duration 
10)  ≥ Grade 3 Fatigue lasting >5 days 
11)  New York Heart Association (NYHA) class III and IV cardiac heart failure      
(Appendix G) 
12)  An asymptomatic decline in LVEF to a value 10 percentage points below baseline or 
lower, and < 45% 
13)  > Grade 3 other non-laboratory toxicity lasting >3 days despite optimal supportive care, 
excluding Alopecia (of any grade). 
 
5.5 General Concomitant Medication and Supportive Care Guidelines 
 
5.5.1 Acceptable Concomitant Medications 
 
All treatments that the investigator considers necessary for a subject’s welfare may be administered 
at the discretion of the investigator in keeping with the community standards of medical care and 
documented in the medical record.  
5.5.2 Prohibited Concomitant Medications 
 
Subjects are prohibited from receiving the following therapies during the screening and treatment 
phase of this trial: 
• Antineoplastic systemic chemotherapy or biological therapy  
• Immunotherapy not specified in this protocol 
• Radiation therapy  
• 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. 

 
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• 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 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.   
• Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the 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 may 
be required.  The investigator should discuss any questions regarding this with the overall 
PI.   
 
5.5.3 Supportive Care Guidelines  
 
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. 
• 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 patient 
is enrolled in the study. 
• Hematopoietic growth factors (e.g., granulocyte-colony stimulating factor [G-CSF], 
granulocyte macrophage colony stimulating factor) may be used at investigator’s 
discretion for the management of treatment-emergent 
neutropenia and/or for secondary prophylaxis per NCCN guidelines or local 
standard practice 
 
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. 
 
5.6 Criteria for Taking a Participant Off Protocol Therapy  
 
Duration of therapy will depend on individual response, evidence of disease progression and 

 
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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 RANO-BM and/or RECIST 1.1 (see note below) 
• Disease progression by iRANO and/or irRC criteria.  
NOTE: Please note that although the primary endpoint is Overall Response Rate in the CNS 
according to response assessment in neuro-oncology-brain metastases (RANO-
BM) criteria, 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. For treatment beyond radiographic progression the following 
criteria must be met: 
o Absence of signs or symptoms of clinically significant progression; 
o No decline in ECOG performance status; 
o Absence of symptomatic rapid disease progression requiring urgent medical 
intervention. 
• 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 
• Physician Discretion. 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 617-632-2335 or nlin@partners.org. 
 
Participants may elect to stop atezolizumab with CR after at least 24 weeks of treatment and having 
had at least two treatments with atezolizumab after documentation of the CR. 
 
Subjects who stop atezolizumab with 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 CR by central 
radiology review (TIMC) 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 
OR 

 
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o Had a CR and stopped atezolizumab treatment after 24 months of study therapy for 
reasons other than disease progression or intolerability. 
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. 
 
5.7 Duration of Follow Up  
An Off-Treatment visit should occur within 30 days of the last dose of study treatment.   
 
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 constitute a protocol deviation or violation. If patients cannot return in 
person, local medical records, or a phone call to the participants’ local provider will be requested 
in order to provide additional follow up information. 
 
Participants who are removed from protocol therapy will be followed for survival every 6 
months or until death. This can be a visit to the clinic, chart review/receipt of local medical 
records, or a phone call to the participants’ local provider. 
   
5.8 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  
• 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.  
 

 
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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, pertuzumab or trastuzumab in this study. If any 
of the three drugs needs to be permanently discontinued, patients can remain on the others at 
descrition of their physician. 
 
6.1 Management of toxicities attributable to atezolizumab 
6.1.1 Guidelines for Dosage Modification and Treatment Interruption or Discontinuation 
 
There will be no dose reduction for atezolizumab in this study.   
 
Atezolizumab treatment may be temporarily suspended in patients experiencing toxicity 
considered to be related to study treatment.  If corticosteroids are initiated for treatment of the 
toxicity, they must be tapered over 1 month to  10 mg/day oral prednisone or equivalent before 
atezolizumab can be resumed.  If atezolizumab is withheld for  105 days, the patient will be 
discontinued from atezolizumab.  However, atezolizumab may be withheld for  105 days to allow 
for patients to taper off corticosteroids prior to resuming treatment.  Atezolizumab can be resumed 
after being withheld for  105 days if PI agrees that the patient is likely to derive clinical benefit.  
Atezolizumab treatment may be suspended for reasons other than toxicity (e.g., surgical 
procedures).  The investigator will determine the acceptable length of treatment interruption.  
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. 
 
In general, 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 

 
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31 
 
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. 
 
Management of diarrhea/colitis, hepatitis/transaminitis, rash, pulmonary, and endocrine adverse 
events 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 
Systemic immune activation 
 
Systemic immune activation is a rare condition characterized by an excessive immune response.  
Given the mechanism of action of atezolizumab, systemic immune activation is considered a 
potential risk when given in combination with other immunomodulating agents.   
 
Recommendations regarding early identification and management of systemic immune activation 
are provided below.  In the event of suspected systemic immune activation, atezolizumab should 
be withheld and the PI should be contacted immediately for additional guidance.  
Refer to the current version of the Atezolizumab Investigator Brochure for management of 
immune-related events, including infusion-related reactions.  
Early disease recognition is critical, and systemic immune activation should be suspected if, in 
the absence of an alternative etiology, the patient meets two or more of the following criteria: 
• Hypotension that is refractory to aggressive IV fluid challenge 
o Vasopressor support may be required. 
• Respiratory distress that requires aggressive supportive care 
o Supplemental oxygen and intubation may be required. 
• Fever  38.5C 
• Acute renal or hepatic failure 
• Bleeding from coagulopathy 
• Any of the following unexplained laboratory abnormalities (change from baseline):  
cytopenias (in two or more lineages), significant transaminitis, and coagulopathy 
 
 
For patients with suspected systemic immune activation, an initial evaluation should include the 
following: 
• 
CBC with peripheral smear 
• 
PT, PTT, fibrinogen, and D-dimer 
• 
Ferritin 

 
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• 
Triglycerides 
• 
AST, ALT, and total bilirubin 
• 
LDH 
• 
Complete neurologic and abdominal examination (assess for hepatosplenomegaly) 
 
Laboratory tests with normal results should be repeated frequently in patients for whom a high 
clinical suspicion of systemic immune activation exists. 
If cytopenias are present (Grade  2 in two or more lineages) or ferritin is  3000 ng/mL, the 
following evaluations should also be performed:   
• 
Bone marrow biopsy and aspirate (assess for evidence of hemophagocytosis) 
• 
Soluble interleukin 2 (IL-2) receptor (sCD25) 
• 
Natural killer cell activity 
 
Cytomegalovirus, Epstein-Barr virus, and herpes-simplex virus evaluation (for 
reactivated or active disease). 
 

 
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Systemic Immune Activation Diagnostic Criteria  
(applicable only when alternative etiologies have been excluded) 
Major Criteria 
Minor Criteria 
• Fever  38.5C on more than one occasion 
• Ferritin  3000 ng/mL 
• Cytopenias (Grade  2 in two or more lineages) 
• Age-adjusted soluble IL-2 receptor elevated by 
 2 standard deviations 
• Severe dysfunction in two or more organs 
• Decreased fibrinogen 
• Splenomegaly  
• Hemophagocytosis in bone marrow, spleen, or lymph nodes 
• Elevated GGT or LFTs (AST, ALT, or total bilirubin) 
• Elevated triglycerides 
• Elevated LDH 
• Decreased natural killer cell activity 
Diagnosis and Management of Systemic Immune Activation 
Number of Criteria 
Diagnosis 
Action to Be Taken 
 4 major criteria 
Consistent 
with systemic 
immune 
activation 
• Withhold pertuzumab and trastuzumab. 
• Permanently discontinue atezolizumab. 
• Consider treatment with an immunosuppressive agent (i.e., tocilizumab, 
infliximab, cyclosporine A, or etoposide) and IV corticosteroids (i.e., 
methylprednisolone 1 g once daily or equivalent). 
• Consider HLH-94 protocol if there is no clinical improvement. 
• If event resolves within 12 weeks from last dose of atezolizumab, and if the 
subject was unequivocally deriving clinical benefit, the subject may be able 
to resume trastuzumab and pertuzumab as determined by the investigator 
3 major criteria 
OR 
2 major plus 
 3 minor criteria 
Probable 
systemic 
immune 
activation 
• Withhold pertuzumab and trastuzumab. 
• Depending on clinical severity, follow guidelines for “Consistent with 
systemic immune activation” or “Possible systemic immune activation” 
diagnosis. 
• If event resolves within 12 weeks from last dose of atezolizumab, and if the 
subject was unequivocally deriving clinical benefit, the subject may be able 
to resume trastuzumab and pertuzumab as determined by the investigator 
2 major plus 
 2 minor criteria 
OR 
1 major plus 
 4 minor criteria 
Possible 
systemic 
immune 
activation 
• Withhold pertuzumab, trastuzumab and atezolizumab. 
• Consider treatment with IV corticosteroids. 
• Follow guidelines for “Consistent with systemic immune activation” 
diagnosis if there is no clinical improvement or if clinical worsening occurs. 
• If clinical improvement occurs, atezolizumab may be resumed following a 
benefit-risk assessment. 
• If event resolves within 12 weeks from last dose of atezolizumab, and if the 
subject was unequivocally deriving clinical benefit, the subject may be able 
to resume trastuzumab and pertuzumab as determined by the investigator 
GGT = -glutamyl transpeptidase; IL-2 = interleukin-2; IV = intravenous; LFT = liver function test. 
Notes:  Criteria are adapted from a Delphi Survey of 26 experts who provided helpful criteria in the positive diagnosis 
of hemophagocytic syndrome in adult patients (Hejblum et al. 2014).   
Case reports and recommendations have been published for cytokine-release syndrome (Teachey et al. 2013; Lee et al. 
2014; Maude et al. 2014), and, on the basis of etiologic similarities, these practices have been incorporated into the 

 
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An adverse event of systemic immune activation should be reported in the patient’s medical 
records if it meets the criteria for "consistent with systemic immune activation" or "probable 
systemic immune activation" as outlined above. 
 
6.1.1.2 
Gastrointestinal Toxicity 
 
Diarrhea/Colitis 
Subjects should be instructed to notify their physician immediately at the first signs of poorly 
formed or loose stool or an increased frequency of bowel movements as both atezolizumab and 
pertuzumab and can be associated with severe diarrhea/colitis. General supportive measures 
should be implemented including continuous oral hydration, correction of fluid and electrolyte 
abnormalities, small frequent meals, and stopping lactose-containing products, high fat meals, and 
alcohol. 
  
Immune-mediated colitis has been associated with the administration of atezolizumab. 
 
Participants experiencing intolerable Grade 2 diarrhea or Grade 3 diarrhea unable to be managed 
with standard antidiarrheal treatments should consult a gastrointestinal (GI) doctor for a potential 
endoscopy and biopsy to help distinguish between pertuzumab vs. atezolizumab mediated toxicity.  
➢ If a GI biopsy is performed, and showed T cell infiltration indicative of atezolizumab-
induced colitis, atezolizumab should be permanently discontinued. Once diarrhea returns 
to Grade 1, restart pertuzumab and trastuzumab.  
➢ If a GI biopsy is performed, and showed no T cell infiltration indicative of atezolizumab-
induced colitis, pertuzumab should be discontinued, and atezolizumab and trastuzumab 
should be resumed at the same dose once diarrhea returns to Grade 1.  
Table 2 
Dose Modification Guidelines for Gastrointestinal Toxicity 
Toxicity 
Description 
Management 
Diarrhea and/or 
Colitis  
Grade 1 
• Continue atezolizumab, trastuzumab and pertuzumab. 
• Initiate symptomatic treatment  
• Endoscopy is recommended if symptoms persist for > 7 days 
• Close monitoring. 
Grade 2  
• 
Hold atezolizumab, and pertuzumab.  
• 
Initiate symptomatic treatment 
• 
Gastroenterology consultation recommended 
• 
For recurrent events or events that persist > 5 days:  
o 
Consider referral to gastroenterologist 
o 
Consider oral budesonide, mesalamine or 10 mg of prednisone 
equivalent per day 
o 
If co-existing abdominal pain, all of the above plus rule out bowel 
perforation and consider prednisone 60 mg per day or equivalent 
Systemic Immune Activation Diagnostic Criteria  
(applicable only when alternative etiologies have been excluded) 
above treatment recommendations. 
These recommendations do not replace clinical judgment and are intended as suggested guidance. 

 
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Toxicity 
Description 
Management 
• 
When symptoms improve Grade ≤1, resume atezolizumab and pertuzumab  
o 
Corticosteroids must be tapered over ≥1 month to <10 mg/day oral 
prednisone or equivalent before resuming  
• 
Atezolizumab and pertuzumab may be resumed if the event improves to Grade 
≤ 1 within 12 weeks from last dose 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 
Grade 3  
• Hold atezolizumab and pertuzumab. 
− Treat with loperamide up to maximum of 8 mg daily. Other antimotilty agents 
may be added or substituted as clinically indicated.  
− If diarrhea improves to grade 2 or less within 7 days, then atezolizumab and 
pertuzumab may be restarted once the diarrhea resolves to </= grade 1. 
− If grade 3 persists > 1 week despite maximum supportive care measures, or if 
grade 3 lasting > 7 days recurs on re-challenge, then 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.  In addition, patients should 
be referred for gastroenterology for consideration of biopsy to rule out 
atezolizumab-mediated colitis. 
➢ If GI biopsy shows T cell infiltration indicative of atezolizumab-induced 
colitis, atezolizumab should be permanently discontinued. Once diarrhea 
returns to Grade 1, restart pertuzumab.  
➢ If GI biopsy shows no T cell infiltration indicative of atezolizumab-induced 
colitis, pertuzumab should be discontinued, and 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. 
− If event does not resolve to </= grade 1 within 12 weeks of holding, permanently 
discontinue both atezolizumab and pertuzumab 
− If the subject was unequivocally deriving clinical benefit, and event resolves to 
</= grade 1 after more the 12 weeks, the subject may be rechallenged with 
atezolizumab and/or pertuzumab as determined by the PI, but the approval must 
be documented in writing. 
 
Grade 4 
• 
Hold atezolizumab and pertuzumab and inform PI. 
− 
Treat with loperamide up to maximum of 8 mg daily. Other antimotility 
agents may be added or substituted as clinically indicated. 
• 
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.  
• 
Gasteroenterology referral and confirmation biopsy.  
 
➢ If GI biopsy shows T cell infiltration indicative of atezolizumab-induced 

 
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Toxicity 
Description 
Management 
colitis, atezolizumab should be permanently discontinued. Once diarrhea 
returns to </=Grade 1, restart pertuzumab.  
➢ If GI biopsy shows no T cell infiltration indicative of atezolizumab-induced 
colitis, pertuzumab should be permanently discontinued. If diarrhea 
improved to grade 1 or better within 12 weeks from last dose of 
atezolizumab, and if the subject was unequivocally deriving clinical benefit, 
and if the GI biopsy showed no indication of T cell infiltration indicative of 
atezolizumab-induced colitis, the subject may be able to resume 
Atezolizumab as determined by the PI, but the approval must be documented 
in writing. 
IV = intravenous; TNF-α = tumor necrosis factor alph 
 
 
6.1.1.3 
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 3. For 
patients with elevated LFTs at baseline (between 3-5-fold ULN) due to documented liver 
metastases, further elevation of LFTs may not require dose interruptions if the ALT and/or AST 
have risen ≤ 3-fold over baseline and if the total bilirubin elevation remains ≤ 2-fold over normal 
with normal PT/INR. Such cases should be also discussed with the principal investigator. 
 
Table 3 
Dose Modification Guidelines for Hepatotoxicity 
Toxicity 
Description 
Management 
LFT and/or total 
bilirubin 
abnormalities, 
deemed related to 
protocol therapy (i.e. 
not related to 
underlying liver 
metastases) 
Grade 1 
• Continue study therapy and monitor labs according to study calendar 
Grade 2 
• Continue study therapy and monitor LFTs more frequently until return 
to baseline or Grade ≤1 
 
• If persistent > 5 days: 
• hold atezolizumab; start prednisone 60 mg/day or equivalent.  When 
LFTs improve to Grade ≤1 taper steroids over ≥1 month  
• Resume atezolizumab, if event resolves to Grade 1, baseline, or better 
within 12 weeks from the last dose of atezolizumab. 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab and contact PI 

 
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Toxicity 
Description 
Management 
• 
if the subject was unequivocally deriving clinical 
benefit, the subject may be able to resume 
Atezolizumab as determined by the PI. 
On second occurrence:  
▪ Manage as grade 3 and 4  
Grade 3 or 4 
deemed 
related to 
protocol 
therapy (i.e. 
not related 
to 
underlying 
liver 
metastases) 
• 
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. 
  
6.1.1.4 
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.  
 
Dermatologic toxicity and rash should be managed according to the guidelines in Table 4 
 
Table 4 
Dose Modification Guidelines for Dermatologic Toxicity 
Toxicity 
Description 
Management 
Dermatologic 
toxicity/rash  
(e.g., maculopapular 
or purpura) 
Grade 1:  
Mild 
 10% BSA 
• Continue study therapy. 
• Consider topical steroids and/or other symptomatic therapy (e.g., 
antihistamines). 
Grade 2:  
Moderate  
10%−30% 
BSA 
• Continue study therapy.   
• Administer topical steroids and consider higher potency topical steroids 
if event does not improve 
• Consider dermatologist referral. 

 
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Toxicity 
Description 
Management 
Grade 3:  
Severe  
 30% BSA 
• Hold atezolizumab and pertuzumab, and administer oral prednisone 
10 mg or equivalent. 
• 
If the rash is not improved after 48−72 hours, increase dose of 
prednisone to 60 mg or equivalent. 
• Refer for dermatology consult 
• Restart atezolizumab and pertuzumab 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. 
  
6.1.1.5 
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.   
 
 
 
Table 5 
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 thyroid replacement hormone 
• 
Monitor TSH weekly 
• 
Consider referral to an endocrinologist 
• 
Restart atezolizumab when symptoms are controlled and thyroid function is 
improving 
Asymptomatic 
Hyperthyroidism 
 
• 
If serum TSH < 0.5 mU/L and > 0.1 mU/L, continue Atezolizumab and monitor 
TSH every 4 weeks 
• 
If TSH < 0.1 mU/L, follow guidelines for symptomatic hyperthyroidism 

 
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Toxicity 
Management 
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. 
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. 
Symptomatic 
panhypopituitarism 
and any other Grade 
3-4 endocrine events 
 
• 
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 steriod taper and taper over ≥ 1 
month, resume atezolizumab 
• 
Consult an endocrinologist 
• 
Perform appropriate imaging 
• 
Initiate hormonre 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. 
 
 
 
6.1.1.6 
Pulmonary Toxicity 
 
Cases of interstitial lung disease (ILD), including pneumonitis, some leading to acute respiratory 
distress syndrome or death, have been reported in patients receiving atezolizumab.  Signs and 
symptoms may include dyspnea, cough, fatigue, and pulmonary infiltrates.  Patients with dyspnea 
at rest due to complications of advanced malignancy and comorbidities may be at risk of 
pulmonary events. 
 
Patients with clinically significant pulmonary symptoms will be excluded from this study (see 
Section 3.2).  
 Recommended management for pulmonary events are listed in table 6 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]) 

 
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Table 6 
Dose Modification Guidelines for Pulmonary Toxicity (Pneumonitis) 
Toxicity 
Description 
Management 
Pulmonary toxicity 
(Pneumonitis) 
Grade 1 
• Continue study therapy with close monitoring 
• Re-evaluate on serial imaging 
• Consider pulmonary consultation 
• For recurrent pneumonitis, treat as a Grade 3 or 4 event 
Grade 2 
• Continue trastuzumab and pertuzumab. 
• Hold 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 from last dose of atezolizumab 
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) 
 
Grade 3-4 
• Hold trastuzumab and pertuzumab. 
• Permanently discontinue atezolizumab start prednisone 60 
mg/day or equivalent and notify PI  
• 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 
 
 
6.1.1.7 
Pancreatic Toxicity 
 
Symptoms of abdominal pain associated with elevations of amylase and lipase, suggestive of 
pancreatitis, have been associated with administration of other immunomodulatory 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. 

 
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Table 7 Pancreatic Toxicity 
Amylase and/or lipase elevation, 
Grade 2 
• Continue atezolizumab. 
• Monitor amylase and lipase weekly 
• For prolonged elevation (> 3 weeks) consider treatment with 10 
mg/day oral prednisone or equivalent  
Amylase and/or lipase elevation, 
Grade 3 or 4 
• Withhold atezolizumab. 
• Refer to gastrointestinal specialist 
• Monitor amylase and lipase every other day 
• If no improvement, consider treatment with 1-2 mg/kg/day oral 
prednisone or equivalent  
• Resume atezolizumab if event resolves to Grade 1 or better within 
12 weeks after event onset 
• Permanently discontinue atezolizumab if event does not resolve to 
Grade 1 or better within 12 weeks and contact PI. 
o 
if the subject was unequivocally deriving clinical benefit, 
the subject may be able to resume as determined by the PI  
• For recurrent events, permanently discontinue Atezolizumab and 
contact PI. 
Immune-related pancreatitis, Grade 2 
or 3 
• Withhold atezolizumab 
• Refer to gastrointestinal specialist 
• Initiate treatment with 1-2 mg/day IV methylprednisolone or 
equivalent and convert to 1-2 mg/kg/day oral prednisone or 
equivalent 
• Resume atezolizumab if event resolves to Grade 1 or better within 
12 weeks of event onset 
• Permanently discontinue atezolizumab if event does not resolve to 
Grade 1 or better within 12 weeks of event onset 
o 
if the subject was unequivocally deriving clinical benefit, 
the subject may be able to resume as determined by the PI  
• For recurrent events, permanently discontinue Atezolizumab and 
contact PI. 
 
Immune-related pancreatitis, Grade 4 • Permanently discontinue Atezolizumab and contact PI. 
• Refer to gastrointestinal specialist 
• Initiate treatment with 1-2 mg/day IV methylprednisolone or 
equivalent and convert to 1-2 mg/kg/day oral prednisone or 
equivalent 
• If event does not improve within 48 hours of initiating 
corticosteroids, consider adding an immunosuppressive agent 
• Resume atezolizumab if event resolves to Grade 1 or better within 
12 weeks of event onset, taper corticosteroids over > 1 month 
• Permanently discontinue atezolizumab if event does not resolve to 
Grade 1 or better within 12 weeks of event onset 
if the subject was unequivocally deriving clinical benefit, the subject 
may be able to resume as determined by the PI  

 
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6.1.1.8 
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 8 and the Atezolizumab 
Investigator. 
 
Table 8 
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, pertuzumab and 
trastuzumab. 
• 
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 

 
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Toxicity 
Description 
Management 
o 
If the subject was unequivocally deriving 
clinical benefit, the subject may be able to 
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. 
 
6.1.1.9 
Left Ventricular Dysfunction 
 
Patients treated with atezolizumab are at risk of developing left ventricular dysfunction.  To date, 
significant cardiac events, including left ventricular ejection fraction (LVEF) of  40%, have 
been observed infrequently in clinical trials of atezolizumab. 
 
Patients must meet specified LVEF requirements to be included in this study (see Section 3.1).  
 
Left ventricular function will be monitored by measurement of ejection fraction using 
echocardiogram (ECHO) or multiple-gated acquisition (MUGA) scans as described in Section 
6.2.1. 
 
Guidelines for management of patients who develop left ventricular dysfunction are provided in 
Apendix H.  
 
6.1.1.10 
 Neurologic disorders 
 
Neurologic toxicity/disorder should be managed according to the guidelines in Table 9. 
 
   Table 9 Dose Modification Guidelines for Neurologic Disorders 
Neurologic disorders 
 
Immune-related neuropathy, Grade 2  • Withhold atezolizumab. 
• 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. 
Immune-related neuropathy, Grade 3 
or 4  
• Permanently discontinue atezolizumab. 
Myasthenia gravis and 
Guillain-Barré, all grades 
• Permanently discontinue atezolizumab. 
Immune-related 
meningoencephalitis,  
all grades 
• Permanently discontinue atezolizumab. 
 

 
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6.2 Management of toxicities attributable to pertuzumab and/or trastuzumab 
Administration of trastuzumab may be delayed to assess or treat adverse events, such as changes 
in LVEF, as shown in Appendix J. Since pertuzumab is also associated with a risk for cardiac 
dysfunction, the management of cardiac safety for patients receiving both drugs in the study, as 
outlined in the next section, applies to both drugs. 
  
1. Diarrhea/Colitis 
Refer to section 6.1.1.2 
2. Hepatotoxicity 
Refer to section 6.1.1.3 
3. Dermatology toxicity 
Refer to section 6.1.1.4 
4. Non-hematological, Grade 1 or 2 (NCI CTCAE 
v4.0) adverse evets, excluding cardiaca, 
diarrhea/colitis, hepatotoxicity, and dermatology 
toxicity 
Continue study treatment. 
5. Non-hematological, deemed related grade 3 or 4 
(NCI CTCAE v4.0) adverse events, excluding 
cardiaca, diarrhea/colitis, hepatotoxicity, and 
dermatology toxicity 
Hold study treatment (all medications in the cycle) 
until recovery to Grade 2. 
Toxicity resolved to Grade 1 within a maximum 
of 3 weeks calculated from last administration: 
resume study treatment. 
Toxicity did not resolve to Grade 2 within a 
maximum of 3 weeks calculated from last 
administration: discontinue the related study 
medication (pertuzumab or trastuzumab) 
permanently. Continue treatment as deemed 
suitable by the local investigator. 
6. Recurrence of non-hematological, Grade 3 or 4 
(NCI CTCAE v4.0; excluding cardiaca, 
diarrhea/colitis, hepatotoxicity, and dermatology 
toxicity) toxicity upon rechallenge 
Discontinue the related study medication 
(pertuzumab or trastuzumab) permanently. 
Continue treatment as deemed suitable by the 
local investigator. 
7.       Cardiac toxicity (asymptomatic drop in LVEF 
or symptomatic CHF) 
Study treatment (all medication in the cycle) to be 
held, continued, or resumed according to the 
algorithm in Appendix F 
Related study medication (pertuzumab or 
trastuzumab) to be discontinued permanently in 
case of symptomatic CHF (refer to Management 
of Symptomatic Cardiac Changes). 
8. Cardiac toxicity (NCI CTCAE or other cardiac 
toxicities not covered by the treatment algorithm in 
Appendix F 
Actions must follow rules 4 to 6 for 
non-hematological toxicities. 
9. Hematological toxicity − neutropenia 
Hold study treatment (all medication in the cycle) 
until neutrophils 1000/mcL 
CHF = congestive heart failure; LVEF = left ventricular ejection fraction; NCI CTCAE = National 
Cancer Institute Common Terminology Criteria for Adverse Events; NYHA = New York Heart 
Association. 
a Severity corresponding to NYHA classification (see Appendix G). 
 
6.2.1 Management of Cardiac Toxicity  
 
All patients must have a baseline evaluation of cardiac function including a measurement of LVEF 
by either ECHO or MUGA scan prior to study entry. Only patients with LVEF of  50% should 

 
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be entered into this study. While receiving treatment, all patients will have regular monitoring of 
LVEF with ECHO or MUGA (at screening, 6 weeks and 12 weeks [after Cycle1, Day 1], followed 
by LVEF evaluations every 3 months or as clinically indicated). During the course of therapy with 
pertuzumab and trastuzumab, patients should be monitored for signs and symptoms of heart failure 
(i.e., dyspnea, tachycardia, new unexplained cough, neck vein distention, cardiomegaly, 
hepatomegaly, paroxysmal nocturnal dyspnea, orthopnea, peripheral edema, and rapid 
unexplained weight gain). The diagnosis must be confirmed using the same method used to 
measure LVEF at baseline (either ECHO or MUGA).  
 
Patients who develop signs and symptoms of heart failure NCI CTCAE v4.0 Grade 2, 3, or 4 
should have atezolizumab, pertuzumab and trastuzumab held and should receive treatment for 
heart failure as prescribed by the Heart Failure Society of American (HFSA 2010; e.g., ACE 
inhibitors, angiotensin-II receptor blockers, -blockers, diuretics, and cardiac glycosides, as 
needed). 
 
Consideration should be given to obtaining a cardiac consultation. LVEF should be reassessed 
after 3 weeks (using the same method of measurement). If the symptoms of heart failure resolve 
with treatment, and cardiac function (as measured by ECHO or MUGA) improves, atezolizumab, 
pertuzumab and trastuzumab may be restarted after discussion with the patient concerning the risks 
and benefits of continued therapy. If the patient is benefiting clinically from study therapy, the 
benefit of continued treatment may outweigh the risk of cardiac dysfunction. If pertuzumab and 
trastuzumab are restarted, continued surveillance with noninvasive measures of LVEF (ECHO or 
MUGA) will continue per protocol. 
 
Study treatment will be adjusted if necessary according to the algorithm described in Appendix F 
If an investigator is concerned that an adverse event may be related to cardiac dysfunction, an 
additional LVEF measurement should be performed. Trastuzumab and pertuzumab will be 
discontinued permanently in any patient who develops clinical signs and symptoms suggesting 
symptomatic CHF, with the diagnosis confirmed by a suggestive chest X-ray and a drop in LVEF 
by ECHO or MUGA.  
 
CHF should be treated and monitored according to standard medical practice. At present, there are 
inadequate data available to assess the prognostic significance of asymptomatic drops of LVEF. 
Study treatment must be held in all patients for whom a drop of LVEF to <40% or 40% −45% with 
a 10%-point or greater drop below baseline (Appendix H). If this value is confirmed or LVEF has 
not recovered to > 45% or 40% − 45% and LESS than 10% below baseline with a repeat assessment 
within 3 weeks of the first assessment, using the same assessment method, study drug must be 
discontinued (see Appendix H). If the subject was unequivocally deriving clinical benefit, the 
subject may be able to resume atezolizumab as determined by the investigator. 
 
Patients who resume therapy will resume pertuzumab at the study dose of 420 mg every 3 weeks 
(840 mg loading dose of pertuzumab required if study drug is held > 6 weeks) and trastuzumab at 
the study dose of 6 mg/kg every 3 weekly. Atezolizumab will resume at the study dose of 1200 
mg every 3 weeks. Patients will be allowed to hold and resume therapy for a maximum of three 
times, after which the study drug must be discontinued. 
 

 
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The incidence of CHF will also be recorded throughout the study. See Appendix I for details of 
NYHA classification, Appendix J for LVSD according to NCI CTCAE v4.0 grading, and 
Appendix K for reporting conventions for LVSD/heart failure. 
 
6.2.2 Management of Infusion Reactions   
 
Like other monoclonal antibodies, pertuzumab and trastuzumab have been associated with 
infusion-related reactions (IRRs), such as chills, diarrhea, fatigue, headache, nausea, and pyrexia. 
The infusion rate of pertuzumab may be slowed or interrupted and appropriate medical therapies 
should be administered if the patient develops a significant IRR. Patients should be evaluated and 
carefully monitored until complete resolution of signs and symptoms. 
 
The infusion should be discontinued immediately if the patient experiences a serious 
hypersensitivity reaction.  
 
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. 
 
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 
assessed and reported, if appropriate. Each reported AE or SAE will be described by its duration 
(i.e., start and end dates), expectedness, regulatory seriousness criteria if applicable, suspected 
relationship to the atezolizumab and actions taken. 
 
After initiation of study treatment, all adverse events will be reported until 30 days after the last 
dose of study treatment or until initiation of new systemic anti-cancer therapy, whichever occurs 
first. Serious adverse events and adverse events of special interest deemed to be reasonably related 
to Atezolizumab will continue to be reported until 90 days after the last dose of study treatment or 
until initiation of new systemic anti-cancer therapy, whichever occurs first.   
 
7.1 Adverse Events Lists 
 
7.1.1 Anticipated Toxicities for Atezolizumab 
 
Atezolizumab has been associated with risks such as the following:  IRRs and immune-related 
hepatitis, pneumonitis, colitis, pancreatitis, diabetes mellitus, hypothyroidism, hyperthyroidism, 
adrenal insufficiency, Guillain-Barré syndrome, myasthenic syndrome or myasthenia gravis, and 
meningoencephalitis.  In addition, systemic immune activation (described below) is a potential 
risk associated with atezolizumab when given in combination with other immunomodulating 
agents.   
 

 
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Refer to the Atezolizumab Investigator's Brochure for a detailed description of anticipated safety 
risks for atezolizumab.   
 
7.1.2 Anticipated Toxicities for Trastuzumab and Pertuzumab 
 
Trastuzumab and pertuzumab have been associated with risks such as the following: cardiac 
dysfunction, ARRs, pulmonary AEs, neutropenia/febrile neutropenia, diarrhea, fatigue, nausea, 
vomiting, and decreased appetite. Please see Section 6 of the trastuzumab and pertuzumab 
Investigator’s Brochures for a detailed description of anticipated safety risks for trastuzumab and 
pertuzumab. 
 
7.2 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. 
 
• Expectedness: 
Expected adverse events are those adverse events that are listed or characterized in the 
current adverse event list, the Package Insert, the Investigator Brochure or is included in 
the informed consent document as a potential risk. 
 
Unexpected adverse events are those not listed in the Package Insert (P.I.) or current 
Investigator Brochure (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 
 

 
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7.3 
DF/HCC Expedited Adverse Event Reporting  
Investigators must report to the Overall PI any serious adverse event (SAE) within 24 business 
hours of first awareness of the event (immediately if the event is fatal or life-threatening). 
 
For multi-institution studies where a DF/HCC investigator is serving as the Overall Principal 
Investigator, each participating institution must abide by the reporting requirements set by the 
DF/HCC. This applies to any medical event equivalent to an unexpected grade 2 or 3 with a 
possible, probable or definite attribution, unexpected grade 4 toxicities, and grade 5 (death) 
regardless of study phase or attribution. 
 
Investigative sites within DF/HCC and DF/PCC will report SAEs directly to the DFCI Office for 
Human Research Studies (OHRS) per the DFCI IRB reporting policy.  
 
Other investigative sites will report SAEs to their respective IRB according to the local IRB’s 
policies and procedures in reporting adverse events. A copy of the submitted institutional SAE 
form should be forwarded to the Overall PI within the timeframes detailed in the table below.   
 
The Coordinating Center will submit SAE reports from outside institutions to the DFCI 
OHRS according to DFCI IRB policies and procedures in reporting adverse events. 
 
DF/HCC Reportable AEs 
 
 
 
Attribution 
DF/HCC Reportable AEs 
Gr. 2 & 3 AE 
Expected 
Gr. 2 & 3 AE 
Unexpected 
Gr. 4 AE Expected 
Gr. 4 AE 
Unexpected 
Gr. 5 AE 
Expected or 
Unexpected 
Unrelated 
Unlikely 
Not required 
Not required 
5 calendar days# 
5 calendar days 
24 hours* 
Possible 
Probable 
Definite 
 
Not required 
 
5 calendar days 
 
5 calendar days# 
 
5 calendar days 
 
24 hours* 
# If listed in protocol as expected and not requiring expedited reporting, event does not need to be reported. 
 
* For participants enrolled and actively participating in the study or for AEs occurring within 30 days of the last 
intervention, the AE should be reported within 24 business hours of learning of the event. 
 
 
7.4 
Expedited Reporting to the Food and Drug Administration (FDA) 
 
The Overall PI, as study sponsor, will be responsible for all communications with the FDA. The 
Overall PI will report to the FDA, regardless of the site of occurrence, any serious adverse event 
that meets the FDA’s criteria for expedited reporting following the reporting requirements and 
timelines set by the 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. 
 
The overall PI will also notify the FDA and all participating investigators, in a written IND 

 
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Safety Report, of any serious, unexpected AE that is considered reasonably or possibly related to 
the use of Atezolizumab, Trastuzumab, or Pertuzumab. An unexpected adverse event is one that 
is not already described in the Atezolizumab, Trastuzumab, or Pertuzumab.investigator brochure. 
 
7.5 
Expedited Reporting to Genentech  
Investigators must report SAEs to Genentech within the timelines described below. The 
completed MedWatch/case report should be faxed (immediately upon completion to Genentech 
Drug Safety using the Genentech Safety Reporting Fax Cover Sheet found in Appendix N to: 
650-238-6067  
 
Serious adverse events (SAEs), pregnancy reports and AEs of special interest (AESIs), where the 
patient has been exposed to the Product, will be sent on a MedWatch3500A form to Roche. The 
Genentech-specific protocol number, ML40055, should be referenced on all submissions to 
Genentech., Transmission of these reports (initial and follow-up) will be either electronically or 
by fax and within the timelines specified below: 
• SAEs: 
Serious AE reports that are related to Atezolizumab shall be transmitted to Genentech-
Roche within fifteen (15) calendar days of the awareness date. 
• Other SAEs: 
Serious AE reports that are unrelated to Atezolizumab shall be transmitted to Genentech-
Roche within thirty (30) calendar days of the awareness date. 
• Pregnancy Reports: 
While such reports are not serious AEs per se, any reports of pregnancy, where the fetus 
may have been exposed to the Product, shall be transmitted to Genentech-Roche within 
thirty (30) calendar days of the awareness date. Pregnancies will be followed up until the 
outcome of the pregnancy is known, whenever possible, based upon due diligence taken to 
obtain the follow-up information. 
• AESIs: 
AESIs requiring expedited reporting shall be forwarded to Roche within fifteen (15) 
calendar days of the awareness date. Others shall be sent within thirty (30) calendar days.  
 
Relevant follow-up information should be submitted to Genentech Drug Safety as soon as it 
becomes available and/or upon request. 
 
7.5.1 Adverse Events of Special Interest (AESI) 
 
The following AEs are considered events of special interest and must be reported to the Genentech 
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: - 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  

 
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• Suspected transmission of an infectious agent by the study treatment, as defined below:   
o 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.  
 
• Atezolizumab AESIs: 
o Pulmonary toxicity (Pneumonitis)  
o Colitis  
o Endocrinopathies: diabetes mellitus, pancreatitis, adrenal insufficiency, 
hyperthyroidism, and hypophysitis  
o Hepatitis, including AST or ALT > 10xULN  
o Systemic lupus erythematosus  
o Neurological disorders: Guillain-Barré syndrome, myasthenic syndrome or 
myasthenia gravis, and meningoencephalitis  
o Events suggestive of hypersensitivity, infusion-related reactions, cytokine release 
syndrome, influenza-like illness, systemic inflammatory response syndrome, and 
systemic immune activation  
o Nephritis  
o Ocular toxicities (e.g., uveitis, retinitis) Myositis Myopathies, including 
rhabdomyolysis  
o Grade > 2 cardiac disorders (e.g., atrial fibrillation, myocarditis, pericarditis) 
o Vasculitis 
• Trastuzumab AESI: 
o Congestive heart failure 
• Pertuzumab AESI: 
o Asymptomatic decline in LVEF requiring treatment or leading to discontinuation of 
Trastuzumab or Pertuzumab 
 
7.6 
Additional Reporting Requirements for Genentech 
7.6.1 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 Genentech, 
Inc. 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. 
 
Additional information on any Trastuzumab or Pertuzumab-exposed pregnancy and infant will 
be requested by Roche Drug Safety at specific time points (i.e. after having received the initial 

 
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report, at the end of the second trimester, 2 weeks after the expected date of delivery, and at 3, 6, 
and 12 months of the infant’s life). 
 
7.6.2 Post-Study Adverse Events 
 
The investigator should expeditiously report any SAE occurring after a subject has completed or 
discontinued study participation if attributed to Atezolizumab 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.  
 
7.6.3  Reconciliation 
 
The Sponsor agrees to conduct reconciliation for the product. Genentech 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 Genentech 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.   
 
7.6.4 Product Complaints 
 
A product complaint is any written or oral information received from a complainant that alleges 
deficiencies related to identity, quality, safety, strength, purity, reliability, durability, 
effectiveness or performance of a product after it has been released and distributed to the 
commercial market or clinical trial. 
 
How to file a complaint: 
For all Investigator Initiated Studies (interventional and non-interventional):  
Product Complaints with an AE (adverse event) should be reported via email/fax to:  
Usds_aereporting-d@gene.com OR 650-238-6067 
 
Product Complaints without an AE (adverse event) should be reported via email to: 
• For Interventional Investigator Initiated Studies: 
kaiseraugst.global_impcomplaint_management@roche.com 
• For Non-Interventional Investigator Initiated Studies: us-acmo-d@gene.com 
 
All complaints must be filed within 1 business day for pre-approved products and 15 calendar 
days for approved products. Complaints can be reported using a Medwatch, CIOMS or any 
Genentech-approved reporting form (same as SAEs, AESI etc.).  
 
 

 
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7.7 
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.  
 
7.8 
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.  Abnormal laboratory results deemed to be not-
clinically significant (NCS) by a treating investigator do not need to be entered as an adverse event 
in the 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).  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 

 
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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 Genentech. 
 
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. The prepared solution for infusion should be used immediately 
to limit microbial growth in case of potential accidental contamination. If not used 
immediately, in-use storage time and conditions prior to use are the responsibility of the user. 
In 250-mL IV infusion bags, the dose solution may be stored at 2°C–8°C (36°F-46°F) for 24 
hours or at ambient temperature ≤ 25°C (77°F) for 8 hours.  
 
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. 
 
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. 
 

 
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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 Genentech. 
 
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. 
 
8.2 
Pertuzumab 
8.2.1 Description 
 
Pertuzumab (Perjeta®) is a humanized monoclonal antibody to the HER2 receptor that blocks 
ligand-dependent heterodimerization of HER2 with other HER family members. This results 
in the inhibition of ligand-initiated intracellular signaling. In addition, pertuzumab mediates 
antibody-dependent cellular cytotoxicity. 
 
8.2.2 Form, storage and stability 
 
Pertuzumab is provided as a single-use formulation containing 30 mg/mL pertuzumab in 20 
mM L-histidine acetate (pH 6.0), 120 mM sucrose, and 0.02% polysorbate 20. Each 20-mL 
vial contains 420 mg of pertuzumab (14.0 mL/vial). Pertuzumab does not contain any 
antimicrobial preservative. Therefore, care must be taken to ensure the sterility of the prepared 
solution for infusion and should be prepared by a healthcare professional. The appropriate dose 
of pertuzumab should be withdrawn from the vial using aseptic techniques and added to 250 
mL 0.9% sodium chloride for injection for subsequent patient administration. For information 
on the formulation, packaging, and handling of pertuzumab, see the pertuzumab Investigator's 
Brochure. 
 

 
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8.2.3 Compatibility 
 
No incompatibilities between pertuzumab and polyvinylchloride, polyethylene, or non-PVC 
polyolefin bags have been observed. Dextrose (5%) in water (D5W) solution should not be 
used to dilute pertuzumab since it has been shown to be chemically and physically unstable in 
such solutions (dilute formulations of pertuzumab liquid formulations in D5W IV bags did not 
maintain stable pH after storage at room temperature [27°C − 33°C] for 24 hours followed by 
24 hours at refrigerator temperature [2°C − 8°C]). 
 
8.2.4 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.  
 
8.2.5 Availability 
 
   Pertuzumab is an investigational agent and will be supplied free of charge from Genentech. 
 
8.2.6 Preparation 
 
Pertuzumab can be diluted into a 250 mL 0.9% sodium chloride PVC or non-PVC polyolefin 
infusion bag. The dose solution should be used immediately. If not used immediately, it can 
be stored at 2°C–8°C for up to 24 hours. 
 
Pertuzumab vials should not be used beyond the expiration date provided by the manufacturer.  
No preservative is used in the pertuzumab 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. 
 
8.2.7 Administration 
 
The loading dose of pertuzumab will be 840 mg administered as a 60-minute IV infusion, 
followed every 3 weeks thereafter by a dose of 420 mg administered over a period of 30 to 60 
minutes. For patients already receiving pertuzumab as part of their ongoing systemic therapy, 
no loading dose is required in the case of an interval < 6 weeks between last dose of pertuzumab 
and the first administration of on-study pertuzumab. An observation period of 30 to 60 minutes 
is recommended after each pertuzumab infusion, according to each participating site’s 
institutional guidelines.  
 
8.2.8 Ordering 
 
Pertuzumab will be obtained directly from Genentech. 
 
8.2.9 Accountability 
 

 
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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.) 
 
8.2.10 Destruction and Return 
 
At the end of the study, unused supplies of pertuzumab should be destroyed according to 
institutional policies. Destruction will be documented in the Drug Accountability Record 
Form. 
 
8.3 
Trastuzumab 
8.3.1 Description 
 
Trastuzumab (Herceptin®) is a recombinant monoclonal antibody that binds specifically and 
with high affinity to the extracellular domain of HER2. Trastuzumab has been shown to inhibit 
the proliferation of human tumor cells overexpressing HER2 both in vitro and in vivo. 
 
8.3.2 Form, storage and stability 
 
This study will use trastuzumab from investigational supply. Trastuzumab is a sterile, white to 
pale yellow, preservative free lyophilized powder for intravenous (IV) administration, supplied 
as a 150 mg vial. Each single-dose vial of trastuzumab delivers 150 mg trastuzumab, 136.2 mg 
α,α-trehalose dihydrate, 3.4 mg L-histidine HCl monohydrate, 2.2 mg L-histidine, and 0.6 mg 
polysorbate 20. 
 
Use appropriate aseptic technique. Reconstitute each 150 mg vial of single-dose Trastuzumab 
with 7.4 mL of sterile water for injection (SWFI) to yield a solution containing 21mg/mL 
trastuzumab that delivers 7.15 mL (150 mg trastuzumab), at a pH of approximately 6. 
Use of other reconstitution diluents should be avoided. Determine the dose of trastuzumab 
needed, based on a loading dose of 8 mg trastuzumab/kg body weight for q3wk dosing 
schedules or a maintenance dose of 6 mg/kg trastuzumab/kg body weight for q3w dosing 
schedules. Calculate the correct dose using 21 mg/mL trastuzumab solution. Withdraw this 
amount from the vial and add it to an infusion bag containing 250 mL of 0.9% sodium chloride, 
USP. DEXTROSE (5%) SOLUTION SHOULD NOT BE USED. Gently invert the bag to 
mix the solution. The reconstituted preparation results in a colorless to pale yellow transparent 
solution. Parenteral drug products should be inspected visually for particulates and 
discoloration prior to administration. 
  
Trastuzumab should not be mixed or diluted with other drugs. Trastuzumab should not be 
filtered during administration.  
Trastuzumab vials must be used within 24 hours after dilution when stored at 2°C to 8°C. 
 

 
DF/HCC Protocol #: 17-546 
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57 
 
For information on the formulation, packaging, and handling of trastuzumab, see the pharmacy 
manual and the trastuzumab Investigator's Brochure. 
 
 
8.3.3 Compatibility 
 
No incompatibilities between trastuzumab and polyvinylchloride, polyolefin, or polypropylene 
bags have been observed. Dextrose 5% solution should not be used because it causes 
aggregation of the protein. Trastuzumab should not be mixed or diluted with other drugs. 
 
8.3.4 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.  
 
8.3.5 Availability 
 
Trastuzumab is an investigational agent and will be supplied free of charge from Genentech. 
 
8.3.6 Preparation 
 
Trastuzumab vials should not be used beyond the expiration date provided by the 
manufacturer.  No preservative is used in the trastuzumab 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. 
 
8.3.7 Dosage and administration 
 
High-dose trastuzumab will be administered at a dose of 6 mg/kg weekly, infused 
intravenously over 30 -90 minutes. No loading dose is required. Trastuzumab-naïve patients 
should receive their first dose over 90 minutes. Patients who are actively receiving 
trastuzumab prior to enrollment will have a dose increase to 6 mg/kg IV weekly. The dose of 
trastuzumab should be based on institutional guidelines.  Weekly doses may be administered 
+4 -2 days apart. 
 
8.3.8 Ordering 
 
Trastuzumab will be obtained directly from Genentech  
 
8.3.9 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.) 

 
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8.3.10 Destruction and Return 
 
At the end of the study, unused supplies of trastuzumab 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. 
 
Patients with an accessible tumor outside the field of radiation will be asked to undergo an optional   
baseline tumor biopsy. We plan to use baseline biopsy tissue to perform several immune profiling 
assays, detailed below.  On baseline tumor biopsies, we will perform characterization based on 
histology (TILs), protein expression, and mRNA expression.  Additionally, we will bank 
specimens for possible future DNA analysis, and further testing. 
 
Serial blood draws for correlative science are required on this trial; blood draws will be obtained 
per the schedule in Table 9-1.  On each blood draw, we will perform flow cytometry to characterize 
protein expression of immune mediators, 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 
Blood  
Cycle 1 Day 1 
1-9 mL Streck Tube 
5- 10mL green top tubesa,b  
Cycle 3 Day 1 
1-9 mL Streck Tube 
5- 10mL green top tubesa,b 
Cycle 5 Day 1 
1-9 mL Streck Tube 
5- 10mL green top tubesa,b 
Cycle 9 Day 1 
1-9 mL Streck Tube 
5- 10mL green top tubesa,b 
At progression or off protocol therapy 
1-9 mL Streck Tube 
5- 10mL green top tubesa,b 
Fresh Tissue  
Biopsy (optional)  
Pre-treatment 
5-7 cores  
Cycle 2 Day 1 to 21 
5-7 cores  

 
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59 
 
Research 
Sampling 
Time point 
Contents 
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 
CSF  
Screening 
3-10 mL in Streck Tubes 
Anytime before cycle 3 
3-10 mL in sterile 
collection tubes 
At progression or off protocol therapy 
3-10 mL in sterile 
collection tubes 
a. EDTA (purple top) tubes or CPT tubes may be used interchangeably with green top tubes. 
b. This collection will only be performed at DFCI due to the time sensitive nature of processing. 
 
9.1 
Archival Tissue Collection 
 
1 block or 15, 4 microns thick unstained, charged slides will be collected for future research. 
Archival tissue sample does not need to be collected prior to registration.  
  
9.2 
Fresh Tissue Collection 
 
9.2.1 Collection at Dana-Farber Cancer Institute 
 
Biopsies are optional at all timepoints [baseline (pre-treatment), Cycle 2 Day 1, and at the time of 
progression for patients who achieved an objective response and/or a prolonged stable disease (≥ 
24 weeks)].  The Cycle 2 Day 1 biopsy should be performed as close to Cycle 2 Day 1 as possible 
but may be collected anytime between Cycle 2 Day 1 and Cycle 2 Day 21.  
Biopsies should not be performed on Friday afternoons, as there may not be time for processing 
of the fresh tissue.  If a biopsy must be performed on Friday morning, the lab of Mariano 
Severgnini must be notified ahead of time to ensure that there will be adequate time for 
processing fresh tissue, since fresh tissue cannot be stored over the weekend (contacts: Tara 
Patel, tara_patel@dfci.harvard.edu; or Amy Cunningham, Amy_Cunningham@dfci.harvard.edu; 
or Martha Holland, marthak_holland@dfci.harvard.edu).  The specimens in RNALater and 
formalin may be stored over the weekend and shipped on Monday. Specimens in RNAlater and 
formalin should be stored at room temperature until shipment. 
 
Ideally, five core biopsies will be obtained: 
 
• Two cores should be placed in 10% neutral buffered formalin tube supplied by the study. 
• One cores should be placed in RNAlater 
• Two cores should be placed in sterile DMEM 
 
The order of specimen collection should be: 
• First core: 10% neutral buffered formalin 

 
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• Second core: Sterile DMEM 
• Third core: RNAlater 
• Fourth core: Sterile DMEM 
• Fifth core: 10% neutral buffered formalin 
 
If additional cores are obtained, they should be processed as follows: 
• Sixth core: RNAlater 
• Seventh core: 10% neutral buffered formalin 
 
Guidelines for biopsy from various metastatic sites can be found in Appendix M. 
 
9.2.2 Collection at Northwestern University Medical Centter 
 
Biopsies are optional at all timepoints [baseline (pre-treatment), Cycle 2 Day 1, and at the time of 
progression for patients who achieved an objective response and/or a prolonged stable disease (≥ 
24 weeks)].  The Cycle 2 Day 1 biopsy should be performed as close to Cycle 2 Day 1 as possible 
but may be collected anytime between Cycle 2 Day 1 and Cycle 2 Day 21.  
 
The specimens in RNALater and formalin may be stored over the weekend and shipped on 
Monday. Specimens in RNAlater and formalin should be stored at room temperature until 
shipment. 
 
Ideally, five core biopsies will be obtained: 
• Two cores should be placed in 10% neutral buffered formalin tube supplied by the study. 
• One cores should be placed in RNAlater 
• Two cores should be frozen in OCT 
 
The order of specimen collection should be: 
• First core: 10% neutral buffered formalin 
• Second core: OCT 
• Third core: RNAlater 
• Fourth core: OCT 
• Fifth core: 10% neutral buffered formalin 
 
If additional cores are obtained, they should be processed as follows: 
• Sixth core: RNAlater 
• Seventh core: 10% neutral buffered formalin 
 
 
9.2.3 Handling and Shipping  
 
After being obtained, processing of the cores is as follows: 
 
• All samples should be de-identified and labeled with the Participant initials, Participant 

 
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Study ID number and date of procedure. 
 
• Complete the requisition form (Appendix G) for the sample 
 
• Cores in sterile DMEM should be brought as fresh tissue immediately to the lab of Mariano 
Severgnini at:  
Center for Immuno-Oncology 
Dana-Farber Cancer Institute 
1 Jimmy Fund Way, JF0406 
Boston, MA 02215 
Phone: (617) 632-2421 
Pager: 42093 
 
Cores must arrive to the lab to be processed for TILs (as described below) within 1.5 
hours of its collection ideally, though and additional 2-hour window is allowed.  In 
addition, a small piece of one core will be immediately frozen in liquid nitrogen upon 
arrival to Mariano Severgnini, for later use for RNA sequencing. Please notify the lab of 
expected specimen collection approximately one week in advance of specimen drop-off 
(contacts: Tara Patel, tara_patel@dfci.harvard.edu; or Amy Cunningham, 
amy_cunningham@dfci.harvard.edu; or Martha Holland, 
marthak_holland@dfci.harvard.edu). 
 
• Cores in formalin collected at DFCI should be brought to the Brigham and Women’s 
SHL lab (with appropriate work order submitted and printed) on the 6th floor of the Thorn 
building, where a block will be made.  An email will be sent to the CRC within 2-3 days 
to confirm that the block has been made.  The block should then be picked up from the 
SHL lab and brought to Dr. Scott Rodig on the 6th floor of the Thorn building. 
 
• Cores in formalin collected at Northwestern should either be processed into an FFPE 
block per local policies and shipped to the current DFCI CRC or can be shipped 
overnight to the DF/HCC Clinical Trial Laboratory, who can process the sample into an 
FFPE block.  
 
If FFPE Block: 
Dana-Farber Cancer Institute 
Attn: 17-546 Study Team 
450 Brookline Ave., DA157 
Boston, MA 02215 
If in Formalin: 
Brigham and Women’s Hospital 
Attn: Breast Tissue/Blood Bank 
Thorn Building – Room 428 
20 Shattuck Street 
Boston, MA 02115 
 
 
If mailing to the the DF/HCC Clinical Trials Core Laboratory, please email 
dfcibreastbank@partners.org with participant name, study ID, date of collection, approximate 
time of collection, and study time point the day prior to collection. Any tissue remaining after 
study-specific protocol testing occurs will be banked in the DF/HCC Clinical Trial Core 

 
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62 
 
Laboratory and may be used for additional or future analyses as needed.   
 
 
• Cores in RNAlater should be brought or shipped overnight to the DF/HCC Clinical Trial 
Core Laboratory with the sample requisition (Appendix G):   
 
Brigham and Women’s Hospital 
Attn: Breast Tissue/Blood Bank 
Thorn Building – Room 428 
20 Shattuck Street 
Boston, MA 02115 
dfcibreastbank@partners.org  
 
Please email the DF/HCC Clinical Trials Core Laboratory (dfcibreastbank@partners.org) with 
participant name, study ID, date of collection, approximate time of collection, and study time 
point the day prior to collection. Any tissue remaining after study-specific protocol testing occurs 
will be banked in the DF/HCC Clinical Trial Core Laboratory and may be used for additional or 
future analyses as needed.   
 
• Cores in OCT collected at Northwestern may be stored locally at -80°C and batch shipped 
overnight on dry ice to OR shipped overnight on dry ice on the day of collection to the 
DF/HCC Clinical Trial Core Laboratory with the sample requisition (Appendix G) to: 
 
Brigham and Women’s Hospital 
Attn: Breast Tissue/Blood Bank 
Thorn Building – Room 428 
20 Shattuck Street 
Boston, MA 02115 
dfcibreastbank@partners.org  
 
Please email the DF/HCC Clinical Trials Core Laboratory (dfcibreastbank@partners.org) with 
participant name, study ID, date of collection, approximate time of collection, and study time 
point the day prior to collection. Any tissue remaining after study-specific protocol testing occurs 
will be banked in the DF/HCC Clinical Trial Core Laboratory and may be used for additional or 
future analyses as needed.   
 
 
9.3 
Blood Collection 
 
9.3.1 Collection at Dana-Farber Cancer Institute 
 
Research blood collection is mandatory for all patients for flow cytometry and potential DNA 
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.  
 

 
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63 
 
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 Mariano Severgnini 
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:  
• 1-9 mL Streck Tube for whole blood 
• 5- 10mL green top tubes for whole blood 
 
Cycles 3, 5, and 9 Day 1:  
• 1-9 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): 
• 1-9 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: 
• 1-9 mL Streck Tube for whole blood 
• 5- 10mL green top tubes for whole blood 
 
If green top tubes are unavailable, CPT tubes or purple tops may be substituted. 
 
9.3.2 Collection at Northwestern University Medical Center 
 
Research blood collection is mandatory for all patients for flow cytometry and potential DNA 
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. 
 
The following research blood samples are required:  
Cycle 1 Day 1:  
• 1-9 mL Streck Tube for whole blood 
 
Cycles 3, 5, and 9 Day 1:  
• 1-9 mL Streck Tube for whole blood 
 
Off Treatment (at progression or off protocol therapy, whichever comes first): 

 
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• 1-9 mL Streck Tube 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: 
• 1-9 mL Streck Tube for whole blood 
 
9.3.3 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 3-4 hours of being drawn at ambient temperature immediately 
after being drawn to Mariano Severgnini at: 
 
Center for Immuno-Oncology 
Dana-Farber Cancer Institute 
1 Jimmy Fund Way, JF0406 
Boston, MA 02215 
Phone: (617) 632-2421 
Pager: 42093  
 
• Streck tubes: 
 
Fill the Streck tube completely and immediately mix by gentle inversion 8 to 10 times. 
Inadequate or delayed mixing may result in accurate results. 
 
Tube precautions: 
- 
DO NOT FREEZE OR REFRIGERATE TUBES as this could result in cfDNA 
breakage. Blood collected in the Streck tube can be stored for 14 days between 6-
37 degrees Celsius. 
- 
Do not use tubes after expiration date. 
- 
Fill the tube completely; overfilling or underfilling of tubes will result in an 
incorrect blood-to-additive ratio and may lead to incorrect analytical results. 
 
  
Streck tubes and sample requisition (Appendix G) should be shipped to: 
 
Brigham and Women’s Hospital 
Attn: Breast Tissue/Blood Bank 
Thorn Building – Room 428 
20 Shattuck Street 
Boston, MA 02115 
dfcibreastbank@partners.org 
 

 
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65 
 
Please email the DF/HCC Clinical Trials Core Laboratory (dfcibreastbank@partners.org) 
with participant name, study ID, date of collection, approximate time of collection, and 
study time point the day prior to collection. Any tissue remaining after study-specific 
protocol testing occurs will be banked in the DF/HCC Clinical Trial Core Laboratory and 
may be used for additional or future analyses as needed.   
 
 
 
9.4 
Cerebrospinal fluid (CSF) 
 
9.4.1 Collection 
 
CSF collection is mandatory, except in patients in whom the treating investigator believes CSF 
collection would be associated with excessive risk (e.g. risk of herniation, significant midline 
shift, need for therapeutic anticoagulation) . We plan to collect CSF at baseline for cytology and 
potential DNA isolation, before cycle 3 day 1, and at progression or off protocol therapy, 
whichever comes first. 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. 
 
The following CSF blood samples are mandatory: 
Screening (baseline):  
• 2-10 mL in sterile collection tubes (Northwestern should use Streck Tubes) 
▪ Only 5cc of CSF is required per tube 
 
 
Between C2D1 and C3D1:  
• 2-10 mL in sterile collection tubes (Northwestern should use Streck Tubes) 
▪ Only 5cc of CSF is required per tube 
 
              
Off Treatment (at progression or off protocol therapy, whichever comes first): 
• 2-10 mL in sterile collection tubes (Northwestern should use Streck Tubes) 
▪ Only 5cc of CSF is required per tube 
The first (baseline) CSF collection is billed to the patient’s insurance. It is recommended that the 
following clinical tests be ordered at the baseline CSF collection, in addition to the research 
collection: Glucose, Cytology, and Total Protein. 
 
 
 
9.4.2 Handling and Shipping 
 
CSF tubes should be brought or shipped overnight on the day of collection at ambient temperature 
to the DF/HCC Clinical Trial Core Laboratoryat the following address:   
 
Brigham and Women’s Hospital 
Attn: Breast Tissue/Blood Bank 
Thorn Building – Room 428 
20 Shattuck Street 

 
DF/HCC Protocol #: 17-546 
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66 
 
Boston, MA 02115 
dfcibreastbank@partners.org 
 
Please email the DF/HCC Clinical Trials Core Laboratory (dfcibreastbank@partners.org) with 
participant name, study ID, date of collection, approximate time of collection, and study time 
point the day prior to collection. 
 
Note: All liquid transfers should be performed in a sterile laminar flow hood. 
1. Process samples within 2 hours of collection. Those collected with Streck preservative 
can be processed within 24 hours. 
2. Transfer CSF to a 15mL Falcon tube 
3. Spin 15mL tubes containing CSF at 1900g for 10 minutes at room temperature with the 
brake reduced to 6  
a. A small pellet may be visible after the spin 
b. If also using sample for single cell analysis, reduce speed to 400-700g to pellet 
cells 
4. Carefully remove tubes from centrifuge and transfer 6 mL CSF to a barcoded FluidX 
10mL tube  
a. Transfer any additional CSF to a separate FluidX 10mL tube 
b. Note: If FluidX tubes are unavailable, store samples in well-labeled cryotubes 
c. If also using sample for single cell analysis, lyse red blood cells in pellet (after 
collecting supernatant) using 1X BD Pharm Lyse per the manufacturer's protocol 
and resuspend in RPMI 
5. Store tube(s) at -80oC until analysis 
 
9.5 
Planned Assays for Correlative Objectives 
 
All of the below-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. 
 
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] 

 
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67 
 
 
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 per 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. 
 
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 

 
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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 conducted at the Broad Institute.   
 
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 start of protocol therapy unless 
otherwise specified. Screening laboratory assessments must be done within 8 calendar days prior 
to initiating protocol therapy.  
 
All assessments must be performed prior to administration of any study agent unless otherwise 
specified. The following windows apply:   
• Screening assessments performed within 8 days prior to Day 1 of Cycle 1 do not have 
to be repeated for Day 1 of Cycle 1.  
• Day 1 study assessments for Cycle 2 and beyond must be performed within +/- 3 days of 
the protocol-specified date.   
• Weekly trastuzumab (first 24 weeks) must be given within +4/- 2 days of the protocol-
specified date. 
• Restaging scans are performed within the last 15-21 of the previous cycle to ensure scans 
are reviewed in advance. 
• LVEF assessments may be performed up to 7 days prior to scheduled evaluation 
Deviations within +/- 2 days of the protocol-specified timepoints for treatment of study 
assessments are permitted and should be recorded on the minor deviation log. 
 
If a participant’s condition is deteriorating, laboratory evaluations should be repeated within 48 

 
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hours prior to initiation of the next cycle of therapy.  
 
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 restaging 
assessments or questionnaires after a patient has been taken off protocol therapy will not constitute 
a protocol violation. 

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Pre-Study 
Cycle 1 
Cycle 2 
Cycle 3 
Cycle 5 
Subsequent Cycles 
Follow-up 
Day 28 to  
Day -1 
D1 
D1 
D1 
D1 
D1 of each cycle 
Off-Treatment 
Follow-up 
 
+ 3 days 
+ 3 days 
+ 3 days 
+ 3 days 
within 30 days  
Physical exam, ECOG PS 
X 
X 
X 
X 
X 
X 
X 
 
Medical History a 
X 
 
 
 
 
 
 
 
Vital signs, weight b 
X 
X 
X 
X 
X 
X 
X 
 
CBC w/differential c   
X 
X 
X 
X 
X 
X 
X 
 
Chemistry d  
X 
X 
X 
X 
X 
X 
X 
 
TSH e 
X 
X 
X 
X 
 
Xe 
(even cycles) 
 
 
Pregnancy Test f  
X 
 
 
 
 
 
 
 
Echocardiogram or MUGA g 
X 
 
 
X 
X 
Xg 
 
 
Neurological Assessment 
X 
X 
X 
X 
X 
X 
X 
 
Tumor Measurements h  
X 
 
 
X 
X 
Xh 
X 
Xh 
Brain MRI i 
X 
 
 
X 
X 
Xi 
X 
Xi 
Research Blood j 
 
X 
 
X 
 
X 
X 
 
Research Biopsy j, k 
X 
 
Xk 
 
 
 
X 
 
CSF Collection l 
X 
 
X 
 
 
 
X 
 
Archival Tissue Collection j 
X 
 
 
 
 
 
 
 
NANO Scale, MDASI-BT, and 
EQ-5D questionnaires m 
X 
 
 
X 
X 
Xm 
X 
Xm 
General Impression Worksheet n 
X 
 
 
X 
X 
Xn 
Xn 
 
AE Assessment o 
X 
X 
X 
X 
X 
X 
Xo 
 
Safety Follow-Up p/ Survival 
status q 
 
 
 
 
 
 
 
Xq 

 
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71 
 
a. 
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.  
b. Vital signs to include: heart rate, systolic and diastolic blood pressures while the patient is in a seated position. Vital signs and weight will be assessed 
before treatment on Day 1 of every 3-week cycle 
c. 
Hematology: hemoglobin, hematocrit, platelet count, RBC count, WBC count, neutrophil percent and absolute differential count.   
d. Chemistry: sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, calcium, total bilirubin, total protein, albumin, ALT, AST, alkaline 
phosphatase, and LDH.  
e. 
Beginning with cycle 4, TSH is collected every other cycle on Day 1 (i.e. cycles 4, 6, 8, etc).  
f. 
In female subjects of child-bearing potential as defined in the eligibility criteria, serum or urine pregnancy test must be performed within 8 days of 
C1D1. If a urine pregnancy test is positive or cannot be confirmed as negative, a serum pregnancy test will be required.   
g. LVEF evaluations will be assessed at screening, on cycle 3 day 1 (- 7 days) and cycle 5 day 1 (- 7 days), followed by LVEF evaluation every 3 months 
(- 7 days) during the treatment period. Measurements will be done by either ECHO or MUGA scan (with ECHO as the preferred method). 
h. Clinical and radiological tumor assessments will be performed by CT and/or MRI of the chest, abdomen and pelvis at baseline and repeated on the last 
15-21 days of a cycle every 6 weeks for the first 24 weeks and then reduced to every 9 weeks until progression. The same radiographic procedures and 
technique must be used throughout the study for each patient. For participants who have not progressed after 1 year on protocol therapy, re-evaluation 
can be performed every 12 weeks.  For those taken off-treatment for reasons other than progressive disease, tumor measurements should continue to be 
repeated every 6-12 weeks until progression or initiation of a new anticancer regimen; failure to adhere to this schedule will not be considered a protocol 
violation. 
i. 
Screening MRI must be done within 28 days of C1D1.  Subsequent assessments should be done during the last 15-21 days of a cycle, q6weeks for the 
first 24 weeks and then can be reduced to q9 weeks.  If progression is suspected, an unscheduled assessment is permitted.    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 initiation of a new 
anticancer regimen; failure to adhere to this schedule will not be considered a protocol violation. 
j. 
See Section 9 for further information regarding research blood, biopsy, and archival tissue collection  
k. Research biopsies are optional at all 3 timepoints (baseline, at Cycle 2 Day 1, and at the time of progression). The Cycle 2 Day 1 biopsy should be 
performed as close to Cycle 2 Day 1 as possible but may be collected between Cycle 2 Day 1 and Cycle 2 Day 21.   
l. 
CSF collection will be performed at 3 time-points (baseline, before cycle 3, and at progression or off treatment (whichever comes first). It is 
recommended that the following clinical tests be ordered at the baseline CSF collection, in addition to the research collection: Glucose, Cytology, and 
Total Protein. CSF collection is required except in patients in whom the treating investigator believes CSF collection would be associated with excessive 
risk (e.g. risk of herniation, significant midline shift, need for therapeutic anticoagulation) 
m. MDASI-BT, NANO Scale, and EQ-5D questionnaires (Appendices C, D, E and F) will be completed at baseline (which can occur during screening or on 
cycle 1 day 1), and  day 1 of Cycles 3, 5, 9 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 initiation of a new anticancer regimen. 
n. General Impression Worksheet (Appendix L) to be completed by the treating physician at baseline (which can occur during screening or on cycle 1 day 
1) and at the end of each 3-week cycle until and at progression or off treatment (whichever comes first) 
o. Adverse events will be collected until 30 days after removal from study therapy.  
p. Off-Treatment visit should occur within 30 days (+ 7 days) of the date the decision is made to remove the participant from protocol therapy.  Tumor 
assessments (including brain MRI and CAP CT/MRI do not need to be repeated if done within 28 days of off-treatment visit). 
q. Survival status collected every 6 months or until death either via clinic visit or telephone call to the patient or patient’s local provider

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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 have not progressed after 1 year on protocol therapy, re-evaluation can be 
performed every 12 weeks. 
 
Central review by TIMC will take place for all participants to determine response and progression 
in the CNS and in non-CNS disease sites. For clinical decision-making, central radiology results 
will be used at DF/HCC sites. Outside sites may use local review of restaging scans to determine 
disease response for clinical decision-making, if central radiology results are not available in real-
time. Participating sites will submit imaging scans (either hard copy or through secure electronic 
interface) to the coordinating center to be reviewed by TIMC for central review. The TIMC review 
will be entered in the Case Report Forms and used for analysis of antitumor effect. 
 
11.1 
Antitumor Effect – CNS disease  
Tumor response and progression for CNS disease will be assessed using Neuro-Oncology-Brain 
Metastases (RANO-BM) Criteria.  
 
11.1.1 Definitions 
• 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). 
• 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. 
 
11.1.2 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 

 
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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 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’. 
 
11.1.3 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. 
 
11.1.4 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. 
 
11.1.5 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). 

 
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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 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 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 

 
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again at a subsequent protocol scheduled evaluation or sooner although surgery and/or use 
of an advanced imaging modality are strongly encouraged. (2) Surgical pathology obtained 
via biopsy or resection. 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. 
 
Summary of the Proposed RANO Response Criteria for CNS Metastases 

 
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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. 
 
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 

 
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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) 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 

 
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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.  
 
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 

 
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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 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 

 
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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. 
 
11.2.4 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. 
 
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. 
 
11.2.5  Evaluation of Non-Target Lesions 
 

 
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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). 
 
11.2.6  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. 
 
11.2.7  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 
4 wks Confirmation** 
CR 
Not evaluated 
No 
PR 

 
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Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
PR 
Non-CR/Non-
PD/not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not 
evaluated 
No 
SD 
 
PD 
Any 
Yes or No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
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 
 
‘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 
 
11.2.8 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. 
 
 

 
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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.  
 
11.2.9 Clinical Benefit rate  
 
Clinical benefit rate: defined as CR, PR and stable disease (SD) ≥ 24 weeks. 
 
11.3 
Other Response Parameters 
 
11.3.1 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. 
 
11.3.2 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 irRC 
criteria for tumor response.  Therefore, new non-measurable lesions will not discontinue 
any subject from the study. 
 
11.3.3 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. 
 
11.3.4 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 

 
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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). 
 
11.3.5 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 an 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 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: 

 
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11.3.6 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. 
 
11.3.7 Definition of immunotherapy Response Assessment in Neuro-Oncology (iRANO) 
 
Standard RANO criteria differ according to whether the target population is high-grade 
glioma, low-grade brain tumors, or solid tumor brain metastases [Wen et al., 2010{Lin, 
2015 #1185, 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. 
 

 
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If disease progression is confirmed on subsequent scan(s), then the date of progression is 
backdated to the original date of radiographic worsening. 
 
iRANO treatment algorithm for the assessment of progressive imaging fi ndings in patients with neuro-
oncological malignancies undergoing immunotherapy [Okada et al., 2015]. 
 
 
iRANO=immunotherapy Response Assessment in Neuro-Oncology. 

 
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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 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. 
 
11.3.8 Progression-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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11.3.9 Patient-Reported Outcome Measure 
 
The PRO outcome measure for this study is as follows: Scores from the MDASI-BT 
assessment (APPENDIX C) 
 
11.3.10 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 (APPENDIX 
D)[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. 
 
11.3.11  EQ-5D evaluation 
 
In order to evaluate the impact of the study treatment, general health status will be assessed 
by EQ-5D questionarie (APPENDIX E). 
 
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). 
 
12.1 
Data Reporting 
 
12.1.1 Method 
 
The Office of Data Quality (ODQ) will collect, manage, and perform quality checks on the 
data for this study. 
 
12.1.2 Responsibility for Data Submission 
 
Each investigative site is  responsible for submitting data and/or data forms to the ODQ 
according to the schedule set by the ODQ. 
 
12.2 
Data Safety Monitoring 
 

 
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The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity 
and accrual data from this study. The committee is composed of clinical specialists with experience 
in oncology and who have no direct relationship with the study. Information that raises any 
questions about participant safety will be addressed with the Overall PI and study team. 
 
The DSMC will review each protocol up to four times a year or more often if required to review 
toxicity and accrual data. Information to be provided to the committee may include: up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or higher 
unexpected adverse events that have been reported; summary of all deaths occurring with 30 days 
of intervention for Phase I or II protocols; for gene therapy protocols, summary of all deaths while 
being treated and during active follow-up; any response information; audit results, and a summary 
provided by the study team. Other information (e.g. scans, laboratory values) will be provided 
upon request.  
 
The Data and Safety Monitoring Plan (DSMP) for this study is located in Appendix O.  
12.3 
Multicenter Guidelines 
This protocol will adhere to the policies and requirements of the DF/HCC Multi-Center Data and 
Safety Monitoring Plan. The specific responsibilities of the Overall PI, Coordinating Center, and 
Participating Institutions and the procedures for auditing are presented in Appendix O. 
• The Overall PI/Coordinating Center is responsible for distributing all IND Action Letters 
or Safety Reports to all participating institutions for submission to their individual IRBs 
for action as required. 
• Mechanisms will be in place to ensure quality assurance, protocol compliance, and 
adverse event reporting at each site. 
• Except in very unusual circumstances, each participating institution will order the study 
agent(s) directly from supplier. A participating site may order the agent(s) only after the 
initial IRB approval for the site has been forwarded to the Coordinating Center. 
 
12.4 
Collaborative Research and Future Use of Samples  
 
Tissue, blood, and CSF fluid will be collected in this study to analyze genes, DNA, RNA, 
proteins, and cells for the study’s correlative endpoints and potential future research, utilizing 
new types of biomarker testing as it becomes available. Collectively, this research may help 
doctors to better understand:  
• Breast cancer, including causes of breast cancer, and reasons why past, current, and 
future treatments are effective or not 
• The effects of the study treatment  
• Which patients may benefit most, and least, from the study treatment 
• The human microbiome and its role in disease onset and progression 
• Other diseases 
 
These samples will be stored in a laboratory at Dana-Farber/Brigham & Women’s Hospital. The 
specimens will be retained indefinitely and will only be accessible by designated researchers.  

 
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These samples may be used for future research studies and may be provided to collaborating 
investigators both within and outside of DF/HCC.  Samples and data may be shared with outside 
non-profit academic investigators as well as with for-profit pharmaceutical investigators or 
commercial entities, with whom we collaborate. When samples are sent to investigators, and 
when any research is performed on samples, the samples will be identified with a code, but will 
not contain patient identification information such as name, birthdate, or medical record 
numbers.  
 
In order to allow the greatest amount of research to be performed on the study specimens, 
researchers for this study may share results of genetic sequencing with other scientists. De-
identified specimens or genetic data may be placed into one or more publicly-accessible 
scientific databases, such as the National Institutes of Health's Database for Genotypes and 
Phenotypes (dbGaP). The results from the correlative research on this study will be shared with 
these public databases. Through such databases, researchers from around the world will have 
access to de-identified samples or data for future research. More detailed information, beyond 
the public database, may only be accessed by scientists at other research centers who have 
received special permission to review de-identified data. 
 
 
13. STATISTICAL CONSIDERATIONS 
  
13.1 
Study Design/Endpoints 
This is an open-label, single arm phase II study to evaluate the efficacy of the combination of 
atezolizumab with pertuzumab plus high-dose trastuzumab for the treatment of CNS metastases in 
patients with HER2-positive metastatic breast cancer, as measured by ORR in the CNS. The target 
enrollment is 33 patients. 
 
Primary Endpoint 
The primary endpoint is the confirmed ORR in the CNS according to response assessment in 
neuro-oncology-brain metastases (RANO-BM) criteria (Section 11).  
 
Secondary endpoints include: 
Secondary endpoints include PFS according to RANO-BM bi-compartiment model, as well 
according to RECIST 1.1 single compartment model, objective extra-CNS response rates, 
according to RECIST 1.1, irRC, RANO-BM, and iRANO-BM criteria (as defined in Section 11); 
DOR, clinical benefit rate, OS, safety, tolerability, patient-reported outcome, and investigator-
assessed neurological evaluation, and EQ-5D evaluation. 
 
Correlative science objectives include:  
• To explore whether the number and/or type of mutations identified using a next generation 
sequencing (NGS) panel is correlated with patient outcomes (PFS, CNS ORR, CBR, and OS). 
• 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, CNS ORR, CBR, and OS). 

 
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• 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. 
• To characterize a broad array of immune markers in metastatic HER-2 positive breast cancer 
(characterization will be based on histology, protein expression, and mRNA expression), and 
their changes with immune checkpoint blockade.  
• To explore how different immunosuppressive and/or immune-stimulating immune marker 
profiles at baseline correlate with patient outcomes (PFS, CNS ORR, CBR and OS). 
• To characterize changes in immune marker profiles on treatment and at time of progression 
• To characterize serial changes in immune marker profile in peripheral blood mononuclear 
cells (PBMCs) and in plasma over the course of the trial treatment. 
• To explore whether induction of changes in the immunosuppressive and/or immune-
stimulating immune marker profile in PBMC correlates with clinical outcomes (PFS, CNS 
ORR, and OS). 
• 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.   
• To explore whether cfDNA load in CSF is associated with clinical outcomes (PFS, CNS 
ORR, CRR, and OS). 
• 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. 
13.2 
Sample Size, Accrual Rate and Study Duration 
This study uses a Simon ‘optimal’ two-stage design with a one-sided type I error of 0.1 and type 
II error of 0.1 (90% power) to detect the difference between null (15%) and alternative (35%) CNS 
response rates. In the first stage, 19 patients will be enrolled. If less than 4 patients have a 
confirmed CNS response, the study will be discontinued after stage 1. If 4 or more patients have 
CNS response, the study will continue to stage 2 with additional 14 patients enrolled. If there are 
8 or more responses among the 33 patients, the regimen will be declared worthy for further study. 
If the true response rate is 15%, the chance that the regimen is declared ineffective after stage 1 is 
68.4% and the chance the regimen is declared ineffective after stage 2 is 90.4% (exact type I 
error=0.096). If the true response rate is 35%, the chance that the regimen is falsely declared 
ineffective is 9.6% (exact power = 90.4%).  
 
H0 
H1 
Total # of 
patients 
# of patients 
in stage 1 
Maximal # of 
responses to claim 
regiment inactive 
in stage 1 
Maximal total # 
of responses to 
claim regiment 
inactive in stage 2 
Prob. of 
discontinuation 
after stage 1 if 
H0 is true 
15% 
35% 
33  
 19 
3  
7  
68.4% 
 

 
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13.3 
Interim Monitoring Plan 
An initial safety run-in of 6 patients who have received at least 1 dose of protocol therapy wil be 
included. After up to 6 patients are enrolled, a safety pause in accrual will be implemented.  If 2 
or more patients develop a DLT within the DLT reporting period (within 21 days of C1D1 
treatment), the regimen will be deemed overly toxic and the study will close to further enrollment.  
Patients already enrolled and who are receiving clinical benefit will be allowed to continue on 
protocol therapy.  However, no new patients will be enrolled.  If 1 or fewer of the first 6 patients 
develop a DLT within the DLT reporting period, the study will re-open to accrual. 
 
In addition, an interim analysis for futility is planned to minimize the likelihood of exposing study 
patients to an inactive regimen. The interim analysis will be performed after 19 patients who have 
received at least 1 dose of protocol therapy have been enrolled in the study and have been 
evaluated. If less than 4 patients have CNS response, the study will be discontinued after stage 1. 
If 4 or more patients have CNS response, the study will continue to stage 2 with an additional 14 
patients enrolled. The design was done using a Simon ‘optimal’ two-stage design with a one-sided 
type I error of 0.1 and type II error of 0.1 (90% power). If the true response rate is 15%, the chance 
that the regimen is declared ineffective after stage 1 is 68.4%. 
 
13.4 
Analysis of Primary Endpoint 
The primary endpoint is ORR in the CNS, which will be assessed among all patients who initiated 
protocol therapy. CNS response will be assessed using RANO-BM criteria as defined in section 
11.  
 
Patients who initiate protocol therapy will be in included in the efficacy analysis population. In the 
efficacy analysis population, any patient without sufficient data to determine response (e.g., non-
evaluable patients) will be classified as a non-responder. The estimate of the ORR with 90% 
Clopper-Pearson exact CI will be presented.  
 
13.5 
Analysis of Secondary Endpoints 
Safety Endpoints  
The safety population consists of all patients who took at least one dose of any protocol treatment 
and who have at least one post-baseline safety assessment. Toxicity will be graded according to 
NCI CTCAE, Version 4.0. Toxicities will be summarized by maximum grade.  Incidence rate of 
each toxicity will be reported.   
 
Efficacy Endpoints  
Duration of response (DOR) will be evaluated among patients who had CR or PR. DOR is defined 
as the time from CR or PR achieved until renewed disease progression is detected in the CNS.  
DOR will be calculated per RANO-BM criteria, and descriptive statistics will be used to 
summarize the intervals observed.  
 
Bi-compartmental PFS per RANO-BM criteria, single-compartmental PFS per RECIST 1.1 
criteria, and OS will be also analyzed using Kaplan–Meier product-limit estimatesand 90% 

 
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confidence bands. PFS is defined as the time from first dose of atezolizumab (day 1 cycle 1) to 
disease progression or death due to any cause, whichever occurred first.  Patients alive without 
disease progression are censored at the date of last disease evaluation.  OS is defined as the time 
from first dose of atezolizumab (day 1 cycle 1) to death due to any cause.  If death was not 
observed, patients will be censored at the date they were last known alive.  
 
CNS ORR per iRANO-BM criteria, extracrainial ORR per RECIST 1.1, and extracrainial ORR 
per irRC will be reported with 90% exact confidence intervals. Clinical benefit rate at 18 and 24 
weeks is defined as CR, PR, SD, respectively, ≥ 18 and 24 weeks.  Clinical benefit will be 
calculated using RANO-BM criteria. Clinical benefit rate will be reported respectively with 90% 
exact confidence intervals. 
 
The sites of first progression (CNS vs. extracraniavs. both) will be tabulated respectively. 
 
The M.D. Anderson Symptom Inventory-Brain Tumor (MDASI-BT) will be used to assess patient-
reported outcomes. The MDASI-BT will assess 13 symptom items and 6 interference items from 
the core MDAST, as well as 9 symptoms specific to brain tumors.  Scores of each item will be 
calculated following the MDASI-BT scoring guideline.  
 
Patients’ neurological function will be assessed using the Neurological Assessment in Neuro-
Oncology (NANO) scale. Scoring of the NANO scale will follow the NANO scale socring 
guideline. 
 
General heath status of patients enrolled in this study will be assessed thorugh EQ-5D questionarie.  
 
Correlative endpoints 
Analyses of correlative scientific endpoints are exploratory and hypothesis-generating. Any 
promising findings will be tested in future studies.  
 
Among the patients who agree to undergo optional extracranial biopsies, we will describe the 
landscape of somatic mutations, copy number alterations, and characterize the immune 
microenvironment. We will explore whether the mutation burden (as assessedd in fresh tumor 
specimens, plasma cfDNA, or CSF cfDNA) is correlated with patient outcomes (PFS, CNS 
ORR, CBR, and OS). 
 
We aim to assess cfDNA in the CSF for several purposes; 1) to evaluate the tumor fraction (TFx) 
using ultra low-pass whole genome sequencing (UL-WGS) and to explore whether baseline or 
on-study TFx correlates with clinical outcomes; 2) for those patients with CSF TFx > 10%, to 
perform whole exome sequencing (WES) and to compare this with WES results from plasma 
cfDNA in the same patients; 3) to describe the trajectory of TFx at baseline, on-study, and time 
of progression; 4) to describe copy number, mutations, and mutational load at baseline and time 
of progression in the cfDNA derived from CSF. 
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 

 
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CSF samples and plasma 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. We will describe and compare mutations, copy number variation, and 
tumor mutational burden between cfDNA in blood and CSF both at baseline, as well as in 
baseline versus time-of-progression samples. 
For paired assessments of genomic alterations comparing between cfDNA in plasma and CSF, 
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 phenotype 
# of paired samples (plasma 
cfDNA and CSF cfDNA) 
True 
Cohen’s 
kappa 
20% 
20 
0.63 
 
30 
0.53 
30% 
20 
0.61 
 
30 
0.51 
40% 
20 
0.60 
 
30 
0.50 
The association of baseline CSF and blood 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.     
 
13.6 
Reporting and Exclusions 
13.6.1 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.   
 
13.6.2 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 protocol 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 

 
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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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Ali, H.R., Provenzano, E., Dawson, S., Blows, F.M., Liu, B., Shah, M. et al. (2014) Association 
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Armstrong, T.S., Mendoza, T., Gning, I., Coco, C., Cohen, M.Z., Eriksen, L. et al. (2006) 
Validation of the M.D. Anderson Symptom Inventory Brain Tumor Module (Mdasi-Bt). J 
Neurooncol 80: 27-35. 
 
Casey, S.C., Tong, L., Li, Y., Do, R., Walz, S., Fitzgerald, K.N. et al. (2016) Myc Regulates the 
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Niwinska, A., Murawska, M., and Pogoda, K. (2010) Breast Cancer Brain Metastases: 
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Immunotherapy Response Assessment in Neuro-Oncology: A Report of the Rano Working 
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Olson, E.M., Najita, J.S., Sohl, J., Arnaout, A., Burstein, H.J., Winer, E.P. et al. (2013) Clinical 
Outcomes and Treatment Practice Patterns of Patients with Her2-Positive Metastatic Breast 
Cancer in the Post-Trastuzumab Era. Breast 22: 525-531. 
 
Park, S., Jiang, Z., Mortenson, E.D., Deng, L., Radkevich-Brown, O., Yang, X. et al. (2010) The 
Therapeutic Effect of Anti-Her2/Neu Antibody Depends on Both Innate and Adaptive Immunity. 
Cancer Cell 18: 160-170. 
 
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Universal Her2 Testing. Breast 21: 724-729. 
 
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Promotes Resistance to T Cell-Mediated Immunotherapy. Cancer Discov 6: 202-216. 
 
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Genomic Analysis Reveals That Immune Function Genes Are Strongly Linked to Clinical 
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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 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
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). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 

 
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APPENDIX B 
ANAPHYLAXIS PRECAUTIONS 
 
EQUIPMENT NEEDED 
• 
Monitoring devices:  ECG monitor, blood pressure monitor, oxygen saturation monitor, and 
thermometer 
• 
Oxygen 
• 
Epinephrine for intravenous, intramuscular, and endotracheal administration in accordance 
with institutional guidelines 
• 
Antihistamines 
• 
Corticosteroids 
• 
Intravenous infusion solutions, tubing, catheters, and tape 
 
PROCEDURES 
In the event of a suspected anaphylactic reaction during study treatment infusion, the following 
procedures should be performed: 
1. Stop the study treatment infusion. 
2. Call for additional medical assistance. 
3. Ensure that appropriate monitoring is in place, with continuous ECG and pulse oximetry 
monitoring, if possible. 
4. Administer antihistamines, epinephrine, or other medications as required by participant 
status and as directed by the physician in charge. 
5. Continue to observe the participant and document observations. 
6. Draw serum/plasma samples for immunogenicity testing. 
Ask participant to return for washout immunogenicity sample if appropriate. 
 
 
 
 
 
 
 
 

 
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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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APPENDIX D 
NEUROLOGICAL ASSESSMENT IN NEURO-ONCOLOGY 
(NANO) SCALE 
 

 
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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 ENGLISH QUESTIONNARIE   
 
 
 
 
 
 
 
 
 
 
 
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 SPECIMEN REQUISITION FORM  
Complete this form and include with the specimen shipment.  Label ALL materials with participant initials, DFCI participant study ID, and the 
date the specimen was obtained. Include a pathology report with any archival tissue specimens being submitted.  
 
Ship specimen(s) to: Brigham and Women’s Hospital, Attn: Breast Tissue/Blood Bank, Thorn Building – Room 428, 20 Shattuck Street, Boston, 
MA 02115 
____________________________________________________________________________________________________________ 
Subject Information 
Participant Initials (FML): ______________    Participant Study ID: ______________     DFCI Assigned ONC ID: _______________ 
Date of specimen shipment: _________________________          
Specimen Type  
(indicate inclusion in shipment by checking 
box) 
Quantity  
submitted 
(#tubes or cores) 
Date sample 
collected 
Timepoint 
Comments 
 Five 10 ml green top tubes whole blood 
 
 
 Baseline 
 Cycle _____ 
 Progression 
 
 One 9mL Streck Tube whole blood  
 
 
 
Fresh Tissue 
 Biopsy core in RNA Later 
 Biopsy cores in formalin  
 Biopsy cores in DMEM  
      (frozen in OCT for Northwestern) 
 
 
 
 Baseline 
  Cycle 2 
 Progression 
 
Archival Tissue 
 FFPE Block (archival tissue) OR 
 15 4-micron unstained slides AND 
 Pathology Report 
 
 
 
Primary or Metastatic sample?  
(circle one) 
Cerebrospinal Fluid (CSF) 
 Two 10 mL sterile collection tubes 
 (Streck Tubes for Northwestern) 
 
 
 Baseline 
 Before Cycle 3 
 Progression 
 
Site Responsible Contact:______________________________   
Email:_____________________________________________ 
Phone Number: _____________________________________ 
 
 
 
 

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APPENDIX H ASYMPTOMATIC DECLINE IN LVEF 
 
 
Algorithm for Continuation and Discontinuation of Atezolizumab, Pertuzumab and Trastuzumab 
Based on LVEF Assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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APPENDIX I 
NEW YORK HEART ASSOCIATION CLASSIFICATION OF 
FUNCTIONAL CARDIAC CAPACITY 
 
 
Class 
 
I 
No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or 
palpitation. 
 
II 
Slight limitation of physical activity: Such patients are comfortable at rest. Ordinary 
physical activity results in fatigue, palpitations, dyspnea, or angina. 
 
III 
Marked limitation of physical activity: Although patients are comfortable at rest, less 
than ordinary physical activity will lead to symptoms. 
 
IV 
Inability to carry on physical activity without discomfort: Symptoms of congestive 
heart failure are present even at rest. With any physical activity, increased 
discomfort is experienced. 
 
From: Criteria Committee, New York Heart Association, Inc. Diseases of the heart and blood 
vessels. Nomenclature and criteria for diagnosis. 6th ed. Boston, Little, Brown and Co, 1964:114. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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APPENDIX J 
LEFT VENTRICULAR SYSTOLIC DYSFUNCTION GRADING 
 
NCI CTCAE 
Grade  
 
Left Ventricular Systolic Dysfunction Severity 
1 − 
 
 
2 − 
 
 
3 
Symptomatic due to drop in ejection fraction responsive to intervention 
 
4 
Refractory or poorly controlled heart failure due to drop in ejection fraction; 
intervention such as ventricular assist device, intravenous vasopressor 
support, or heart transplant indicated 
 
5 
Death 
 
NCI CTCAE = National Cancer Institute Common Terminology Criteria for Adverse Events. 
Note: Based on the most recent version of NCI CTCAE (v 4.0), which can be found at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm 
LVSD Definition: A disorder characterized by failure of the left ventricle to produce adequate 
output despite an increase in distending pressure and in end-diastolic volume. Clinical 
manifestations may include dyspnea, orthopnea, and other signs and symptoms of pulmonary 
congestion and edema. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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APPENDIX K 
REPORTING CONVENTIONS FOR LEFT VENTICULAR 
SYSTOLIC DYSFUNCTION/HEART FAILURE 
 
 
 
AE = adverse event; CHF = congestive heart failure; eCRF = electronic Case Report Form; LVEF = left 
ventricular ejection fraction; LVSD = left ventricular systolic dysfunction; N/A = not applicable; NCI 
CTCAE = National Cancer Institute Common Terminology Criteria for Adverse Events; 
NYHA = New York Heart Association; SAE = serious adverse event. 
Note: Any symptomatic LVSD event must be reported as “heart failure.” 
a Report the status “asymptomatic” and the LVEF value in the comments field as appropriate. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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APPENDIX L: 
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 Karnofsky Perfomance Status (see Appendix A for 
definitions): ________ 
 
 
 
 
 
 
 
 
 
 

 
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APPENDIX M 
GUIDELINES FOR COLLECTIING 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: A goal of 2 4-mm punch biopsies will be obtained. 
 
Lymph node: A goal of 3-6 core biopsy specimens will be obtained using an 18-gauge needle. 
 
Liver: A goal of 3-6 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. skin, lymph node, liver), that site should be 
biopsied preferentially. If bone is the only biopsy-accessible site, then a goal of 3-6 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 
present if intravenous conscious sedation is required 
 
 

 
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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 
respond appropriately to physical stimulation and verbal commands. 
The risks of intravenous conscious sedation include: inhibition of the gag reflex and concomitant 

 
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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. 
 
 
For Biopsies of Soft Tissue, Liver, Bone, Breast, Etc: 

 
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1. After biopsy is performed, the tissue mass is placed on a sterile gauze 
2. Using forceps, separate the tumor tissue 
3. Place 2 pieces (cores) of tumor tissue in each cassette (typically end up with 3 cassettes 
per biopsy); the last cassette will contain many small pieces of tumor tissue 
4. Fill cassettes with OCT 
a. Completely cover tissue 
b. Limit the amount of bubbles 
5. Place cassettes on dry ice and prepare for transport by limiting OCT leakage 
6. Return samples to the lab and complete freezing of samples in OCT with dry ice (about 
10 minutes freezing time) 
7. Once samples are frozen, place in plastic bag; label bag with date, protocol number, 
patient number, and number of initials included 
8. Store in –80C freezer 
 
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. 
 
 
 
 
 

 
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APPENDIX N 
GENENTECH SAFETY REPORTING FAX COVERSHEET 
 
 
 
 

 
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APPENDIX O 
DF/HCC MULTI-CENTER DATA AND SAFETY MONITORING 
PLAN 
 
 
 
 
 
 
 
 
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TABLE OF CONTENTS 
15. 
INTRODUCTION ...........................................................................................................134 
15.1 
Purpose .................................................................................................................134 
15.2 
Multi-Center Data and Safety Monitoring Plan Definitions ................................134 
16. 
GENERAL ROLES AND RESPONSIBILITIES ...........................................................135 
16.1 
DF/HCC Sponsor .................................................................................................135 
16.2 
Coordinating Center .............................................................................................136 
16.3 
Participating Institution ........................................................................................136 
17. 
DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS............................137 
17.1 
Protocol Distribution ............................................................................................137 
17.2 
Protocol Revisions and Closures .........................................................................137 
17.3 
Informed Consent Requirements .........................................................................138 
17.4 
IRB Documentation .............................................................................................138 
17.5 
IRB Re-Approval .................................................................................................138 
17.6 
Participant Confidentiality and Authorization Statement ....................................139 
17.7 
DF/HCC Multi-Center Protocol Registration Policy ...........................................139 
17.8 
DF/HCC Protocol Case Number ..........................................................................140 
17.9 
Safety Assessments and Toxicity Monitoring .....................................................141 
17.10 Data Management ................................................................................................142 
18. 
REQUISITIONING INVESTIGATIONAL DRUG........................................................142 
19. 
MONITORING: QUALITY CONTROL ........................................................................143 
19.1 
Ongoing Monitoring of Protocol Compliance .....................................................143 
19.2 
Monitoring Reports ..............................................................................................144 
19.3 
Accrual Monitoring ..............................................................................................144 
20. 
AUDITING: QUALITY ASSURANCE .........................................................................144 
20.1 
DF/HCC Internal Audits ......................................................................................144 
20.2 
Audit Notifications...............................................................................................144 
20.3 
Audit Reports .......................................................................................................145 
20.4 
Participating Institution Performance ..................................................................145 
 
 
 

 
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15. INTRODUCTION 
 
The Dana-Farber/Harvard Cancer Center Multi-Center Data and Safety Monitoring Plan 
(DF/HCC DSMP) outlines the procedures for conducting a DF/HCC Multi-Center research 
protocol. The DF/HCC DSMP serves as a reference for any sites external to DF/HCC that 
are participating in a DF/HCC clinical trial.  
 
15.1 
Purpose 
 
To establish standards that will ensure that a Dana-Farber/Harvard Cancer Center Multi-
Center protocol will comply with Federal Regulations, Health Insurance Portability and 
Accountability Act (HIPAA) requirements and applicable DF/HCC Standard Operating 
Procedures.        
 
15.2 
Multi-Center Data and Safety Monitoring Plan Definitions 
 
DF/HCC Multi-Center Protocol:  A research protocol in which one or more outside 
institutions are collaborating with Dana-Farber/Harvard Cancer Center where a DF/HCC 
investigator is the sponsor. DF/HCC includes Dana-Farber/Partners Cancer Care (DF/PCC) 
Network Clinical Trial Affiliates.  
 
Lead Institution:  One of the Dana-Farber/Harvard Cancer Center consortium members 
(Dana-Farber Cancer Institute (DFCI), Massachusetts General Hospital (MGH), Beth Israel 
Deaconess Medical Center (BIDMC), Boston Children’s Hospital (BCH), Brigham and 
Women’s Hospital (BWH) responsible for the coordination, development, submission, and 
approval of a protocol as well as its subsequent amendments per the DFCI IRB and 
applicable regulatory guidelines (CTEP, Food and Drug Administration (FDA), Office of 
Biotechnology Activities (OBA) etc.).  The Lead Institution is typically the home of the 
DF/HCC Sponsor. The Lead Institution also typically serves as the Coordinating Center for 
the DF/HCC Multi-Center Protocol.   
 
DF/HCC Sponsor:  The person sponsoring the submitted Multi-Center protocol who takes 
responsibility for initiation, management and conduct of the protocol at all research 
locations. In applicable protocols, the DF/HCC Sponsor will serve as the single liaison with 
any regulatory agencies (i.e. FDA). The DF/HCC Sponsor has ultimate authority over the 
protocol and is responsible for the conduct of the study at DF/HCC and all Participating 
Institutions. In most cases the DF/HCC Sponsor is the same person as the DF/HCC Overall 
Principal Investigator; however, both roles can be filled by two different people.  
 
Participating Institution:  An institution that is outside the DF/HCC and DF/PCC 
consortium that is collaborating with DF/HCC on a protocol where the sponsor is a DF/HCC 
Investigator.  The Participating Institution acknowledges the DF/HCC Sponsor as having 
the ultimate authority and responsibility for the overall conduct of the study.    
 
Coordinating Center: The entity (i.e. Lead Institution, Medical Monitor, Contract 
Research Organization (CRO), etc) that provides administrative support to the DF/HCC 

 
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Sponsor in order that he/she may fulfill the responsibilities outlined in the protocol 
document and DSMP, and as specified in applicable regulatory guidelines (i.e. CTEP Multi-
Center Guidelines). In general, the Lead Institution is the Coordinating Center for the 
DF/HCC Multi-Center Protocol.  
 
DF/HCC Office of Data Quality (ODQ): A group within DF/HCC responsible ensuring 
high-quality standards are used for data collection and the ongoing management of clinical 
trials, auditing, and data and safety monitoring. ODQ also coordinates quality assurance 
efforts related to multi-center clinical research. 
 
DF/HCC Research Informatics for Operations (RIO): A group within DF/HCC 
responsible for providing a comprehensive data management platform for managing clinical 
trial data. 
 
16. GENERAL ROLES AND RESPONSIBILITIES 
For DF/HCC Multi-Center Protocols, the DF/HCC Sponsor, the Coordinating Center, and 
the Participating Institutions are expected to adhere to the following general responsibilities:  
 
16.1 
DF/HCC Sponsor 
 
The DF/HCC Sponsor, Nancy Lin, MD will accept responsibility for all aspects of 
conducting a DF/HCC Multi-Center protocol which includes but is not limited to:  
• Oversee the coordination, development, submission, and approval of the protocol as 
well as subsequent amendments.  
• Ensure that the investigators, study team members, and Participating Institutions are 
qualified and appropriately resourced to conduct the protocol.   
• Include the Multi-Center Data and Safety Monitoring Plan as an appendix to the 
protocol. 
• Ensure all Participating Institutions are using the correct version of the protocol. 
• Ensure that each participating investigator and study team member receives 
adequate protocol training (and/or a Site Initiation Visit prior to enrolling 
participants) and throughout trial’s conduct as needed. 
• Ensure the protocol will be provided to each participating site in a language 
understandable to all applicable site personnel when English is not the primary 
language.  
• Monitor progress and overall conduct of the study at all Participating Institutions.  
• Ensure all DFCI Institutional Review Board (IRB), DF/HCC and other applicable 
(i.e. FDA) reporting requirements are met.  
• Review data and maintain timely submission of data for study analysis.  
• Act as the single liaison with FDA (investigator-held IND trials) or as applicable. 
• Ensure compliance with all requirements as set forth in the Code of Federal 
Regulations, applicable DF/HCC requirements, HIPAA requirements, and the 
approved protocol. 
• Commit to the provision that the protocol will not be rewritten or modified by 
anyone other than the DF/HCC Sponsor. 

 
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• Identify and qualify Participating Institutions and obtain accrual commitments prior 
to extending the protocol to that site. 
• Monitor accrual and address Participating Institutions that are not meeting their 
accrual requirements.  
 
16.2 
Coordinating Center  
 
The general responsibilities of the Coordinating Center may include but are not limited to: 
• Assist in protocol development.  
• Maintain FDAcorrespondence, as applicable. 
• Review registration materials for eligibility and register participants from 
Participating Institutions in the DF/HCC clinical trial management system 
(CTMS). 
• Distribute protocol and informed consent document updates to Participating 
Institutions as needed. 
• Oversee the data collection process from Participating Institutions. 
• Maintain documentation of Serious Adverse Event (SAE) reports and 
deviations/violation submitted by Participating Institutions and provide to the 
DF/HCC Sponsor for timely review and submission to the DFCI IRB, as 
necessary.  
• Distribute serious adverse events reported to the DF/HCC Sponsor that fall under 
the DFCI IRB Adverse Event Reporting pPolicy to all Participating Institutions. 
• Provide Participating Institutions with information regarding DF/HCC requirements 
that they will be expected to comply with. 
 
• Carry out plan to monitor Participating Institutions either by on-site or remote 
monitoring.  
• Maintain Regulatory documents of all Participating Institutions which includes but 
is not limited to the following: local IRB approvals/notifications from all 
Participating Institutions, confirmation of Federalwide Assurances (FWAs) for all 
sites, all SAE submissions, Screening Logs for all sites, IRB approved consents for 
all sites 
• Conduct regular communications with all Participating Institutions (conference 
calls, emails, etc) and maintain documentation all relevant communications. 
 
16.3 
Participating Institution 
 
Each Participating Institution is expected to comply with all applicable federal regulations 
and DF/HCC requirements, the protocol and HIPAA requirements.  
 
The general responsibilities for each Participating Institution may include but are not limited 
to: 
• Document the delegation of research specific activities to study personnel. 
• Commit to the accrual of participants to the protocol. 
• Submit protocol and/or amendments to their local IRB of record. 
• Maintain regulatory files as per sponsor requirements. 

 
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• Provide the Coordinating Center with regulatory documents or source documents as 
requested. 
• Participate in protocol training prior to enrolling participants and throughout the trial 
as required (i.e. teleconferences). 
• Update Coordinating Center with research staff changes on a timely basis. 
• Register participants through the Coordinating Center prior to beginning research 
related activities.  
• Submit Serious Adverse Event (SAE) reports to local IRB per institutional 
requirements and to the Coordinating Center, in accordance with DF/HCC 
requirements. 
• Submit protocol deviations and violations to local IRB per institutional requirements 
and to the DF/HCC Sponsor in accordance with DF/HCC requirements. 
• Order, store and dispense investigational agents and/or other protocol mandated 
drugs per federal guidelines and protocol requirements. 
• Have office space, office equipment, and internet access that meet HIPAA standards. 
• Participate in any quality assurance activities and meet with monitors or auditors at 
the conclusion of a visit to review findings. 
• Promptly provide follow-up and/or corrective action plans for any monitoring 
queries or audit findings. 
 
17. DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS 
The following section will clarify DF/HCC Requirements and further detail the expectations 
for participating in a DF/HCC Multi-Center protocol.  
 
17.1 
Protocol Distribution 
 
The Coordinating Center will distribute the final DFCI IRB approved protocol and any 
subsequent amended protocols to all Participating Institutions.    
 
17.2 
Protocol Revisions and Closures 
 
The Participating Institutions will receive notification of protocol revisions and closures 
from the Coordinating Center.  It is the individual Participating Institution’s responsibility 
to notify its IRB of these revisions. 
 
• Non life-threatening revisions: Participating Institutions will receive written 
notification of protocol revisions regarding non life-threatening events from the 
Coordinating Center. Non-life-threatening protocol revisions must be IRB approved 
and implemented within 90 days from receipt of the notification. 
 
• Revisions for life-threatening causes: Participating Institutions will receive 
immediate notification from the Coordinating Center concerning protocol revisions 
required to protect lives with follow-up by fax, mail, e-mail, etc.  Life-threatening 
protocol revisions will be implemented immediately followed by IRB request for 
approval. 

 
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• Protocol closures and temporary holds: Participating Institutions will receive 
notification of protocol closures and temporary holds from the Coordinating Center. 
Closures and holds will be effective immediately.  In addition, the Coordinating 
Center, will update the Participating Institutions on an ongoing basis about protocol 
accrual data so that they will be aware of imminent protocol closures. 
 
17.3 
Informed Consent Requirements 
 
The DF/HCC approved informed consent document will serve as a template for the 
informed consent for Participating Institutions. The Participating Institution consent form 
must follow the consent template as closely as possible and should adhere to specifications 
outlined in the DF/HCC Guidance Document on Model Consent Language for Investigator-
Sponsored Multi-Center Trials.  This document will be provided separately to each 
Participating Institution upon request. 
 
Participating Institutions are to send their version of the informed consent document and 
HIPAA authorization, if a separate document, to the Coordinating Center for review and 
approval prior to submission to their local IRB. The approved consent form must also be 
submitted to the Coordinating Center after approval by the local IRB for all consent 
versions. 
 
The Principal Investigator (PI) at each Participating Institution will identify the physician 
members of the study team who will be obtaining consent and signing the consent form for 
therapeutic protocols. Participating institutions must follow the DF/HCC requirement that 
for all interventional drug, biologic, or device research, only attending physicians may 
obtain initial informed consent and any re-consent that requires a full revised consent form.   
 
17.4 
IRB Documentation 
 
The following must be on file with the Coordinating Center: 
• Initial approval letter of the Participating Institution's IRB.  
• Copy of the Informed Consent Form(s) approved by the Participating Institution’s 
IRB.  
• Participating Institution’s IRB approval for all amendments. 
• Annual approval letters by the Participating Institution's IRB. 
 
 
 
17.5 
IRB Re-Approval 
 
Verification of IRB re-approval from the Participating Institutions is required in order to 
continue research activities.  There is no grace period for continuing approvals. 
 
The Coordinating Center will not register participants if a re-approval letter is not received 
from the Participating Institution on or before the anniversary of the previous approval date.   

 
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17.6 
Participant Confidentiality and Authorization Statement 
 
In 1996, congress passed the first federal law covering the privacy of health information 
known as the Health Insurance Portability and Accountability Act (HIPPA). Any 
information, related to the physical or mental health of an individual is called Protected 
Health Information (PHI). HIPAA outlines how and under what circumstances PHI can be 
used or disclosed.  
 
In order for covered entities to use or disclose protected health information during the course 
of a study, the study participant must sign an authorization statement.  This authorization 
statement may or may not be separate from the informed consent document.  The 
Coordinating Center, with the approval from the DFCI IRB, will provide a consent template, 
with information regarding authorization for the disclosure of protected health information.  
 
The DF/HCC Sponsor will use all efforts to limit its use of protected health information in 
its trials. However, because of the nature of these trials, certain protected health information 
must be collected. DF/HCC has chosen to use authorizations, signed by the participant in 
the trial, rather than limited data sets with data use agreements. 
 
17.6.1  DF/HCC Multi-Center Protocol Confidentiality 
 
All documents, investigative reports, or information relating to the participant are strictly 
confidential. Whenever reasonably feasible, any participant specific reports (i.e. Pathology 
Reports, MRI Reports, Operative Reports, etc.) submitted to the Coordinating Center should 
be de-identified. It is recommended that the assigned protocol case number (as described 
below) be used for all participant specific documents. Participant initials may be included 
or retained for cross verification of identification.  
 
17.7 
DF/HCC Multi-Center Protocol Registration Policy 
 
17.7.1  Participant Registration and Randomization  
 
• Please refer to Protocol Section 4.3 and 4.4 for participant registration information. 
Treatment cannot begin until site has received confirmation that participant has been 
registered with DF/HCC CTMS. 
 
The Coordinating Center will review the submitted documents in order to verify 
eligibility and consent. To complete the registration process, the Coordinating Center 
will: 
• Register the participant on the study with the DF/HCC Clinical Trial Management 
System (CTMS). 
• Upon receiving confirmation of registration, the Coordinating Center will inform 
the Participating Institution and provide the study specific participant case number, 
and, if applicable, assigned treatment and/or dose level.  
 

 
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Treatment or other protocol-specific interventions may not begin without 
confirmation from the Coordinating Center that the participant has been 
registered.  
 
17.7.2  Initiation of Therapy 
 
Participants must be registered with the DF/HCC CTMS before the initiation of treatment 
or other protocol-specific interventions. Treatment and other protocol-specific interventions 
may not be initiated until the Participating Institution receives confirmation of the 
participant’s registration from the Coordinating Center. The DF/HCC Sponsor and DFCI 
IRB must be notified of any violations to this policy. 
 
17.7.3  Eligibility Exceptions 
 
No exceptions to the eligibility requirements for a protocol without DFCI IRB approval will 
be permitted. All Participating Institutions are required to fully comply with this 
requirement. The process for requesting an eligibility exception is defined below. 
 
17.8 
DF/HCC Protocol Case Number 
 
At the time of registration, the following identifiers are required for all subjects: initials, 
date of birth, gender, race and ethnicity. Once eligibility has been established and the 
participant successfully registered, the participant is assigned a unique protocol case 
number.  Participating Institutions should submit all de-identified subsequent 
communication and documents to the Coordinating Center, using this case number to 
identify the subject.   
 
17.8.1 Protocol Deviations, Exceptions and Violations 
 
Federal Regulations require an IRB to review proposed changes in a research activity to 
ensure that researchers do not initiate changes in approved research without IRB review 
and approval, except when necessary to eliminate apparent immediate hazards to the 
participant. DF/HCC requires all departures from the defined procedures set forth in the 
IRB approved protocol to be reported to the DF/HCC Sponsor, who in turn is responsible 
for reporting to the DFCI IRB. 
 
 
For reporting purposes, DF/HCC uses the terms “violation”, “deviation” and “exception” 
to describe departures from a protocol. All Participating Institutions must adhere to these 
requirements for reporting to the DF/HCC Sponsor and will follow their institutional policy 
for reporting to their local IRB. 
 
17.8.2  Definitions 
 
Protocol Deviation: Any departure from the defined procedures set forth in the IRB-
approved protocol which is prospectively approved prior to its implementation. 
 

 
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Protocol Exception:  Any protocol deviation that relates to the eligibility criteria, e.g. 
enrollment of a participant who does not meet all inclusion/exclusion criteria. 
 
 
 
Protocol Violation: Any protocol departure that was not prospectively approved by the IRB 
prior to its initiation or implementation.  
 
 
17.8.3  Reporting Procedures 
 
DF/HCC Sponsor: is responsible for ensuring that clear documentation is available in the 
medical record and/or regulatory documents to describe all protocol exceptions, deviations 
and violations. The DF/HCC Sponsor will also be responsible for ensuring that all protocol 
violations/deviations are promptly reported per DFCI IRB guidelines.  
 
Participating Institutions: Protocol deviations require prospective approval from the DFCI 
IRB. The Participating Institution must submit the deviation request to the Coordinating 
Center who will then submit the deviation request to the DFCI IRB. Upon DFCI IRB 
approval the deviation is submitted to the Participating Institution IRB, per institutional 
policy. A copy of the Participating Institution’s IRB report and determination will be 
forwarded to the Coordinating Center within 10 business days after the original submission.  
The deviation may not be implemented without all required approvals. 
 
All protocol violations must be sent to the Coordinating Center in a timely manner. The 
Coordinating Center will provide training for the requirements for the reporting of 
violations.  
 
Coordinating Center:  Upon receipt of the violation/deviation report from the Participating 
Institution, the Coordinating Center will submit the report to the DF/HCC Sponsor for 
review. Subsequently, the Participating Institution’s IRB violation/deviation report will be 
submitted to the DFCI IRB for review per DFCI IRB reporting guidelines.  
 
17.9 
Safety Assessments and Toxicity Monitoring 
 
The study teams at all participating institutions are responsible for protecting the safety, 
rights and well-being of study participants. Recording and reporting of adverse events that 
occur during the course of a study help ensure the continuing safety of study participants.  
 
All participants receiving investigational agents and/or other protocol mandated therapy 
will be evaluated for safety. The safety parameters include all laboratory tests and 
hematological abnormalities, physical examination findings, and spontaneous reports of 
adverse events reported by participants.  All toxicities encountered during the study will 
be evaluated according to the NCI criteria specified in the protocol. Life-threatening 
toxicities must be reported immediately to the DF/HCC Sponsor via the Coordinating 
Center.  
 
Additional safety assessments and toxicity monitoring will be outlined in the protocol. 
 

 
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17.9.1 Guidelines for Reporting Serious Adverse Events  
 
Guidelines for reporting Adverse Events (AEs) and Serious Adverse Events (SAEs) are 
detailed in protocol section 7. 
 
 
 
 
 
 
Participating Institutions must report the SAEs to the DF/HCC Sponsor and the 
Coordinating Center following the DFCI IRB Adverse Event Reporting PolicyIRB of 
record’s Adverse Event Reporting Policy.  
 
The Coordinating Center will maintain documentation of all Participating Institution 
Adverse Event reports and be responsible for communicating to all participating 
investigators, any observations reportable under the DFCI IRB Reporting Requirements.  
Participating Institutions will review and submit to their IRB according to their institutional 
policies and procedures 
 
17.9.2 Guidelines for Processing IND Safety Reports  
 
The DF/HCC Sponsor will review all IND Safety Reports per DF/HCC requirements, and 
ensure that all IND Safety Reports are distributed to the Participating Institutions as 
required by DF/HCC Policy. Participating Institutions will review/submit to the IRB 
according to their institutional policies and procedures. 
 
 
 
17.10 Data Management 
 DF/HCC RIO develops case report forms (CRF/eCRFs), for use with the protocol.  These 
forms are designed to collect data for each study. DF/HCC RIO provides a web based 
training for all eCRF users. 
   
17.10.1 Data Forms Review 
Data submissions are monitored for timeliness and completeness of submission. If study 
forms are received with missing or questionable data, the submitting institution will receive 
a written or electronic query from the DF/HCC Office of Data Quality, Coordinating Center, 
or designee.  
 
Responses to all queries should be completed and submitted within 14 calendar days.   
 
Responses may be returned on the written query or on an amended paper case report form, 
or in the case of electronic queries, within the electronic data capture (eDC) system. In the 
case of a written query for data submitted on a paper case report form, the query must be 
attached to the specific data being re-submitted in response.   
 
If study forms are not submitted on schedule, the Participating Institution will periodically 
receive a Missing Form Report from the Coordinating Center noting the missing forms.  
 
18. REQUISITIONING INVESTIGATIONAL DRUG 
 
 
The ordering of investigational agent is specified in the protocol section 8.  

 
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Participating Institutions should order their own agent regardless of the supplier. (i.e., NCI 
or a pharmaceutical company.) 
 
If the agent is commercially available, check with the local Director of Pharmacy and/or the 
Research Pharmacy to ensure that the agent is in stock. If the agent is not stocked, ensure 
that the agent can be ordered once the protocol is approved by the local IRB.  
 
If the agent is investigational, ensure that the pharmacy will be able to receive and store the 
agent according to state and federal requirements. The local IRB should be kept informed of 
who will supply the agent (i.e., NCI or a pharmaceutical company) so that any regulatory 
responsibilities can be met in a timely fashion.  
 
19. MONITORING: QUALITY CONTROL 
 
The quality control process for a clinical trial requires verification of protocol compliance 
and data accuracy. The Coordinating Center, with the aid of the DF/HCC Office of Data 
Quality, provides quality control oversight for the protocol. 
 
19.1 
Ongoing Monitoring of Protocol Compliance 
 
The Participating Institutions may be required to submit participant source documents to the 
Coordinating Center for monitoring. Participating Institution may also be subject to on-site 
monitoring conducted by the Coordinating Center.  
 
The Coordinating Center will implement ongoing monitoring activities to ensure that 
Participating Institutions are complying with regulatory and protocol requirements, data 
quality, and participant safety. Monitoring practices may include but are not limited to 
source data verification, and review and analysis of eligibility requirements, informed 
consent procedures, adverse events and all associated documentation, review of study drug 
administration/treatment, regulatory files, protocol departures reporting, pharmacy records, 
response assessments, and data management.  
 
Additionally, a plan will be formulated to provide regular and ongoing communication to 
Participating Institutions about study related information which will include participation in 
regular Lead Institution initiated teleconferences. Teleconferences will occur every 2 weeks 
and will continue regularly until completion of accrual. Upon completion of accrual, 
teleconferences will occur monthly until all patients complete protocol therapy.  
Upon completion of protocol therapy, teleconferences will occur every 3 months until study 
completion. Additional communication may be distributed via “Newsletter” or email as 
deemed appropriate by DF/HCC Sponsor. 
 
On-Site Monitoring: On-site monitoring will occur on an as-needed basis. Participating 
Institutions will be required to provide access to participants’ complete medical record and 
source documents for source documentation verification during the visit. In addition, 
Participating Institutions should provide access to regulatory documents, pharmacy records, 

 
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local policies related to the conduct of research, and any other trial-related documentation 
maintained by the Participating Site. On-site monitoring visits can be substituted with 
remote (virtual) monitoring visits at the discretion of the Principal Investigator.  
 
Remote Monitoring: Remote monitoring will be performed on an as-needed basis by the 
Clinical Trial Monitor. Sites will be asked to provide source documentation via fax, email, 
or mail as specified by the Clinical Trial Monitor for virtual monitoring. 
 
19.2 
Monitoring Reports 
 
The DF/HCC Sponsor will review all monitoring reports to ensure protocol compliance. 
The DF/HCC Sponsor may increase the monitoring activities at Participating Institutions 
that are unable to comply with the protocol, DF/HCC Sponsor requirements or federal and 
local regulations.  
 
19.3 
Accrual Monitoring 
 
Prior to extending a protocol to an external site, the DF/HCC Sponsor will establish 
accrual requirements for each participating institution. Accrual will be monitored for each 
participating institution by the DF/HCC Sponsor or designee. Sites that are not meeting 
their accrual expectations may be subject to termination. Sites are expected to accrue at 
least 3 patients per year. 
 
20. AUDITING: QUALITY ASSURANCE 
 
Auditing is a method of Quality Assurance and involves the systematic and independent 
examination of all trial related activities and documents.  Audits determine if evaluated 
activities were appropriately conducted and whether data was generated, recorded and 
analyzed, and accurately reported per the protocol, applicable Policies, and the Code of 
Federal Regulations (CFR). 
 
20.1 
DF/HCC Internal Audits 
  
All Participating Institutions are subject to audit by the DF/HCC Office of Data Quality 
(ODQ). Typically, approximately 3-4 participants would be audited at the site over a 2-day 
period. If violations which impact participant safety or the integrity of the study are found, 
more participant records may be audited.  
 
20.2 
Audit Notifications 
 
It is the Participating Institution’s responsibility to notify the Coordinating Center of all 
external audits or inspections (e.g., FDA, EMA, NCI) that involve this protocol. All 
institutions will forward a copy of final audit and/or re-audit reports and corrective action 
plans (if applicable) to the Coordinating Center, within 12 weeks after the audit date.  
 

 
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20.3 
Audit Reports  
 
The DF/HCC Sponsor will review all final audit reports and corrective action plans, if 
applicable. The Coordinating Center, must forward any reports to the DF/HCC ODQ per 
DF/HCC policy for review by the DF/HCC Audit Committee. For unacceptable audits, the 
DF/HCC Audit Committee would forward the final audit report and corrective action plan 
to the DFCI IRB as applicable. 
 
20.4 
Participating Institution Performance 
 
The DF/HCC Sponsor and the IRB of record are charged with considering the totality of an 
institution’s performance in considering institutional participation in the protocol. 
 
Participating Institutions that fail to meet the performance goals of accrual, submission of 
timely and accurate data, adherence to protocol requirements, and compliance with state 
and federal regulations, may be recommended for a six-month probation period. Such 
institutions must respond with a corrective action plan and must demonstrate during the 
probation period that deficiencies have been corrected, as evidenced by the improved 
performance measures. Participating Institutions that fail to demonstrate significant 
improvement will be considered by the DF/HCC Sponsor for revocation of participation. A 
DF/HCC Sponsor and/or the DFCI IRB may terminate a site’s participation if it is 
determined that a site is not fulfilling its responsibilities as described above.