A Phase II Trial of Abbreviated MAPK Targeted Therapy Plus Pembrolizumab in Patients With Unresectable or Metastatic Melanoma
Phase: PHASE2
Conditions: Metastatic Melanoma
Sponsor: Massachusetts General Hospital

1
NCI Protocol #:
N/A 
DF/HCC Protocol #:
16-642
TITLE:  A phase II trial of abbreviated MAPK targeted therapy plus pembrolizumab 
in patients with unresectable or metastatic melanoma
Coordinating Center:
Massachusetts General Hospital Cancer Center
*Principal Investigator (PI): Ryan J. Sullivan, MD
Massachusetts General Hospital Cancer Center
Rsullivan7@partners.org
Other Investigators:
Massachusetts General Hospital
Keith Flaherty, MD
kflaherty@mgh.harvard.edu
Meghan Mooradian, MD
mmooradian@mgh.harvard.edu
Donald Lawrence, MD
dplawrence@mgh.harvard.edu
Howard Kaufman, MD
hlkaufman@mgh.harvard.edu
Krista Rubin, NP
kmrubin@mgh.harvard.edu
Riley Fadden, NP
rfadden@mgh.harvard.edu
Beth Israel Deaconess Medical Center (Biologics)
David F. McDermott, MD
dmcdermo@bidmc.harvard.edu
James W. Mier, MD
jmier@caregroup.Harvard.edu
Dana Farber Cancer Center
      Elizabeth Buchbinder, MD
           
elizabeth_Buchbinder@dfci.harvard.edu
Statistician:
Study Coordinator: 
Anita Giobbie-Hurder, MS 
Natalie Ciano
Dana Farber Cancer Institute
Massachusetts General Hospital Cancer 
Center
Anita_Giobbie-Hurder@dfci.harvard.edu
101 Merrimac Street, Suite 505D
Boston, MA 02114
Phone (617) 643-1540
Fax (617) 724-0599
NCT number: NCT03149029

DF/HCC Protocol #: 16-642
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 nciano@mgh.harvard.edu
Responsible Research Nurse:
Responsible Data Manager: 
 Alexandra Mossali, RN
 Natalie Ciano
Cancer Center Protocol Office 
Massachusetts General Hospital Cancer
55 Fruit Street- Yawkey Center, Suite 7E
Center 
Boston, MA 20114
101 Merrimac Street, 505D Boston,
Phone (617) 643-1922
MA 02114
Fax (617) 643-7602
Phone (617) 643-1540
Amossali@partnerts.org 
 nciano@mgh.harvard.edu
NCI-Supplied Agent(s):  N/A
Other Agent(s):
Pembrolizumab – Merck
Dabrafenib plus trametinib – Commercial 
Trametinib – Commercial
IND #:  132821
IND Sponsor:  Ryan J. Sullivan, MD
Version Date:  4-Sep-2020 

DF/HCC Protocol #: 16-642
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Synopsis
Rationale for Study:  
Over the past decade, amazing progress has been made culminating in the 
development of effective molecularly targeted and immune targeted therapies for the 
treatment of solid tumors.  The two diseases that have been at the forefront of this 
progress are melanoma and non-small cell lung cancer (NSCLC).  In each disease, 
molecular subsets have been identified (BRAF and NRAS mutant in melanoma, EGFR 
and ALK mutant in NSCLC) that define a patient population associated with high 
response rates to targeted agents.  Additionally, monoclonal antibody targeting of the 
program death 1 (PD1) receptor and its ligand (PDL1) has shown impressive activity in 
both diseases with response ranging from 15-30% in NSCLC and 30-50% in melanoma.  
As the field looks to improve upon this activity, one strategy has been to consider 
combining molecular-targeted and immune therapies. 
The preponderance of data supporting this approach is from the melanoma field.  In 
particular, a number of groups have shown that MAPK inhibition leads to increased 
melanoma antigen expression, decreased immunosuppressive cytokines, and 
increased trafficking of CD8+ T-lymphocytes.  Additionally, it appears that BRAF 
inhibitors with or without MEK inhibitors are capable of triggering this phenomenon, 
though these findings dissipate in the setting of acquired, BRAF-inhibitor resistance.   It 
has been well described that a common tissue and tumor response to lymphocytic 
infiltration is the upregulation of PDL1 that then inhibit these invading T-cells through 
interaction with their PD1 receptor. In melanoma, the BRAF-inhibitor associated 
infiltration is associated with increased tumor/stromal PDL1 expression.  Dual inhibition 
of BRAF and PD1 has been shown to be associated with more profound and durable 
responses in animal models of melanoma.  
We propose to test the hypothesis that induction molecularly targeted therapy triggers a 
favorable tumor microenvironment to augment the effects of maintenance PD1 targeting 
with pembrolizumab in two cohorts: BRAF mutant and BRAF-wild-type melanoma. This 
proposal represents a unique opportunity to test the effectiveness of combined immune 
and molecularly targeted therapy in two distinct subsets based on preclinical and clinical 
data.  The successful completion of this study will:
1. Determine the immunologic effects of oncogene targeted therapy on tumor 
microenvironment
2. Prove the concept that abbreviated molecularly targeted therapy will augment the 
effectiveness of pembrolizumab maintenance therapy
Study Objectives:
Primary Objective:
Document the rate of clinical benefit (SD/PR/CR per RECIST) of abbreviated 

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molecularly targeted therapy in combination with pembrolizumab in patients with 
unresectable and/or metastatic melanoma.  A subject will have achieved clinical benefit 
if there is evidence of CR, PR, or SD at the time of the 24-week scan and the subject 
has not resumed targeted therapy.
Secondary Objectives:
1. To describe progression free survival (PFS) and 1 year overall survival (OS) of 
abbreviated molecularly targeted therapy in combination with pembrolizumab in 
patients with metastatic melanoma.
2. To define the effects of targeted and the combination of immune and molecularly 
targeted therapy on tumor microenvironment
Study Design:  
A Simon 2-stage design will be implemented for each disease cohort.  Patients will be 
treated with two-week lead-in of molecularly targeted therapy (MTT), followed by two 3 
week cycles of combined targeted therapy (MTT) and pembrolizumab (at dose of 200 
mg IV every three weeks), followed by maintenance single-agent pembrolizumab in all 
patients with RECIST defined stable disease (SD), partial response (PR), and complete 
response (CR).  MTT only will be resumed if patients develop symptomatic or 
radiographic evidence of progression.  If patients do not develop evidence of 
progressive disease (PD), then they will continue maintenance single-agent 
pembrolizumab for up to two years. In each cohort, patients will be accrued to first stage 
of the Simon design.  If a prespecified number of patients maintain SD/PR/CR off MTT 
but on pembrolizumab at the 24-week time point, then the second stage of the two-
stage design will be opened.  (Please see details in statistical section) Biopsies will be 
performed on all patients enrolled to the first stage of the Simon two-stage for each 
cohort.  These will be obtained at baseline and after the two-week lead-in.  A third 
biopsy obtained after the completion of induction therapy will be obtained if feasible. An 
optional biopsy at time of disease progression will also be performed. 

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SCHEMA
WT = wild-type; MT = mutant
Key Eligibility:

Participants must have histologically confirmed metastatic or unresectable 
melanoma.

Participants must have BRAFV600-mutation status known.

Participants must have measurable disease.

Age greater than or equal to 18 years. 

Participants must have disease amenable to and be willing to undergo serial 
core or excisional biopsies of a tumor lesion(s).

ECOG performance status <1 (see Appendix A).

Participants must have normal organ and marrow function as defined below: 

Participants not previously treated with BRAF inhibitors (vemurafenib, 
dabrafenib, encorafenib), MEK inhibitors (selumetinib, trametinib, binimetinib, 
cobimetinib), and/or anti-PD1/PDL1 monoclonal antibodies for metastatic or 
unresectable disease.  Any other prior therapy will be allowed (including 
ipilimumab, adjuvant anti-PD1 therapy, high-dose IL-2).

Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or 
any other form of immunosuppressive therapy within 7 days prior to the first 
dose of trial treatment.

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
Participants with symptomatic brain metastases will be excluded from this 
clinical trial.  Subjects with asymptomatic, stable brain metastases and/or who 
have been previously treated for these conditions that are asymptomatic in the 
absence of corticosteroid therapy are allowed to enroll.  Brain metastasis must 
be stable with verification by imaging (brain MRI completed at screening 
demonstrating no current evidence of progressive brain metastases).  

No symptomatic or untreated leptomeningeal disease.
Number of Patients & Centers
Total number of patients:  50
Sample Size Justification:  
This trial will provide preliminary estimates of toxicity and efficacy and will be based on 
parallel Simon two-stage designs according to disease cohort.  The rate of clinical 
benefit (CBR), defined as the rate of patients who have CR/PR/SD at week 24 while 
remaining off targeted therapy after induction, will be the primary efficacy endpoint.  For 
each disease cohort, the Simon two-stage design is based on a type-I error rate of 0.1, 
at least 85% power, and a total sample size of 25 subjects.  A complete safety 
assessment is planned to coincide with the review of clinical benefit at the end of the 
first stage.  
For both cohorts, the null hypothesis of a true CBR of 0.50 will be tested against a one-
sided alternative CBR of 0.75.  The benchmark CBR rate of 0.50 is based on the results 
of the Keynote 001 trial in patients with refractory or first-line malignant melanoma 
treated with pembrolizumab (Robert, ASCO 2016) that reported a CBR of 0.51 
regardless of BRAF mutation status. A short course of MAPK-targeted therapy in 
addition to pembrolizumab would be considered worthy of further investigation if there is 
evidence of an improvement in CBR to 0.75. Fourteen (14) subjects that are evaluable 
for 
the 
primary 
endpoint 
(defined 
as 
receiving 
at 
least 
1 
dose 
of 
dabrafenib/trametinib/pembrolizumab 
combination 
therapy 
prior 
to 
treatment 
discontinuation for any reason.) will be enrolled in the first stage, and if 8 or fewer 
subjects with clinical benefit are observed, then enrollment will stop. If there are 9 or 
more subjects with clinical benefit, then an additional 11 subjects will be enrolled, for a 
total of 25. The null hypothesis will be rejected if a total of 16 or more subjects with 
clinical benefit are observed in 25 subjects. This design yields power of 86% (target 
type II error of 0.15) when the CBR rate is 0.75.  If the null hypothesis is true, the 
probability is 0.79 that enrollment to a cohort will stop at the end of the first stage.  This 
high probability of stopping under the null was chosen to require strong evidence of 
benefit before opening the second stage.
Clinical benefit rates will be presented with 90% confidence intervals based on the 
method of Atkinson and Brown, which allows for the two-stage design.
All reported adverse events will be summarized as part of the early safety review at the 

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end of the first stage. With 14-15 subjects per disease cohort, there is high probability of 
observing at least one event if a toxicity has an incidence of at least 10%.  If the true 
incidence of an unexpected or severe toxicity is 10% or greater, the probability is at 
least 0.75 that one or more subjects will experience the toxicity during the early safety 
monitoring period.  
The distribution of secondary endpoints of PFS and OS will be based on the method of 
Kaplan-Meier.  ORR within each disease cohort will be estimated by the number of 
subjects with a best response of CR or PR (per RECIST) and presented with exact 90% 
confidence intervals.  For sample sizes of 25 per disease cohort, the confidence 
intervals will be no wider than 0.35.
Correlative studies will be based on tumor biopsies and will assess changes in 
biomarkers due to OTT.  PD-L1 expression will be classified as positive or negative 
according to IHC.  Pre- versus post-OTT PD-L1 expression will be compared using 
McNemar’s test.  Changes in T cell subtypes and in co-stimulatory molecules will be 
summarized using descriptive methods

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TABLE OF CONTENTS
SCHEMA ........................................................................................................................................5
1.
OBJECTIVES...................................................................................................................10
1.1
Study Design........................................................................................................10
1.2
Primary Objectives..............................................................................................10
1.3
Secondary Objectives.........................................................................................10
2.
BACKGROUND...............................................................................................................10
2.1
Study Disease(s).................................................................................................10
2.2
IND Agents...........................................................................................................12
2.3
Rationale...............................................................................................................33
2.4
Correlative Studies Background .......................................................................34
3.
PARTICIPANT SELECTION .........................................................................................36
3.1
Inclusion Criteria..................................................................................................36
3.2
Exclusion Criteria ................................................................................................38
-
Note:  Subjects with ≤ Grade 2 thyroiditis and/or hypophysitis are an exception to 
this criterion and may qualify for the study..................................................................39
3.3
Inclusion of Women and Minorities ..................................................................41
4.
REGISTRATION PROCEDURES ................................................................................41
4.1
General Guidelines for DF/HCC Institutions...................................................41
4.2
Registration Process for DF/HCC Institutions ................................................42
5.
TREATMENT PLAN .......................................................................................................42
5.1
Treatment Regimen ............................................................................................42
5.2
Pre-Treatment Criteria........................................................................................43
5.3
Agent Administration...........................................................................................44
5.4
General Concomitant Medication and Supportive Care Guidelines ...........45
5.5
Criteria for Taking a Participant off Protocol Therapy ...................................51
5.6
Duration of Follow Up.........................................................................................53
5.7
Criteria for Taking a Participant Off Study.......................................................54
5.8
Contraception.......................................................................................................54
6.
DOSING DELAYS/DOSE MODIFICATION criteria...................................................56
6.1
Pembrolizumab Dose Modifications.................................................................56
6.2
Dabrafenib + Trametinib Dose Modifications..................................................58
7.
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS........................74
7.1
Expedited Adverse Event Reporting to the Overall PI and Merck...............74
7.2
Expedited Reporting to the Food and Drug Administration (FDA) ..............75
7.3
Expedited Reporting to Hospital Risk Management......................................75
7.4
Routine Adverse Event Reporting ....................................................................76

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7.5
Monitoring of Adverse Events and Period of Observation............................76
8.
PHARMACEUTICAL INFORMATION .........................................................................76
8.1
Pembrolizumab....................................................................................................76
8.2
Dabrafenib mesylate (GSK2118436B) (NSC 763760)..................................80
8.3
Trametinib dimethyl sulfoxide (GSK1120212B) (NSC 763093)...................81
9.
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES......................................83
9.1
Collection of Specimen(s)..................................................................................83
9.2
PD-L1 Immunohistochemistry ...........................................................................84
9.3
Adaptive Biotechnologies immunoSEQ ...........................................................85
9.4
Tumor Microenvironment Assessment.............................................................85
9.5
Pharmacodynamic Studies................................................................................85
10.
STUDY CALENDAR.......................................................................................................86
11.
MEASUREMENT OF EFFECT.....................................................................................90
11.1
Antitumor Effect – Solid Tumors.......................................................................90
12.
DATA REPORTING / REGULATORY REQUIREMENTS........................................98
12.1
Data Reporting.....................................................................................................98
12.2
Data Safety Monitoring.......................................................................................98
12.3
Regulatory Considerations ................................................................................99
12.4
Study Documentation .......................................................................................100
12.5
Records Retention ............................................................................................101
13.
STATISTICAL CONSIDERATIONS...........................................................................101
13.1
Study Design/Endpoints...................................................................................101
13.2
Sample Size, Accrual Rate and Study Duration...........................................102
13.3
Analysis of Primary Endpoints ........................................................................102
13.4
Analysis of Secondary Endpoints...................................................................102
13.5
Analysis of Correlative Measures...................................................................103
13.6
Analysis of Safety and Toxicity Data..............................................................104
13.7
Reporting and Exclusions ................................................................................105
14.
PUBLICATION PLAN ...................................................................................................106
APPENDIX A:  PERFORMANCE STATUS CRITERIA ......................................................108
APPENDIX B:  INFORMATION ON POSSIBLE DRUG INTERACTIONS ......................109
APPENDIX C: BIOASSAY.......................................................................................................112

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1. OBJECTIVES
1.1
Study Design
A Simon 2-stage design will be implemented for each disease cohort.  Patients 
will be treated with two-week lead-in, followed by a 6-week combined targeted 
therapy (TT) and pembrolizumab, followed by maintenance single-agent 
pembrolizumab in all patients with RECIST defined stable disease (SD), partial 
response (PR), and complete response (CR).  TT will be resumed if patients 
develop symptomatic or radiographic evidence of progression.  If patients do 
not develop evidence of progressive disease (PD), then they will continue 
maintenance single-agent pembrolizumab for up to two years. In each cohort, 
patients will be accrued to first stage of the Simon design.  If a prespecified 
number of patients maintain SD/PR/CR off TT but on pembrolizumab, then the 
second stage of the two-stage design will be opened.  (Please see details in 
statistical section)  Biopsies will be performed on all patients enrolled to the first 
stage of the Simon two-stage for each cohort.  These will be obtained at 
baseline and after the two-week lead-in.  A third biopsy obtained after the 
completion of induction therapy will be obtained if feasible. An optional biopsy 
at time of disease progression will also be performed. 
1.2
Primary Objectives
Document the rate of clinical benefit (SD/PR/CR per RECIST) of abbreviated 
molecularly targeted therapy in combination with pembrolizumab in patients 
with unresectable and/or metastatic melanoma.  A subject will have achieved 
clinical benefit if there is evidence of CR, PR, or SD at the time of the 24-week 
scan and the subject has not resumed targeted therapy.
1.3
Secondary Objectives
1.3.1. To describe progression free survival (PFS) and 1 year overall survival 
(OS) of abbreviated molecularly targeted therapy in combination with 
pembrolizumab in patients with metastatic melanoma.
1.3.2. To define the effects of targeted and the combination of immune and 
molecularly targeted therapy on tumor microenvironment
2. BACKGROUND
2.1
Study Disease(s)
The incidence of melanoma has dramatically risen over the past several 
decades and in 2012, an estimated 74,0000 new cases and nearly 10,000 
deaths are expected in the United States.  (Seigel CA J 2015)  In fact, 

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melanoma is the 5th and 7th most common malignancy in the US among men 
and women respectively.  The prognosis for patients with metastatic melanoma 
has been traditionally poor, though is dramatically different if the disease is 
limited to subcutaneous and/or lymph nodes (M1a), if the lungs are the only site 
of visceral metastasis (M1b), or if other sites of visceral metastasis are 
identified and/or if the lactate dehydrogenase (LDH) level is elevated (M1c).  In 
particular, per the AJCC database the 1-year survival rates of M1a, M1b, and 
M1c are approximately 70%, 60%, and 40% respectively. Still, melanoma 
typically disseminates widely, and frequently involves sites that are uncommon 
in other cancers, such as the GI tract and the skin. (Balch J Clin Oncol 2009)
Over the past decade, amazing progress has been made culminating in the 
development of effective molecularly targeted and immune targeted therapies 
for the treatment of melanoma. In particular, molecular subsets have been 
identified (BRAF, NRAS, and CKIT mutant) that define a patient population 
associated with response to targeted agents.  Additionally, monoclonal antibody 
targeting of the program death 1 (PD1) receptor and its ligand (PDL1) is 
associated with responses in 25-45% of patients, and more importantly, has 
demonstrated a survival advantage compared to ipilimumab (in the front-line 
setting) and chemotherapy (in front-line and post-ipilimumab settings).  As the 
field looks to improve upon this level of activity, combination regimens have 
emerged that are associated with improved efficacy compared with single-
agent therapy. 
The first therapeutic regimen to demonstrate superiority over single-agent 
therapy is the combination of a BRAF inhibitor (BRAFi) and MEK inhibitor 
(MEKi).  In fact, there are now three “positive” randomized trials of combination 
BRAF/MEK inhibitors showing improved response, progression free survival, 
and overall survival compared to single-agent BRAF inhibitors.  As a result of 
this data, the FDA approved the dabrafenib (BRAFi) plus trametinib (MEKi) 
combination in early 2014 and is evaluating the combination of vemurafenib 
(BRAFi) plus cobimetinib (MEKi) for regulatory approval.  Further, there is no 
longer any dispute that combined targeted therapy is the preferred BRAF-
targeted therapy approach.  Unfortunately, only a small subset of patients have 
durable benefit and remain on therapy for more than two or three years.  
Immunotherapy combination therapy is another approach. The most advanced 
data with this approach is with the combination of ipilimumab and nivolumab. In 
particular, Phase I-III trials show that this regimen is associated with high 
response rates (exceeding 60%) and improved PFS (median ~12 months) at 
the cost of high toxicity (grade 3 or 4 treatment-related adverse events ~55+%). 
Given high rate of severe and life-threatening toxicity, this regimen is unlikely to 
serve the backbone upon which to rationally build three and four drug 
combinations.  
A second approach to improve upon the effectiveness of anti-PD1 therapy is to 
develop patient selection strategies to prospectively differentiate patients most 

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likely to experience long-term benefit from single-agent therapy from those who 
require combinations. Recently, a number of predictive biomarkers of response 
to anti-PD1 antibodies in melanoma and other malignancies have been 
reported. These include tumor factors (such as mutational burden and tumor 
neoantigen expression) immunologic factors (including cytotoxic T-lymphocyte 
infiltration with functional capacity to recognize tumor antigens, so-called T-cell 
diversity), 
and 
tumor-immune 
microenvironmental 
factors 
like 
PD-L1 
expression. With each new report, a clear picture is emerging that tumors with 
high mutational burden and neoantigen expression, increased T-cell diversity, 
and elevated PD-L1 expression are primed for immune destruction in the 
setting of single-agent anti-PD1 antibodies.  Conversely, tumors with low 
mutational load and neoantigen expression, low T-cell diversity, and low PD-L1 
expression are less susceptible to immune-mediated tumor cell destruction.  
One of the next great challenges in the field is to develop strategies that 
convert an immunologically non-responsive tumor microenvironment into one 
primed to respond to anti-PD1 therapy. 
2.2
IND Agents
2.2.1 Pembrolizumab
2.2.1.1
Mechanism of action
The importance of intact immune surveillance in controlling 
outgrowth of neoplastic transformation has been known for 
decades.  Accumulating evidence shows a correlation between 
tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable 
prognosis in various malignancies.  In particular, the presence of 
CD8+ T-cells and the ratio of CD8+ effector T-cells / FoxP3+ 
regulatory T-cells seems to correlate with improved prognosis and 
long-term survival in many solid tumors.
The PD-1 receptor-ligand interaction is a major pathway hijacked 
by tumors to suppress immune control.  The normal function of PD-
1, expressed on the cell surface of activated T-cells under healthy 
conditions, is to down-modulate unwanted or excessive immune 
responses, including autoimmune reactions.  PD-1 (encoded by the 
gene Pdcd1) is an Ig superfamily member related to CD28 and 
CTLA-4 which has been shown to negatively regulate antigen 
receptor signaling upon engagement of its ligands (PD-L1 and/or 
PD-L2).  The structure of murine PD-1 has been resolved.  PD-1 
and family members are type I transmembrane glycoproteins 
containing an Ig Variable-type (V-type) domain responsible for 
ligand binding and a cytoplasmic tail which is responsible for the 
binding of signaling molecules.  The cytoplasmic tail of PD-1 
contains 2 tyrosine-based signaling motifs, an immunoreceptor 

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tyrosine-based inhibition motif (ITIM) and an immunoreceptor 
tyrosine-based switch motif (ITSM).  Following T-cell stimulation, 
PD-1 recruits the tyrosine phosphatases SHP-1 and SHP-2 to the 
ITSM 
motif 
within 
its 
cytoplasmic 
tail, 
leading 
to 
the 
dephosphorylation of effector molecules such as CD3ζ, PKCθ and 
ZAP70 which are involved in the CD3 T-cell signaling cascade.  
The mechanism by which PD-1 down modulates T-cell responses 
is similar to, but distinct from that of CTLA-4 as both molecules 
regulate an overlapping set of signaling proteins.  PD-1 was shown 
to be expressed on activated lymphocytes including peripheral 
CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer cells.  
Expression has also been shown during thymic development on 
CD4-CD8- (double negative) T-cells as well as subsets of 
macrophages and dendritic cells.  The ligands for PD-1 (PD-L1 and 
PD-L2) are constitutively expressed or can be induced in a variety 
of cell types, including non-hematopoietic tissues as well as in 
various tumors.  Both ligands are type I transmembrane receptors 
containing both IgV- and IgC-like domains in the extracellular 
region and contain short cytoplasmic regions with no known 
signaling motifs.  Binding of either PD-1 ligand to PD-1 inhibits T-
cell activation triggered through the T-cell receptor.  PD-L1 is 
expressed at low levels on various non-hematopoietic tissues, most 
notably on vascular endothelium, whereas PD-L2 protein is only 
detectably expressed on antigen-presenting cells found in lymphoid 
tissue or chronic inflammatory environments.  PD-L2 is thought to 
control immune T-cell activation in lymphoid organs, whereas PD-
L1 serves to dampen unwarranted T-cell function in peripheral 
tissues.  Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of 
this T-cell inhibitor.  PD-1 has been suggested to regulate tumor-
specific T-cell expansion in subjects with melanoma (MEL).  This 
suggests that the PD-1/PD-L1 pathway plays a critical role in tumor 
immune evasion and should be considered as an attractive target 
for therapeutic intervention.
Pembrolizumab is a potent and highly selective humanized 
monoclonal antibody (mAb) of the IgG4/kappa isotype designed to 
directly block the interaction between PD-1 and its ligands, PD-L1 
and PD-L2.  KeytrudaTM (pembrolizumab) has recently been 
approved in the United Stated for the treatment of patients with 
unresectable or metastatic melanoma and disease progression 
following ipilimumab and, if BRAF V600 mutation positive, a BRAF 
inhibitor.

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2.2.1.2
Summary of nonclinical and clinical studies.
A phase 1/2, multipart study is being conducted to evaluate the 
combination of the approved doses of pembrolizumab and 
dabrafenib and trametinib for BRAFV600E/K-mutant advanced 
melanoma. Results presented at the American Society of Clinical 
Oncology (ASCO) Annual Meeting June 3-7, 2016 on the 
nonrandomized phase 1, dose-finding part of KEYNOTE-022 
showed Median days on therapy: 115 (range, 4-524). DLTs were 
reported in 3 out of 14 DLT-evaluable patients. Overall, 4 (26.7%) 
patients discontinued because of treatment-related AEs; there were 
no treatment-related deaths. Potentially immune-mediated AEs 
were reported in 6 (40.0%) patients, and included 2 cases of 
hyperthyroidism (1 grade 1, 1 grade 2), 2 cases of hypothyroidism 
(grade 1), 2 cases of uveitis (1 grade 1, 1 grade 2), and 1 case 
each of autoimmune hepatitis (grade 3), severe skin reactions 
(grade 3), and pneumonitis (grade 2). Based on observed DLTs 
and the AE profile, no additional dose levels were opened; 
pembrolizumab 2 mg/kg Q3W + dabrafenib 150 mg BID + 
trametinib 2 mg QD was the MTD. 
2.2.1.3
Nonclinical and clinical pharmacokinetics
An open-label Phase I trial (Protocol 001) is being conducted to 
evaluate the safety and clinical activity of single agent MK-3475.  
The dose escalation portion of this trial evaluated three dose levels, 
1 mg/kg, 3 mg/kg, and 10 mg/kg, administered every 2 weeks 
(Q2W) in subjects with advanced solid tumors.  All three dose 
levels were well tolerated and no dose-limiting toxicities were 
observed.  This first in human study of MK-3475 showed evidence 
of target engagement and objective evidence of tumor size 
reduction at all dose levels (1 mg/kg, 3 mg/kg and 10 mg/kg Q2W).  
No MTD has been identified to date.  10.0 mg/kg Q2W, the highest 
dose tested in PN001, will be the dose and schedule utilized in 
Cohorts A, B, C and D of this protocol to test for initial tumor 
activity.  Recent data from other clinical studies within the MK-3475 
program has shown that a lower dose of MK-3475 and a less 
frequent schedule may be sufficient for target engagement and 
clinical activity.
PK data analysis of MK-3475 administered Q2W and Q3W showed 
slow systemic clearance, limited volume of distribution, and a long 
half-life (refer to IB).  Pharmacodynamic data (IL-2 release assay) 
suggested that peripheral target engagement is durable (>21 days).  

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This early PK and pharmacodynamic data provides scientific 
rationale for testing a Q2W and Q3W dosing schedule.  
A population pharmacokinetic analysis has been performed using 
serum concentration time data from 476 patients. Within the 
resulting population PK model, clearance and volume parameters 
of MK-3475 were found to be dependent on body weight. The 
relationship between clearance and body weight, with an allometric 
exponent of 0.59, is within the range observed for other antibodies 
and would support both body weight normalized dosing or a fixed 
dose across all body weights.  MK-3475 has been found to have a 
wide therapeutic range based on the melanoma indication.  The 
differences in exposure for a 200 mg fixed dose regimen relative to 
a 2 mg/kg Q3W body weight based regimen are anticipated to 
remain well within the established exposure margins of 0.5 – 5.0 for 
MK-3475 in the melanoma indication. The exposure margins are 
based on the notion of similar efficacy and safety in melanoma at 
10 mg/kg Q3W vs. the proposed dose regimen of 2 mg/kg Q3W 
(i.e. 5-fold higher dose and exposure). The population PK 
evaluation revealed that there was no significant impact of tumor 
burden on exposure. In addition, exposure was similar between the 
NSCLC and melanoma indications. Therefore, there are no 
anticipated changes in exposure between different indication 
settings.
The rationale for further exploration of 2 mg/kg and comparable 
doses of pembrolizumab in solid tumors is based on: 1) similar 
efficacy and safety of pembrolizumab when dosed at either 2 mg/kg 
or 10 mg/kg Q3W in melanoma patients, 2) the flat exposure-
response relationships of pembrolizumab for both efficacy and 
safety in the dose ranges of 2 mg/kg Q3W to 10 mg/kg Q3W, 3) the 
lack of effect of tumor burden or indication on distribution behavior 
of pembrolizumab (as assessed by the population PK model) and 
4) the assumption that the dynamics of pembrolizumab target 
engagement will not vary meaningfully with tumor type.

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2.2.1.4
Potential for drug-drug interaction
Given the absence of interaction with the Cytochrome P450 
enzyme system, the potential for drug-drug interaction is quite low 
with pembrolizumab.  
2.2.1.5
Safety Profile
The most common adverse reactions (reported in > 20% of 
patients) of pembrolizumab include fatigue, cough, nausea, 
pruritus, rash, decreased appetite, constipation, arthralgia, and 
diarrhea.  
Pembrolizumab leads to the development of severe or life-
threatening immune related adverse events in 10-15% of patients 
treated.  The following toxicities are of particular interest: Immune-
mediated pneumonitis (occurring in approximately 3% of the 411 
melanoma patients treated on the phase I trial of pembrolizumab), 
immune-mediated colitis (1%), immune-mediated hepatitis (0.5%), 
immune-mediated hypophysitis (0.5%), immune-mediated nephritis 
(0.7%), immune-mediated hyper- (1.2%) and hypothyroidism 
(8.3%). 
2.2.1.6
Rationale for proposed initial dose
The choice of the 200 mg Q3W as an appropriate dose for the 
switch to fixed dosing is based on simulations performed using the 
population PK model of pembrolizumab showing that the fixed dose 
of 200 mg every 3 weeks will provide exposures that 1) are 
optimally consistent with those obtained with the 2 mg/kg dose 
every 3 weeks, 2) will maintain individual patient exposures in the 
exposure range established in melanoma as associated with 
maximal efficacy response and 3) will maintain individual patients 
exposure in the exposure range established in melanoma that are 
well tolerated and safe. 
A fixed dose regimen will simplify the dosing regimen to be more 
convenient for physicians and to reduce potential for dosing errors.  
A fixed dosing scheme will also reduce complexity in the logistical 
chain at treatment facilities and reduce wastage.
There are extensive data that have been generated in the 
pembrolizumab development program supporting that a fixed dose 
of 200 mg is suitable for use in subjects with advanced melanoma 
as a replacement for weight-based dosing of 2 mg/kg. Details of 
these supporting data were were published recently (Freshwater T, 
Kondic A, Ahamadi M, Li CH, de Greef R, de Alwis D, Stone JA. 

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Evaluation of dosing strategy for pembrolizumab for oncology 
indications. J Immunother Cancer. 2017 May 16;5:43. doi: 
10.1186/s40425-017-0242-5. eCollection  2017. PubMed PMID: 
28515943; PubMed Central PMCID: PMC5433037). The results 
presented in this paper demonstrate that fixed dosing of 
pembrolizumab 200 mg Q3W maintains exposures comparable 
with or slightly increased relative to those from 2 mg/kg Q3W. Fixed 
dosing eliminates the waste generated by weight-based dosing, 
improves compliance, and might also reduce the risk of dosing 
errors by reducing dosing complexity.
Based on these data, trials using pembrolizumab monotherapy or in 
combination with other therapies have utilized a fixed dosing 
regimen for pembrolizumab and have resulted in FDA approvals for 
NSCLC, HNSCC, cHL, urothelial carcinoma, and MSI-H cancer 
using 200 mg Q3W.
With respect to melanoma, on May 17, 2017, the FDA approved to 
replace the 2 mg/kg Q3W dose for melanoma patients with 200 mg 
Q3W.
2.2.2 Dabrafenib Mesylate (GSK2118436B)
The RAS/RAF/MEK/ERK pathway is a critical proliferation pathway 
in many human cancers.  This pathway can be constitutively 
activated by molecular alterations including BRAF activating 
mutations.  Approximately 90% of all identified BRAF mutations in 
human cancer consist of a T1799 transversion mutation in exon 15, 
which results in a V600 E/D/K(T1799A) amino acid substitution.  
This mutation appears to mimic regulatory phosphorylation and 
increases BRAF activity approximately 10-fold compared to wild 
type (wt).  RAF is a validated target in BRAF V600E-containing 
melanoma.  In August 2011, the FDA approved vemurafenib 
(PLX4032, Zelboraf®), an ATP-competitive selective RAF inhibitor 
for the treatment of late-stage BRAFV600E melanoma.  In the pivotal 
phase III trial of vemurafenib vs. dacarbazine (Chapman et al., 
2011), vemurafenib demonstrated significant improvement in 
overall survival (OS) (6-month OS of 84% vs. 64%, hazard ratio 
[HR]=0.37; P<0.001), progression-free survival (PFS) (estimated 
median PFS of 5.3 months vs. 1.6 months (HR=0.26; P<0.001]), 
and overall response rate (ORR) (48% vs. 5%).  However, in 
patients with colorectal cancer (CRC) bearing the BRAF V600E 
mutation, there was only one partial response (PR) among 20 
patients treated (ORR 5%) and four minor responses (Kopetz et al., 
2010).

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2.2.2.1
Mechanism of action
Dabrafenib mesylate (GSK2118436B), a 4-(3-
aminosulfonylphenyl)-5-(pyrimidin-3-yl) thiazole, is an ATP-
competitive, selective inhibitor of RAF kinase.  Dabrafenib potently 
inhibits all RAF isoforms, with the strongest potency against the 
V600 mutant, as compared to its activity against wt BRAF and 
CRAF (see below).  In a panel of 270 kinases tested outside RAF 
isoforms, only seven kinases (LIMK1, ALK5, NEK11, SIK, SIK2, 
PKD2, and BRK) were inhibited at a 50% inhibitory concentration 
(IC50) <100 nM (Investigator’s Brochure, 2012a).
Inhibitory activity of dabrafenib on RAF
BRAFV600E
BRAFV600K
BRAFV600D
wt BRAF
CRAF
IC50
0.65 nM
0.50 nM
1.84 nM
3.2 nM
5.0 nM
In a panel of 110 human tumor cell lines with known BRAF 
mutational status, dabrafenib potently inhibited proliferation of a 
majority (73%) of BRAFV600E mutant cell lines with growth IC50 
(gIC50) <100 nM.  In contrast, there was poor or no activity in other 
BRAF mutants or wt BRAF cell lines.
Dabrafenib given orally (PO) for 14 days at doses ranging from 0.1-
300 mg/kg administered once daily (QD), twice daily (BID), or three 
times daily (TID) inhibited tumor growth in mice bearing 
BRAFV600E A375P F11s or Colo205 tumor xenografts.  The effect 
was generally dose dependent up to 10 mg/kg/day (A375P F11s) or 
30 mg/kg/day (Colo205), yielding 90-120% tumor reduction relative 
to untreated animals.  However, cessation of treatment was 
associated with regrowth of the tumors.  In A375P F11s melanoma 
xenografts, inhibition of pERK by >50% in the tumor was seen at 
doses of ≥3 mg/kg.  Based on the single-dose studies, ~100 nM (52 
ng/mL) dabrafenib in blood at 6 h post-dosing was needed for 
effective pharmacodynamic biomarker inhibition in the tumor.  At 
repeated dosing of 30 mg/kg/day, the tumor pERK levels were 
reduced by >50% at 8 h after dosing (69% on Day 1 and 53% on 
Day 14).  Levels of pERK returned to baseline 24 h post-dosing.  
Similar ↓pERK effects were seen in the ES-2 ovarian xenograft 
model, but pERK inhibition was weaker in the Colo205 xenograft 
model.  Of note, concentrations of dabrafenib showing 
pharmacodynamic activity in xenografts did not cause a reduction 
in pERK/tERK levels in the normal intact brain. 

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2.2.2.2
Clinical Pharmacokinetics (PK) and Activity of Dabrafenib
GSK has sponsored several dabrafenib monotherapy studies, 
mostly in patients with BRAF V600 mutant melanoma; and trials for 
combinations with a MEK inhibitor.
FTIH Phase 1 Trial of Dabrafenib Monotherapy (BRF112680)
BRF112680 is the FTIH study of dabrafenib (gelatin capsule) 
monotherapy, administered at escalating doses at different 
schedules (12-600 mg PO QD, BID, or TID).  A total of 184 patients 
who had BRAF mutations (V600E or V600K) in their tumors were 
treated (Investigator's Brochure, 2012a).
PK and metabolism of dabrafenib:
In the single-dose studies, plasma dabrafenib concentrations 
peaked at a median time of 2 h (Tmax) and bi-exponentially declined 
thereafter.  The median terminal half-life (t1/2) was approximately 8 
hours after a single dose.  Increases in Cmax and AUC were 
generally dose proportional up to 300 mg.  However, on repeat 
daily dosing, the drug exposure decreased with time.  At the 
recommended phase 2 dose (RP2D) of 150 mg PO BID, Cmax and 
AUC were about 40% lower on Day 15 vs. Day 8 (geomean Cmax of 
1.35 vs. 0.81 mcg/mL and geomean AUC of 2.62 vs. 4.17 
mcg•hr/mL), although the AUC remained stable over subsequent 
administrations.  The decreased exposure with time may be a result 
of GSK2118436-mediated induction of its own metabolism.
Three metabolites of dabrafenib were characterized and may 
contribute to activity.  GSK2285403 (hydroxy-metabolite [M7]) PK 
paralleled that of dabrafenib, while the carboxy- (GSK2298683 
[M4]) and desmethyl- (GSK2167542 [M8]) metabolites exhibited a 
longer t1/2 and accumulated following repeat dosing.  Similar to 
dabrafenib concentrations, exposure for all metabolites showed a 
less than dose proportional increase with repeat dosing.
Fecal excretion was a major route of dabrafenib elimination in 
humans, accounting for 71.1% of the dose administered, and renal 
excretion accounted for about 20% of drug elimination.
Administration of dabrafenib with a high-fat, high-calorie meal 
reduced the oral bioavailability of dabrafenib when compared to the 
fasted state with a decrease in Cmax and AUC of 51% and 31%, 
respectively, and delayed its absorption.  Therefore, the current 
recommendation is to administer dabrafenib under fasting 
conditions, either 1 h before or 2 h after a meal.

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Drug-drug interactions:
As a CYP3A4 inducer, dabrafenib, when administered 150 mg BID 
in combination with midazolam (a substrate of CYP3A4), 
significantly reduced the midazolam exposure by 74% (the ratios of 
midazolam with or without dabrafenib were 0.39 for Cmax and 0.26 
for AUC).  Dabrafenib thus induces CYP3A4 metabolism and may 
induce other enzymes such as CYP2B6, CYP2C8, CYP2C9, and 
CYP2C19.  Co-administration of dabrafenib and medicinal products 
which are affected by the induction of these enzymes such as 
hormonal contraceptives, warfarin, or dexamethasone may result in 
decreased concentrations and loss of efficacy.
Based on preclinical in vitro studies, dabrafenib was shown to be 
primarily metabolized by CYP2C8 and CYP3A4.  Co-administration 
of ketoconazole (CYP3A4 inhibitor) increased the AUC of 
dabrafenib by 57%.  Medicinal products that are strong inhibitors or 
inducers of CYP2C8 or CYP3A are likely to increase or decrease, 
respectively, dabrafenib concentrations.  Alternative agents should 
be considered during administration with dabrafenib when possible.  
Use caution if strong inhibitors (e.g., ketoconazole, nefazodone, 
clarithromycin, ritonavir) or inducers (e.g., rifampin, phenytoin, 
carbamazepine, phenobarbital) of CYP2C8 or CYP3A4 are 
coadministered with dabrafenib.
Pharmacodynamic effect of dabrafenib:
Median tumor pERK inhibition was 83.9% (range:  38.0 to 93.3%) in 
BRAF mutant melanoma subjects receiving doses of 70 to 200 mg 
BID.  The relationship between exposure and % pERK inhibition 
was characterized using a maximum response (Emax) model with 
100% maximum inhibition and IC50 of 134 ng/mL (95% CI:  92.7, 
155) based on the sum of the potency-adjusted parent and active 
metabolite concentrations.  A dose-related decrease in pERK was 
predicted with total daily doses <200 mg (100 mg BID) dabrafenib, 
with a plateau occurring beyond total daily doses of 200 mg 
thereafter.
Selection of the RP2D:
The single-agent MTD for dabrafenib was not reached.  A dose of 
150 mg BID was selected for further single-agent development, 
based on the following PK/pharmacodynamics, safety, and activity:  
a) dose increases beyond 150 mg BID yielded no increase in Cmax 
and <50% increase in AUC; b) incidence and severity of AEs was 
similar at 100-300 mg BID; c) pERK target suppression was >80%; 
and d) the tumor response rate (RR) was 50% at 150 mg BID.

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Antitumor Activity of Dabrafenib Monotherapy 
Activity in patients with BRAF V600E or V600K melanoma:
The FTIH monotherapy study (BRF112680) enrolled 114 enrolled 
patients with BRAF V600 mutant melanoma in the dose escalation 
phase (Part 1), and 70 patients at the RP2D (150 mg BID) in Part 2.  
Within this study, a cohort of 10 patients with previously untreated 
asymptomatic brain metastasis was evaluated for intracranial 
response to dabrafenib (Long et al., 2011).  All patients had 
decreases in the size of the brain metastasis; three patients 
achieved complete radiographic resolution of brain lesions (bCR) 
as well as reduction in extracranial disease.  The response rates in 
patients treated at 150 mg BID are shown below.
FTIH monotherapy study (BRF112680) response rates in melanoma patients
Subgroup
Patient #
ORR
Part 1
V600E
77
50%
V600K
14
20%
Part 2, Cohort 
A
V600E/K with brain mets
10
40%
V600E/K without brain 
mets
20
55%
When dabrafenib was used at 50 mg BID (Part 2, Cohort C) in 
patients with BRAF V600E mutant melanoma, the response rate 
was only 17%.
Correlative studies in the phase 1 monotherapy trial:
Preliminary genomic analysis was performed on 37 patients with 
melanoma, using a Sequenom mutation analysis for 11 genes 
(AKT, BRAF, CDK4, CDKN2A, GNAQ, GNA11, Kit, MEK1, MEK2, 
and NRAS), and PTEN analysis by sequencing, comparative 
genomic hybridization (CGH), and multiplex ligation-dependent 
probe amplification (MPLA) (Nathanson et al., 2011).  Nine patients 
(24%) had PTEN genetic alterations including mutation, hemi-
/homozygous deletion.  PTEN deficiency was associated with lower 
responses (ORR of 11% and 54% in patients with and without 
PTEN alteration, respectively).
Phase III trial of dabrafenib versus chemotherapy in patients with 
advanced BRAFV600 mutant melanoma (BREAK3 Trial):
Patients with previously untreated, unresectable stage III or IV 
BRAFV600E-mutated melanoma were randomized (3:1) and stratified 
by stage to dabrafenib (150 mg PO BID) or dacarbazine (DTIC) 
(1000 mg/m2, IV, every 3 weeks [Q3W]).  Of 250 patients enrolled, 
187 were randomized to dabrafenib and 63 to DTIC from February 

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to September 2011.  At the time of the primary analysis, there were 
118 events (77 dabrafenib and 41 DTIC).  The hazard ratio for PFS 
was 0.30 (95% CI:  0.18-0.53; P<0.0001), with median PFS of 5.1 
months for dabrafenib and 2.7 for DTIC.  OS data were immature, 
with 30 deaths reported.  Confirmed RR was 53% for dabrafenib 
and 19% for DTIC.  Benefits in PFS and RR were observed in all 
subgroups evaluated.
Activity in BRAF V600E mutant tumors other than melanoma:
Efficacy data for dabrafenib in non-melanoma tumors are limited to 
18 patients enrolled in the phase 1 trial.  Among them, seven had 
CRC, nine had thyroid cancer, and one each had NSCLC and 
ovarian cancer, respectively.  Confirmed partial responses (PRs) 
were seen in one patient with CRC, and in 2 patients with thyroid 
cancer; the patient with NSCLC had an unconfirmed PR at 6 weeks 
followed by progressive disease (PD) at 12 weeks.  Eleven patients 
(six with thyroid cancer and five with CRC) had stable disease (SD) 
as their best response; the ovarian cancer patient had SD before 
progressing at approximately 36 weeks.
2.2.2.3
Safety Profile
A comprehensive list of adverse events is included in Section 7 of 
the protocol.
As of February 20, 2012, among 184 patients treated on the FTIH 
phase 1 trial, 99% experienced at least one adverse event (AE) 
(any grade).  The most common (>20% of all subjects) AEs of any 
grade across all dosing cohorts in Part 1 and Part 2 were fatigue 
(42%), pyrexia (37%), headache (35%), nausea (34%), 
hyperkeratosis (33%), diarrhea (27%), arthralgia (25%), pain in 
extremity (25%), decreased appetite (24%), alopecia (23%) and 
rash (23%).  
Serious AEs (SAEs) were reported in 39% of patients, including 
SCC (12%), pyrexia (7%), and urinary tract infection (3%).  Sixty-
four patients are reported to have had study drug interrupted due to 
the occurrence of AEs.  Pyrexia was the AE that led most 
frequently to a dose interruption.  Fifteen patients reported a dose 
reduction due to the occurrence of AEs.  There were no instances 
of discontinuation of study treatment due to AEs and no fatal AEs 
reported in the study among patients who received at least one 
dose of dabrafenib.
AEs of special interest:
The following events observed in dabrafenib monotherapy studies 

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are discussed in detail because they may be a class effect of BRAF 
inhibitor compounds, have occurred at high frequency, and/or are 
potentially life-threatening.
Dermatologic effects:  Rashes and other skin lesions, from 
hyperkeratosis to SCC, have been observed at the frequencies 
below in FTIH study BRF112680.
AE Term
Any Grade
Grade ≥3
Hyperkeratosis
61 (33)
0
Skin papilloma
46 (25)
1 (<1)
Rash
42 (23)
1 (<1)
Skin lesion
26 (14)
0
Actinic keratosis
21 (11)
0
Squamous cell carcinoma
22 (12)
21 (11)
Pruritis
22 (12)
0
Seborrheic keratosis
25 (14)
0
Acrochordon
19 (10)
0
Melanocytic nevus
19 (10)
0
Rash pruritic
11 (6)
0
Pre-malignant and malignant skin lesions:  Cutaneous SCC and 
keratocanthoma were reported in 11% and 2%, respectively, of 
patients treated with dabrafenib in FTIH study BRF112680.  SCC 
and proliferative skin toxicities are considered a class effect of 
BRAF inhibitors such as vemurafenib and sorafenib (Long et al., 
2011).  SCC was treated with local excision, and treatment with 
dabrafenib was continued.  Most SCCs of the skin have been 
localized and generally treated with curettage, and have been 
without significant clinical sequelae.  Only one patient required a 
dose reduction in response to the event.  The median onset of the 
first SCC occurred on Day 67 (range:  Day 9-217).
Other treatment-emergent malignancies:  Other treatment-
emergent cutaneous malignancies such as basal cell carcinoma 
and new primary melanoma have been reported with BRAF 
inhibitors (Zelboraf, 2011).
Pyrexia:  Across dabrafenib studies, all SAEs of pyrexia, influenza-
like illness, cytokine release syndrome, systemic inflammatory 
response syndrome underwent clinical review for serious events of 
pyrexia complicated by hypotension, dehydration, circulatory 
collapse, severe rigors, or renal failure in the absence of another 
identifiable etiology (i.e., infection).
Abnormal ejection fraction:  Left ventricular ejection fraction (LVEF) 
changes were not observed in the early safety reviews of 

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dabrafenib.  However, these events are included in AEs of special 
interest because they are known side effects of several kinase 
inhibitors including imatinib, sunitinib, and lapatinib (Force et al., 
2007).
Cardiac valvular abnormalities:  Data from preclinical studies 
suggested that dabrafenib has the potential to cause cardiac valve 
abnormalities.  In a 28-day dog toxicology study, high doses (50 
mg/kg/day; approximately 40-fold over the therapeutic dose) of 
dabrafenib in 1 dog (n=10) resulted in hypertrophy of the right atrio-
ventricular valve (tricuspid valve).  Therefore, this was monitored in 
clinical trials with echocardiograms.
Uveitis:  Uveitis was reported at a frequency of 3.8% as an AE of 
vemurafenib in previously treated patients with BRAF V600 
mutation-positive metastatic melanoma (Chapman et al., 2011; 
Sosman et al., 2010), and has been observed in patients receiving 
dabrafenib (incidence in study BRF112680 was 1%).
Renal failure:  Cases of renal failure have been identified on clinical 
trials with a possible causal relationship to dabrafenib.
2.2.2.4
Clinical Experience with the Combination of Dabrafenib + Trametinib
Data on 247 patients with metastatic melanoma and BRAF V600 
mutations participating in the phase 1/2 study of dabrafenib and 
trametinib, BRF113220, have been published (Flaherty et al., 2012 
#2).
PK
Repeat-dose trametinib (2 mg QD) had no effect on the PK of 
single-dose dabrafenib (75 mg), but the plasma levels of dabrafenib 
after repeated dosing were higher in combination with trametinib as 
compared to that with previously reported PK with monotherapy.  
Geometric mean Day 15 AUC of dabrafenib in combination ranged 
from 3539 to 5187 ng•hr/mL, while the AUC observed in the 
monotherapy study was 2619 ng•hr/mL.  The data suggest that 
trametinib may have a minor inhibitory effect on dabrafenib 
clearance (Flaherty et al., 2012 #2).
Preliminary results showed that trametinib accumulated with repeat 
dosing; Day 21 AUC0-24 was 314 ng•hr/mL in combination with 
dabrafenib at 75 mg BID and 335 ng•hr/mL in combination with 
dabrafenib at 150 mg BID (Investigator’s Brochure, 2012b).
Safety and the RP2D for the combination of trametinib and 

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dabrafenib
In the dose escalation portion (Part B) of study BRF113220, one 
DLT of a recurrent grade 2 neutrophilic panniculitis occurred, 
among the 24 patients treated at the highest dose level (150 mg 
dabrafenib BID + 2 mg trametinib QD) (150/2) (Flaherty et al., 
2012).  The MTD of the combination was not reached, and the 
RP2D was therefore 150/2.  Pyrexia was common in the 150/2 
group, occurring in 88% of patients.
In the randomized, open-label, phase 2 portion (Part C) of the 
study, the incidence of certain AEs were lower with the combination 
as compared to single agent dabrafenib:  cutaneous squamous-cell 
carcinoma (including keratoacanthoma) (19 vs. 7%), and rash (27 
vs. 36%) (Flaherty et al., 2012 #2).  On the other hand, the 
frequencies of pyrexia appeared increased (39 vs. 14%).  The 
combination was also associated with an increased prevalence of 
MEK inhibitor-associated acneiform dermatitis (16 vs. 4%, with no 
grade 3 or 4 events reported).  There was one death from sepsis in 
the 150/1 combination group, and there were three deaths in the 
combination 150/2 group (two from brain hemorrhage and one from 
pulmonary embolism); none of these events were considered to be 
related to a study drug.  The incidences of main AEs (all grades) 
observed in Part C of the trial are presented in the table below as 
patients (percent).
Adverse Event
Dabrafenib 
Monotherapy 
(n=53)
Combination 
150/1
(n=54)
Combination 
150/2
(n=55)
Pyrexia
14 (26)
37 (69)
39 (71)
Nausea
11 (21)
25 (46)
24 (44)
Vomiting
8 (15)
23 (43)
22 (40)
Diarrhea
15 (28)
14 (26)
20 (36)
Rash
19 (36)
11 (20)
15 (27)
Hyperkeratosis
16 (30)
3 (6)
5 (9)
Cutaneous squamous cell 
carcinoma
10 (19)
1 (2)
4 (7)
Alopecia
18 (34)
5 (9)
3 (5)
Skin papilloma
8 (15)
4 (7)
2 (4)
Decreased ejection fraction
0
2 (4)
5 (9)
Cardiac failure
0
1 (2)
0
Hypertension
2 (4)
2 (4)
5 (9)
Chorioretinopathy
0
0
1 (2)
Neutropenia
(11)
Acneiform dermatitis
(4)
(11)
(16)
Activity
Efficacy analyses were performed in the intention-to-treat 

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26
population of the phase 2 portion (Part C) of study BRF113220, 
with a median follow-up of 14.1 months (Flaherty et al., 2012).  All 
major efficacy endpoints were improved, including PFS, 12-month 
PFS, ORR, and duration of response.  Endpoint values as 
assessed by site investigators for this portion of the study are 
presented in the table below.
End Point
Dabrafenib 
Monotherapy 
(n=54)
Combination 
150/1
(n=54)
Combination 
150/2
(n=54)
Progression-free Survival – 
months
Median (95% CI)
5.8 (4.6-7.4)
9.2 (6.4-11.0)
9.4 (8.6-16.7)
Progression-free Survival at 12 
mo. % (95% CI)
9 (3-20)
26 (15-39)
41 (27-54)
CR or PR
Patients (% [95% CI])
29 (54 [40-67])
27 (50 [36-64])
41 (76 [62-86])
Duration of response
Median months (95% CI)
5.6 (4.5-7.4)
9.5 (7.4-NA)
10.5 (7.4-14.9)
2.2.2.5
Rationale for proposed starting dose
The safe and efficacious dose of dabrafenib is 150 mg PO twice-
daily as reflected by the FDA approval of this dose. Further, this 
dose is safe and effective in combination with trametinib.  Given the 
known survival advantage with this therapy taken at this dose and 
schedule, we believe it is a priority to administer this dose of 
dabrafenib as the backbone of the proposed combination therapy.
2.2.3 Trametinib Dimethyl Sulfoxide (GSK1120212B)
The RAF-MEK-ERK pathway plays a critical role in multiple cellular 
functions.  Activation of the pathway can result from 
activation/mutations of the upstream receptor tyrosine kinases 
(RTKs) and RAS, or upregulation/mutations in RAF and MEK.  
Upon activation, RAF acts as the MAPK kinase and activates 
MAPKK (MEK1/2), which in turn catalyze activation of the effectors 
ERK1/ERK2.  Once activated, ERK1/2 translocate into the nucleus 
and phosphorylate a number of effector proteins and transcriptional 
factors that regulate cell proliferation, motility, differentiation, and 
survival.  Trametinib is one of the several MEK inhibitors in clinical 
development.  
Experience to date indicates that MEK is a valid target.  In a phase 
III trial comparing trametinib with dacarbazine or paclitaxel in 
patients with BRAF V600E or V600K mutant metastatic melanoma, 

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trametinib demonstrated a significantly better response rate, 
progression-free survival, and overall survival (Flaherty et al., 2012 
#1).  However, single agent activities are limited.  Extensive 
research is underway to identify the patient selection markers and 
develop rational combination strategies.  Preclinical studies have 
provided strong rationale and proof of principle for combination of 
MEK inhibitors with RTK inhibitors (EGFR or IGF-1R) (Gopal et al., 
2010; Ebi et al., 2011), PI3K/AKT inhibitors (Engelman et al., 2008; 
Hoeflich et al., 2009), and mTOR inhibitors.  On the other hand, the 
optimal dose/schedule and patient selection criteria for combination 
regimens have not been defined.  Phase 1 results for a number of 
combinations have been reported, including AZD6244 + MK2206 
(Tolcher et al., 2011) and GDC-0973 + GDC-094 (MEK + PI3K 
inhibitor) (Bendell et al., 2011).
2.2.3.1
Mechanisms of Action and Preclinical Data with Trametinib
Trametinib is a dimethyl sulfoxide (DMSO) solvate compound (ratio 
1:1) with potent, allosteric and ATP non-competitive inhibition of 
MEK1/2 (IC50 of 0.7 and 0.9 nM against MEK1 and MEK2, 
respectively) (Gilmartin et al., 2011).  Trametinib inhibited MEK1/2 
kinase activity and prevented RAF-dependent MEK 
phosphorylation (S217 for MEK1), producing prolonged pERK1/2 
inhibition.  Trametinib showed better potency against 
unphosphorylated MEK1/2 (u-MEK1/2) when compared with 
preactivated diphosphorylated MEK (pp-MEK), suggesting that u-
MEK affords a higher affinity binding site for trametinib than does 
pp-MEK.
The specificity of trametinib was confirmed against a panel of 183 
kinases, including MEK5 (the closet kinase homolog to MEK1/2), 
CRAF, BRAF, ERK1, and ERK2 (Yamaguchi et al., 2011).  
Trametinib demonstrated equal potency against activated MEK1- 
and MEK2-mediated phosphorylation of ERK (sequence identity of 
85% across the whole protein and 100% in the active site for 
humans).  Trametinib demonstrated preferential inhibition of RAF-
mediated MEK1 activation (IC50 = 0.60 nM) over pMEK1 kinase 
activity (IC50 = 13 nM) (Investigator’s Brochure, 2012a).
BRAF-mutant Colo205, A375P F11s, and HT-29 human tumor 
xenograft mouse models showed the most significant mean tumor 
growth inhibition (TGI) (80% to 87%) at 3.0 mg/kg trametinib, with 
multiple complete and partial tumor regressions.  In the Colo205 
model, tumor regression was observed even at a dose of 0.3 mg/kg 
(Yamaguchi et al., 2011).  Two KRAS-mutant xenograft models, 
HCT-116 and A549, also showed significant TGI (83% and 75%) 

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but without significant tumor regressions (Gilmartin et al., 2011).  
As predicted by cell proliferation assays, tumor xenograft lines with 
wild-type (wt) RAF/RAS (PC3, BxPC3, and BT474) were much less 
sensitive, showing only modest TGI (44-46%) with no tumor 
regressions.
Pharmacodynamic studies were performed in mice treated with 
trametinib for 14 days (Gilmartin et al., 2011).  In the A375P F11s 
xenograft model, the first dose of trametinib (3 mg/kg) significantly 
reduced pERK for more than 8 hours on Day 1.  pERK inhibition 
was more sustained (over 24 hours) after the Day 7 dose, probably 
due to an increase in the steady-state levels of trametinib after 
repeated doses.  The average Cmax in blood was 1,410 nM on Day 
7, with an estimated half-life (t1/2) of 33 hours.  In addition, 
immunohistochemistry (IHC) also confirmed inhibition of cell 
proliferation (reduced Ki67) and G1 cell cycle arrest (elevated 
p27Kip1/CDKN1B) following 4 days of treatment.
2.2.3.2
Clinical Pharmacokinetics (PK) and Activity of Trametinib
FTIH Phase 1 Trial of Trametinib Monotherapy (MEK111054)
There are 3 parts in this ongoing study.  Part 1:  The dose-
escalation portion involves administration of trametinib (repeat 
doses of 0.125 mg to 4.0 mg) to patients with solid tumors or 
lymphoma in one of three schedules - (1) QD for 21 days followed 
by 7 days without drug, (2) loading dose on Day 1 or Day 1-2, 
followed by QD with the designated dose, or (3) QD dosing without 
a drug holiday.  Part 2:  cohort expansion at the recommended 
phase 2 dose (RP2D) for pancreatic cancer, melanoma, NSCLC, 
CRC, or any BRAF mutation-positive cancer.  Part 3:  expansion to 
characterize the biologically active range of trametinib via analysis 
of pharmacodynamic biomarkers (biopsies or FDG-PET).
The dose escalation part and some of the cohort expansion 
components have been completed.  The MTD of trametinib was 
established as 3 mg QD, but the recommended phase 2 dose 
(RP2D) was chosen at 2 mg QD based on tolerability of repeated 
cycles (Infante et al., 2010).
PK and metabolism of trametinib:
PK measurements were conducted under fasting conditions.  After 
a single dose (Day 1), AUC0-24 and Cmax values were dose-
proportional up to 6 mg, lower than dose proportional following 8 
mg, and greater than dose proportional following the 10 mg dose.  
Median Tmax was 1.5 hours.

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After repeat doses (Day 15), trametinib accumulated with a mean 
accumulation ratio of 6.6 at the RP2D of 2 mg QD.  Between-
subject variability in exposure ranged from 27-50% for Cmax and 20-
41% for AUC0-24 across all dosing regimens.  The effective t1/2 was 
approximately 4.5 days, and steady state was reached by 
approximately Day 15.  Trametinib had a small peak:trough ratio of 
~2 (Infante et al., 2010).  At 2 mg QD on Day 15, mean AUC0-24 
was 376 ng•h/mL and Cmax 23 ng/mL, and the mean trough 
concentrations ranged from 10.0 to18.9 ng/mL.  The long half-life 
and small peak:trough ratio of trametinib allowed constant target 
inhibition within a narrow range of exposure.
Drug-drug interactions:
Trametinib is metabolized predominantly via deacetylation (non-
cytochrome P450 [CYP450]-mediated) with secondary oxidation or 
in combination with glucuronidation biotransformation pathways 
(Investigator’s Brochure, 2012a).  The deacetylation is likely 
mediated by hydrolytic esterases, such as carboxylesterases, or 
amidases.  Based on in vitro studies, trametinib is not an inhibitor of 
CYP1A2, CYP2A6, CYP2B6, CYP2D6, and CYP3A4.  Although 
trametinib was found to be an in vitro inhibitor of CYP2C8, 
CYP2C9, and 2C19; inducer of CYP3A4; and inhibitor of 
transporters (OATP1B1, OATP1B3, P-glycoprotein [P-gp], and 
breast cancer resistance protein [BCRP]), its low efficacious dose, 
and low clinical systemic concentration (22.2 ng/mL or 0.04 mcM at 
2 mg) relative to the in vitro inhibition/induction potency suggests 
an overall low potential for drug-drug interactions.
Pharmacodynamic effect and biomarkers:
The relationship between dose and tumor biomarkers such as 
pERK, Ki67, and p27, were evaluated in patients with BRAF or 
NRAS mutation-positive metastatic melanoma (Investigator's 
Brochure, 2012a).  In general, increasing exposures and/or doses 
provided greater pharmacodynamic effects.  The median change 
observed at a dose of 2 mg QD was 62% inhibition of pERK, 83% 
inhibition of Ki67, and a 175% increase in p27.
Antitumor Activity of Trametinib Monotherapy
In the FTIH phase 1 trial, 14 patients with BRAF-mutant melanoma 
received trametinib at 2 mg QD (2 mg/day continuously, or 2 mg for 
21 days followed by a 1 week break).  The overall objective 
response rate (ORR) was 43% (6/14), including 2 complete 
responses (CRs) (Investigator's Brochure, 2012a).  In 9 patients 
with BRAF wt melanoma, 2 patients achieved a partial response 
(PR), and 3 stable disease (SD) (Infante et al., 2010).  In 26 
evaluable pancreatic cancer patients, there were 2 PRs (1 PR was 

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KRAS mutation-positive) and 11 SD (2 achieved ≥20% tumor 
reduction) (Messersmith et al., 2011).  Among the 27 CRC patients 
(without selection of RAS or RAF mutations), 8 SD were observed.
In a phase 3 trial, patients with unresectable stage IIIC or IV 
cutaneous melanoma with a BRAF V600E or V600K mutation were 
randomized (2:1) to trametinib (2 mg, PO, QD) or chemotherapy 
(dacarbazine or paclitaxel) (Flaherty et al., 2012).  There were 322 
patients in the intention-to-treat (ITT) population, of whom 273 
(85%) were in the primary efficacy population (patients with 
BRAFV600E-positive cancer who did not have brain metastases at 
baseline).  In the ITT analyses, the ORR was 22% in the trametinib 
group and 8% in the chemotherapy group; the median duration of 
PFS was 4.8 months in the trametinib group as compared with 1.5 
months in the chemotherapy group; and the 6-month OS rate was 
81% in the trametinib group and 67% in the chemotherapy group.
Antitumor Activity of Trametinib in Cancer Other Than Melanoma
In a phase 1/2 monotherapy study, acute myeloid leukemia (AML) 
or myelodysplastic syndrome (MDS) patients were given trametinib 
at dose levels from 1-2 mg QD.  Drug-related AEs in 45 patients 
were similar to that observed in patients with solid tumors, and 2 
mg PO QD was selected for further investigation in this patient 
population.  Twelve patients (23%) withdrew due to an AE, 
including cardiac failure (2) and infection (2).  Efficacy was reported 
in 39 patients (Borthakur et al., 2010).  The best response in 13 
patients with KRAS or NRAS mutations included 3 CRs (23%), 7 
SD (54%), and 1 PD (progressive disease) (5%).  In 26 patients 
with wild-type RAS or an unknown mutation, there were 2 PRs 
(8%).
2.2.3.3
Trametinib Safety Profile
A comprehensive list of adverse events is included in Section 7 of 
the protocol.
Due to limited experience in human subjects, there is currently 
incomplete information available about the relationship of AEs and 
administration of trametinib.  Based on available AE data from 
clinical studies involving trametinib to date, the most common 
toxicities are rash and diarrhea.  Rash and diarrhea are common, 
class-effect toxicities for MEK inhibitors. In addition, visual 
impairment and left ventricular ejection fraction (LVEF) reduction, 
although observed at lower frequencies, are also considered class-
effect toxicities as they have been observed with trametinib as well 
as other MEK inhibitors.

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AEs of special interest:
Rash, diarrhea, visual disorders, hepatic disorders, cardiac-related 
AEs, and pneumonitis are considered AEs of special interest 
because they are either known class effects (i.e., have been 
observed with other MEK inhibitors) or are potentially life-
threatening (Investigator’s Brochure, 2012a).
Rash:  Rash was a common AE observed across different dose 
levels and in different combinations.  The majority of rash observed 
with trametinib was acneiform and appeared to occur most 
frequently on the face, scalp, chest, and upper back.  At the 2 mg 
dose, rash was seen in 48% to 91% of patients in different trials.  
The majority of rash AEs were grades 1 or 2 (68% to 80%); 1% to 
18% of patients experienced grade 3 rash AEs, and one patient 
had a grade 4 rash AE.
Diarrhea:  At the 2 mg monotherapy dose, 28% to 58% of patients 
in three trials had diarrhea.  Of 219 patients with diarrhea at this 
dose, the majority of diarrhea AEs were grade 1 or 2 in severity 
(28% to 56% of all study patients); 6 patients had grade 3 diarrhea, 
and none had grade 4 diarrhea.
Visual disorders:  At the 2 mg monotherapy dose, 6% to 21% of the 
patients in three trials experienced visual disorders.  Of the 62 total 
patients experiencing visual disorders at this dose level, the 
majority of visual disorders were grades 1 or 2 (6% to 20% of all 
study patients); five patients experienced grade 3 visual disorders, 
and one patient experienced a grade 4 visual disorder.
Central serous retinopathy (CSR):  CSR is a class side effect of 
MEK inhibitors.  As of 22 May 2012, 13 cases of CSR have been 
reported amongst approximately 1,600 patients treated with 
trametinib, either as monotherapy or in combination with other anti-
cancer agents:  two cases of grade 1, eight cases of grade 2, and 
three cases of grade 3.  All 13 resolved.
Retinal vein occlusion (RVO):  As of 22 May 2012, four cases of 
RVO have been observed with trametinib.  All four cases occurred 
in one eye only, and study drug was stopped at time of diagnosis in 
all cases.  There was a decrease in visual acuity in two patients 
with central RVO (CRVO), while the other two patients experienced 
no meaningful decrease in visual acuity.  Three of the four cases 
were considered related to study treatment by the investigators.
Hepatic disorders:  Abnormalities of liver enzymes and bilirubin 
have been observed with administration of trametinib.  However, 
assessment of these cases was often confounded by co-morbid 
conditions (such as biliary obstruction), concomitant use of other 

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potentially hepatotoxic drugs, and liver metastases.  At the 2 mg 
monotherapy dose, 10% to 19% of patients in three trials had 
hepatic disorders.  Of the 56 total patients experiencing hepatic 
disorders, the majority were grade 1 or 2 in severity (7% to 15% of 
all study patients); 12 patients had grade 3 hepatic disorders, and 3 
patients had grade 4 hepatic disorders.
Cardiac-related AEs:  At the 2 mg monotherapy dose in three trials, 
3% to 21% of patients had cardiac-related AEs.  Of the 43 total 
patients experiencing cardiac-related AEs, the majority were grade 
1 or 2 in severity (4% to 16% of all study patients); six patients at 
this trametinib dose level had grade 3 cardiac-related AEs (three 
left ventricular dysfunction, two decreased LVEF, and one 
ventricular dilatation), and one patient experienced a grade 4 
cardiac-related AE (cardiogenic shock).  One patient died of acute 
cardiac failure, with evidence of massive tumor invasion of the 
heart; this AE was considered not drug-related by the investigator.
In the phase 3 trial of trametinib vs. chemotherapy in patients with 
melanoma (MEK114267), patients were monitored by serial 
echocardiogram or MUGA scans.  As of 23 June 2012, among 211 
patients on the trametinib arm, 17 cardiac-related AEs were 
reported and included:  decreased LVEF (ten grade 1-2, and two 
grade 3), left ventricular dysfunction (two grade 2, and two grade 
3), and one grade 3 cardiac failure.  No cardiac-related AEs have 
been observed on the chemotherapy arm of the study.  Cardiac-
related AEs leading to permanent discontinuation of study drug 
included decreased LVEF (n=2), left ventricular dysfunction (n=2), 
cardiac failure (n=1), myocardial infarction (n=1), and tachycardia 
(n=1).  There was also one death due to cardiogenic shock 
secondary to ischemic heart disease, but it was not considered 
related to trametinib.
Pneumonitis:  As of the Investigator Brochure’s cut-off date, 20 
cases of pneumonitis were reported in subjects treated with 
trametinib, either as monotherapy or in combination with other anti-
cancer agents, in six studies:  five cases of grade 1, five cases of 
grade 2, nine cases of grade 3, and one case of grade 4.
2.2.3.4
Rationale for proposed starting dose
The safe and efficacious dose of trametinib is 2 mg PO daily as 
reflected by the FDA approval of this dose. Further, this dose is 
safe and effective in combination with dabrafenib.  Given the known 
survival advantage with this therapy taken at this dose and 
schedule, we believe it is a priority to administer this dose of 
trametinib as the backbone of the proposed combination therapy.

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2.3
Rationale
It has been shown that inhibition of the mitogen-activated protein kinase 
(MAPK) pathway in patients with melanoma, through inhibition of BRAF and/or 
MEK, leads to increased melanoma antigen expression, decreased 
immunosuppressive cytokines, increased trafficking of CD8+ T-lymphocytes, 
and upregulation of immune exhaustion markers such as PD1 and PDL1.  Also, 
in collaboration with Adaptive Biotechnologies, we have shown that patients 
with a higher proportion of preexisting tumor infiltrating lymphocyte clones, 
determined by T-Cell Receptor (TCR) rearrangement sequencing (so-called 
ImmunoSeq), have better outcomes with BRAF/MEKi therapy, although nearly 
all patients have an increase in TCR clonality in the setting of BRAF/MEKi 
therapy.  The major conclusion from this data is that MAPK pathway targeting 
enhances anti-tumor immunity within the tumor microenvironment, which 
provides a strong rationale for combination MAPK targeted therapy with 
immune targeted therapy.  
A number of trials of combination MAPK targeted therapy (MTT) with immune 
targeted therapy have been opened in recent years with mixed results.  One of 
the major issues has been tolerability, particularly with combinations of MTT 
and ipilimumab.  We believe that the value of combining MTT with 
immunotherapies, such as pembrolizumab, is that MTT may enhance immune 
responses in the tumor microenvironment and convert an immunologically non-
responsive tumor microenvironment into an environment that is responsive to 
anti-PD1 immunotherapy. Thus, we are interested in testing trial designs that 
incorporate a lead-in phase of MTT and a brief period of concomitant MTT and 
immune targeted therapy.  
This trial has two planned cohorts, BRAFV600 mutant (cohort 1) and BRAF-
wild-type melanoma (cohort 2). Treatment commences with 2 weeks of MTT 
(dabrafenib plus trametinib in cohort 1, trametinib in cohort 2), then two 3 
weeks cycles of concomitant MTT and pembrolizumab, followed by single-
agent pembrolizumab thereafter.  Serial biopsies will be performed prior to 
MTT, and (if feasible) following the 2-week lead-in of MTT, and (if feasible) 
following six weeks of combination immune therapy and MTT.  An optional 
biopsy at time of disease progression will also be performed.  This trial 
represents a unique opportunity to not only test the effectiveness of combined 
immune and MTT, but also to determine which patients are most likely to 
benefit from this approach and, more importantly, to begin to understand why 
patients do or do not benefit. This valuable information that may lead to the 
next wave of combinatorial therapy in melanoma that involves MTT, anti-PD1 
therapy, and other agents that target critical mediators of adaptive or innate 
resistance to combined MTT and pembrolizumab.  Due to a recent shortage of 
research grade dabrafenib and trametinb, we plan to use commercially 
availability dabrafenib and trametinib.  Since we cannot guarantee supply of 
“off-label” trametinib for cohort 2, we will open cohort 1 initially and consider 

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opening cohort 2 in mid-2017, after more data is available for MEK inhibitors in 
patients with BRAF wild-type melanoma.
2.4
Correlative Studies Background
Recently, a number of predictive biomarkers of response to anti-PD1 antibodies 
in melanoma and other malignancies have been reported. These include tumor 
factors (such as mutational burden and tumor neoantigen expression) 
immunologic factors (including cytotoxic T-lymphocyte infiltration with functional 
capacity to recognize tumor antigens, so-called T-cell diversity), and tumor-
immune microenvironmental factors like PD-L1 expression. With each new 
report, a clear picture is emerging that tumors with high mutational burden and 
neoantigen expression, increased T-cell diversity, and elevated PD-L1 
expression are primed for immune destruction in the setting of single-agent 
anti-PD1 antibodies.  Conversely, tumors with low mutational load and 
neoantigen expression, low T-cell diversity, and low PD-L1 expression are less 
susceptible to immune-mediated tumor cell destruction.  One of the next great 
challenges in the field is to develop strategies that convert an immunologically 
non-responsive tumor microenvironment into one primed to respond to anti-
PD1 therapy.
In this trial, we expect that lead-in MTT will trigger changes in the tumor 
immune microenvironment that will allow patients to have a more robust 
response to the anti-PD1 antibody, pembrolizumab.  However, it will be critical 
to document these changes in tumor immune microenvironment.  As such, 
tumor biopsies will be performed in all patients enrolled onto the first Stage of 
the Simon 2-stage design for both cohorts at four time points: 
1. Prior to commencing MTT
2. Following 2-week MTT lead-in
3. Following 6-weeks of combined pembrolizumab with MTT (if feasible)
4. At the time of disease progression (optional)
Multiple cores will be obtained and/or sufficient tumor excised at each biopsy 
time-point, assuming that it is safe to do so (e.g. patients with rapid responses 
may have very little tumor to biopsy safely at the latter time points).  Core 
biopsies or portions of the excised tumor will be processed with the following 
hierarchy in mind:
1. DNA/RNA/protein extraction
(Sullivan)
2. Disaggregation and flow cytometry
(Sharpe)
3. FFPE
(Sullivan)
4. Single-cell RNA seq of T cells
(Hacohen)
5. Single-cell RNA seq of tumor cells
(Garraway)

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Analysis will then be carried out to compare changes seen longitudinally and to 
determine if those changes are associated with improved outcomes to therapy 
with study treatment.  Most of this work will exploratory in nature, as analysis 
such as the technology for single-cell sequencing of tumor and T-cells is 
emerging and no data is presently available to inform how these analyses might 
be used to help predict which patients are most likely to benefit from single-
agent or combination therapy.  However, based on previous work, there are two 
assays that will be incorporated into a predictive model, PD-L1 expression by 
immunohistochemistry (IHC) and immuno-sequencing (immunoSEQ) using the 
Adaptive Biotechnologies platform.
PD-L1 Immunohistochemistry
Immunohistochemistry for PD-L1 and CD8 was performed using a monoclonal 
anti-PD-L1 antibody (Clone E1L3N, Cell Signaling Technologies; Danvers, MA) 
and a CD8 monoclonal antibody (4B11, RTU, Leica Biosystems, Buffalo Grove, 
IL), respectively, with an automated stainer (Bond Rx, Leica Microsystems, 
Buffalo Grove, IL).  As there is no recognized standard PD-L1 scoring protocol, 
we will define PD-L1 positivity as membranous +/- cytoplasmic staining of 
tumor cells of any intensity using two different cut-offs (≥1% and ≥5 tumor cells) 
since both have been associated with clinical benefit to PD-1 pathway blockade 
in melanoma. 
Adaptive Biotechnologies immunoSEQ
FFPE specimens (or isolated tumor DNA) and frozen PBMC samples will be 
shipped to Adaptive. Samples sent to Adaptive will be handled in accordance 
with Adaptive SOPs.  All arriving packages will be opened the same day they 
arrive and inspected thoroughly for correct labeling and packaging integrity.  
Adaptive will perform “survey level” sequencing on each tissue sample and 
“deep level” sequencing on each of the PBMC derived gDNA samples 
provided.  As part of these analyses, Adaptive uses a proprietary assay for the 
amplification and massive parallel sequencing of millions of CDR3 regions in 
the T cell receptor beta gene (TCRB) using a multiplex PCR amplification 
across the VDJ junction of rearranged TCRB.
Using Adaptive’s unique capacity to perform next generation sequencing of T-
cell receptors for this study, a large amount of data will be generated using 
tissue specimens and PBMC samples from all collection time points. In addition 
to the immunoSEQ Analyzer software, which is available to all of Adaptive 
clients to aid in data analysis and visualization, Adaptive can directly involve its 
computational biology and biostatistics personnel in the data analysis.
Tumor Microenvironment Assessment
To determine how the tumor cells are modulated during MTT alone, anti-PD1 

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plus MTT and anti-PD1 monotherapy combination, we will use single-cell and 
bulk RNA-seq, whole exome, etc. to assess the evolution of tumor cells during 
therapy. Sequential biopsies will provide a means to analyze evolution of tumor 
cell responsiveness and resistance to therapy
To determine how immune cells in the tumor microenvironment are modulated 
during MTT alone, anti-PD1 plus MTT and anti-PD1 monotherapy combination, 
we will use single-cell and bulk RNA-seq, and assays to compare immune cell 
function (e.g., T cell activation vs. exhaustion using cellular immunologic 
assays, as well as analysis of phosphoproteins and ubiquitination signaling) in 
temporal biopsies. These studies should reveal how anti-tumor immunity is 
modulated during the lead-in phase of the clinical trial with MTT, during MTT 
and anti-PD1 combination therapy and during subsequent anti-PD1 
monotherapy. 
3. PARTICIPANT SELECTION
3.1
Inclusion Criteria 
3.1.1 Participants must have histologically confirmed metastatic or unresectable 
melanoma 
3.1.2 Participants must have BRAFV600-mutation status known (molecularly 
confirmed using validated, commercially available assay performed in a CLIA-
approved laboratory).
If test at CLIA-certified lab used a non-FDA approved method, information 
about the assay must be provided.  (FDA approved tests for BRAF V600 
mutations in melanoma include:  THxID BRAF Detection Kit and Cobas 4800 
BRAF V600 Mutation Test).
3.1.3 Participants must have measurable disease, defined as at least one lesion that 
can be accurately measured in at least one dimension (longest diameter to be 
recorded) as > 20 mm with conventional techniques or as > 10 mm with spiral CT 
scan. See section 11 for the evaluation of measureable disease. 
3.1.4 Age greater than or equal to 18 years. Because no dosing or adverse event data 
are currently available on the use of the combination of trametinib with or without 
dabrafenib, and pembrolizumab in participants less than 18 years of age, 
children are excluded from this study. 
3.1.5 ECOG performance status ≤ 1 (see Appendix A).
3.1.6 Life expectancy of greater than three months in the opinion of the investigator.  

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3.1.7 Participants must have normal organ and marrow function as defined below: 

Leukocytes (WBC) > 3,000/uL

Absolute neutrophil count > 1,500uL

Platelets > 100,000/uL

total bilirubin < 1.5 X  institutional upper limits of normal; total 
bilirubin > 1.5X above institutional upper limits of normal will be 
allowed if direct bilirubin is within normal limits or if patients has a 
documented history of Gilbert’s disease

AST (SGOT)/ALT (SGPT) < 2.5 X institutional upper limit of 
normal

Creatinine within normal institutional limits or creatinine clearance 
(eGFR) > 60 mL/min/1.73 m2 for subjects with creatinine levels about 
institutional normal. 

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3.1.8 Participants must have disease amenable to and be willing to undergo serial core 
or excisional biopsies of a tumor lesion(s).
3.1.9 Because both dabrafenib and trametinib are class D agents with the potential for 
teratogenic or abortifacient effects. Because there is an unknown but potential 
risk of adverse events in nursing infants secondary to treatment of the mother 
with either dabrafenib and trametinib, breastfeeding should be discontinued if the 
mother is treated with either dabrafenib, trametinib, or the combination of 
dabrafenib and trametinib. Female subjects of childbearing potential should be 
willing to use 2 methods of birth control or be surgically sterile, or abstain from 
heterosexual activity for the course of the study through 120 days after the last 
dose of study medication or 14 days prior to the initiation of study medication for 
oral contraceptives (Reference Section 5.8.  Subjects of childbearing potential 
are those who have not been surgically sterilized or have not been free from 
menses for > 1 year. Should a woman become pregnant or suspect she is 
pregnant while she or her partner is participating in this study, she should inform 
her treating physician immediately.  Male subjects with partners of childbearing 
potential should agree to use an adequate method of contraception starting with 
the first dose of study therapy through 120 days after the last dose of study 
therapy. If there is any question that a subject of childbearing potential will not 
reliably comply with the requirements for contraception, that subject should not 
be entered into the study.
3.1.10  Ability to understand and the willingness to sign a written informed consent 
document.
3.1.11  Ability to swallow and retain oral medication.
3.2
Exclusion Criteria
3.2.1 Participants with any clinically significant gastrointestinal abnormalities that may 
alter absorption.
3.2.2 Participants treated with prior chemotherapy, targeted small molecule therapy, or 
radiation therapy within 2 weeks prior to study Day 1 or who has not recovered 
(i.e., ≤ Grade 1 or at baseline) from adverse events due to  the prior 
chemotherapy, targeted small molecule therapy, and radiation therapy 
-
Note:  Subjects with ≤ Grade 2 neuropathy and/or alopecia are an exception 
to this criterion and may qualify for the study.
-
Note:  If subject received major surgery, they must have had the surgery > 2 
weeks prior to Study Day 1 and recovered adequately from the toxicity 
and/or complications from the intervention prior to starting therapy

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3.2.3 Participants previously treated with BRAF inhibitors (vemurafenib, dabrafenib, 
encorafenib), MEK inhibitors (selumetinib, trametinib, binimetinib, cobimetinib), 
and/or anti-PD1/PDL1 monoclonal antibodies for metastatic or unresectable 
disease.  Any other prior therapy will be allowed (including ipilimumab, adjuvant 
anti-PD1 therapy, high-dose IL-2).
3.2.4 Participants with any prior ≥ Grade 3 immune-related adverse event (irAE) which 
began while receiving immunotherapy.
3.2.5 Participants with any unresolved immune-related adverse event (irAE) at time of 
study entry. 
-
Note:  Subjects with ≤ Grade 2 thyroiditis and/or hypophysitis are an 
exception to this criterion and may qualify for the study.
3.2.6 Participants who have had a prior anti-cancer monoclonal antibody (mAb) within 
4 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at 
baseline) from adverse events due to agents administered more than 4 weeks 
earlier.
3.2.7 Patients may not be receiving any other anti-neoplastic agents. 
3.2.8 Participants with symptomatic brain metastases will be excluded from this 
clinical trial because of their poor prognosis and because they often develop 
progressive neurologic dysfunction that would confound the evaluation of 
neurologic and other adverse events.  Subjects with asymptomatic, stable brain 
metastases and subjects who, if they have been previously treated for these 
conditions that are asymptomatic in the absence of corticosteroid therapy are 
allowed to enroll.  Brain metastasis must be stable with verification by imaging 
(brain MRI completed at screening demonstrating no current evidence of 
progressive brain metastases).  If asymptomatic brain metastasis are first 
identified on the required pre-study scans, another set of scans must be 
completed to confirm that they are stable.
3.2.9 Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or 
any other form of immunosuppressive therapy within 7 days prior to the first dose 
of trial treatment. Corticosteroids to prevent contrast reactions is allowable.
3.2.10 Pregnant women are excluded from this study because both dabrafenib and 
trametinib are class D agents with the potential for teratogenic or abortifacient 
effects. Because there is an unknown but potential risk of adverse events in 
nursing infants secondary to treatment of the mother with either dabrafenib and 
trametinib, breastfeeding should be discontinued if the mother is treated with 
either dabrafenib, trametinib, or the combination of dabrafenib and trametinib. 

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3.2.11 Participants known to be HIV-positive and on combination antiretroviral therapy 
are ineligible because of the potential for pharmacokinetic interactions with either 
dabrafenib or trametinib. Appropriate studies will be undertaken in participants 
receiving combination antiretroviral therapy when indicated.
3.2.12 Has a known history of active TB (Bacillus Tuberculosis)
3.2.13 Known hypersensitivity to pembrolizumab or any of its excipients.
3.2.14 Symptomatic or untreated leptomeningeal disease.
3.2.15 Participants are not permitted to receive enzyme inducing anti-epileptic drugs. 
3.2.16 Has active autoimmune disease that has required systemic treatment in the past 
2 years (i.e. with use of disease modifying agents, corticosteroids or 
immunosuppressive drugs). Replacement therapy (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 Has a history of non-infectious pneumonitis that required steroids or has 
current/active pneumonitis.
3.2.18 History of or current evidence of retinal vein occlusion (RVO) or retinal pigment 
epithelial detachment (RPED):
-
History of RVO or RPED
-
Current evidence of visible retinal pathology as assessed by pre-study 
ophthalmic exam that is considered a risk factor for RVO or RPED such as 
evidence of new optic disc cupping, evidence of visual field defects, and/or 
intraocular pressure >21 mm Hg.
3.2.19 Uncontrolled intercurrent illness including, but not limited to:
a. Ongoing or active infection 
b. LVEF <50% as determined by either MUGA scan or Echo
c. Edema > Grade 1
d. Documented myocardial infarction or unstable/uncontrolled cardiac 
disease (eg, unstable angina, severe arrhythmias, congestive heart 
failure [New York Heart Association (NYHA) > Class II]) within 6 
months of study entry
e. Arterial thrombosis or vascular ischemic events, such as transient 
ischemic attack, cerebral infarction, within 6 months prior to study entry
f.
Serious or non-healing wound
g. History of any medical condition including cardiovascular disease or 
chronic obstructive pulmonary disease (COPD), that in the opinion of 
the investigator, may increase the risks associated with study 
participation or study treatments or may interfere with the conduct of 
the study or interpretation of study results

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h. Psychiatric illness/social situations that, in the opinion of the 
investigator, would limit compliance with study requirements
3.2.20 Individuals with a history of a different malignancy are ineligible except for the 
following circumstances:

Individuals with a history of other malignancies are eligible if they 
have been disease-free for at least 3 years and are deemed by the 
investigator to be at low risk for recurrence of that malignancy. 

Individuals with the following cancers are eligible if diagnosed and 
treated within the past 3 years: cervical cancer in situ and basal cell 
or squamous cell carcinoma of the skin.
3.2.21 Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV 
RNA [qualitative] is detected). 
3.2.22 Has received a live vaccine within 30 days of planned start of study therapy.
3.3
Inclusion of Women and Minorities
Men and women and members of all races and ethnic groups are eligible for 
this trial.  There are no inclusion/exclusion criteria that should explicitly lead to 
reduced enrollment of any specific minority population.  Malignant melanoma is 
similarly prevalent in men and women; however its incidence varies greatly 
among ethnic groups. 
4. REGISTRATION PROCEDURES
4.1
General Guidelines for DF/HCC Institutions
Institutions will register eligible participants in the Clinical Trials Management System 
(CTMS) OnCore. Registrations must occur prior to the initiation of protocol therapy. Any 
participant not registered to the protocol before protocol therapy begins will be 
considered ineligible and registration will be denied.
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. Lab values do not need 
to re-meet eligibility criteria on Day 1 Week 1 prior to first. Issues that would cause 
treatment delays should be discussed with the Overall Principal Investigator (PI). If a 
participant does not receive protocol therapy following registration, the participant’s 
registration on the study must be canceled. Registration cancellations must be made in 
OnCore as soon as possible. 

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4.2
Registration Process for DF/HCC Institutions
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject 
Protocol Registration (SOP #: REGIST-101) must be followed.  
5. TREATMENT PLAN
5.1
Treatment Regimen
Treatment will be administered on an outpatient basis. Expected toxicities and 
potential risks as well as dose modifications for dabrafenib, trametinib, and 
pembrolizumab are described in Section 6 (Expected Toxicities and Dosing 
Delays/Dose Modification). No investigational or commercial agents or therapies 
other than those described below may be administered with the intent to treat the 
participant’s malignancy.
Response and progression will be assessed at the end of the lead-in phase, and at 
the start of each 3-week visit thereafter by history and physical exam or in the 
interim if any new symptoms arise.  In addition, radiological imaging (either CT or 
MRI) will be obtained within 4 weeks of lead-in therapy commencement, within 1 
week prior to Week 9, and at 6-week intervals (with a window of -1 week), following 
the commencement of pembrolizumab for 24 weeks and then extended to 12-week 
intervals (+2 weeks) while patients remain on the study.  Response and progression 
will be determined based on the Response Evaluation Criteria in Solid Tumors 1.1 
(RECIST 1.1).  Further, if a patient does not tolerate the combination phase of 
combination MTT plus pembrolizumab, then MTT will be discontinued and 
pembrolizumab single-agent phase will begin, presuming that it is safe to treat with 
pembrolizumab (as outlined in Section 5.3.1).
All patients will be evaluated for anti-tumor activity of the combination. Disease 
control rate (DCR) at the 24-week time point after commencement of 
pembrolizumab (in combination with MTT) is the primary anti-tumor end-point.  DCR 
is defined as the percentage of patients per cohort who have stable disease (SD), 
complete or partial response (CR, PR) without requiring restart of MTT for any 
reasons.  Progression free survival (PFS), CR and PR rates, and overall survival 
(OS) will also be summarized for patients in each cohort.  
A Simon 2-stage design will be implemented for two disease cohorts, BRAFV600 
mutant and BRAFV600 wild-type unresectable Stage III or Stage IV melanoma.  
Patients will be treated with a two-week lead-in of MTT, followed by a 6-week 
course of combined MTT and pembrolizumab (at dose of 200 mg IV every three 
weeks), followed by maintenance single-agent pembrolizumab in all patients with 
RECIST defined stable disease (SD), partial response (PR), and complete 
response (CR).  MTT only will be resumed if patients develop symptomatic or 
radiographic evidence of progression.  If patients do not develop evidence of 
progressive disease (PD), then they will continue maintenance single-agent 

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pembrolizumab for up to two years; at which time treatment will be discontinued.  In 
each cohort, patients will be accrued to first stage of the Simon design.  If a pre-
specified number of patients maintain SD/PR/CR off MTT but on pembrolizumab at 
the 24-week time point, then the second stage of the two-stage design will be 
opened.  (Please see details in statistical section).  Biopsies will be performed on all 
patients enrolled to the first stage of the Simon two-stage for each cohort.  These 
will be obtained at baseline, after the two-week lead-in, and after the completion of 
induction therapy if feasible. An optional biopsy at the time of disease progression 
will also be performed. 
5.2
Pre-Treatment Criteria
Please note: TSH results are not required to be available prior to dosing.
5.2.1 Targeted Therapy Lead-in Phase, Day 1 Week 1

Physical examination including vital signs and performance status 

Labs values do not need to re-meet eligibility criteria on Week 1, Day 1

Comprehensive metabolic panel including liver function tests

Complete blood count (CBC w/diff, plts) 

ECG (in BRAFV600 mutant cohort only)
5.2.2 Combination Targeted Therapy Plus Phase, Day 1 Week 3 and Day 22 Week 6

Physical exam including vital signs and performance status

Comprehensive metabolic panel including liver function tests

Complete blood count (CBC w/diff, plts)

ECG (in BRAFV600 mutant cohort)

Serum pregnancy test (Day 1 Week 3 for women of childbearing potential only)
5.2.3 Single-agent pembrolizumab Phase, Week 9

Physical examination including vital signs and performance status

Dermatology Exam

Ophthalmology Exam

Echo/MUGA

Comprehensive metabolic panel including liver function tests

Complete blood count (CBC w/ diff, plts)

Serum pregnant test (for women of childbearing potential only)
5.2.4 Single-agent pembrolizumab Phase, Week 12 onwards

Physical examination including vital signs and performance status

Comprehensive metabolic panel including liver function tests

Complete blood count (CBC w/ diff, plts)

Serum pregnant test (Week 5 and 21 only and for women of childbearing 
potential only)

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5.3
Agent Administration
5.3.1 Pembrolizumab
o
Intravenous
o
200 mg IV every three weeks, to commence after 2-week lead-in 
Phase of MTT
o
Missed doses held for toxicity will not be made up.
o
On days when this treatment is given, it should be done so after trametinib 
dosing, during the concurrent MTT phase
5.3.2 Dabrafenib (BRAFV600 mutant cohort only)
o
Oral 
o
150 mg PO BID, to be taken every twelve hours; can be taken 
together with trametinib
o
Dabrafenib should be taken on an empty stomach at least one hour before 
or two hours after a meal; water is permitted during this fasting period. 
o
Missed or vomited doses will not be made up.
o
If a dose is missed, it can be taken up to 6 hours prior to the next dose to 
maintain the twice daily regimen.
o
The drug cannot be crushed, chewed, or dissolved
o
In the BRAF mutant cohort, this should be taken before trametinib
o
The medication diary and pill bottles will be returned to clinic staff at the 
end of the lead in period and at the end of each three week cycle.
5.3.3 Trametinib (BRAFV600 mutant or BRAFV600 wild-type cohorts)
o
Oral 
o
2 mg PO daily; can be taken together with dabrafenib
o
Trametinib should be taken on an empty stomach at least one hour before 
or two hours after a meal; water is permitted during this fasting period. 
o
Missed or vomited doses will not be made up.
o
If a dose is missed, it can be taken up to 12 hours after scheduled dose 
time.
o
The drug cannot be crushed, chewed, or dissolved
o
In the BRAFV600 mutant cohort, this should be taken after dabrafenib.
o
On days when pembrolizumab is given to patients in either the BRAFV600 
mutant or BRAFV600 wild-type cohorts, this should be taken before 
pembrolizumab therapy.
o
The medication diary and pill bottles will be returned to clinic staff at the 
end of the lead in period and at the end of each three week cycle.

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5.3.4 Other Modality(ies) or Procedures  
Palliative sterotactic radiation or surgery may be performed during study 
participation. Dabrafenib and/or trametinib must be held for two days before 
and two days after surgery or the commencement and completion of 
stereotactic radiation.  Pembrolizumab dosing must be held for two weeks 
before and after surgery or the commencement and completion of stereotactic 
radiation.  If palliative, standard fractionated, external beam radiation is 
indicated, then a discussion with the investigator, the principal investigator, 
and Merck will be held to discuss whether the patient should be allowed to 
remain on trial, and if so, if and for how long dabrafenib, trametinib, and/or 
pembrolizumab should be held. 
5.4
General Concomitant Medication and Supportive Care Guidelines
5.4.1 Acceptable Concomitant Medications
All treatments (outside of the medications or vaccinations specifically 
prohibited in the exclusion and in Section 5.4.2) that the investigator 
considers necessary for a subject’s welfare may be administered at the 
discretion of the investigator in keeping with the community standards of 
medical care.  All concomitant medication will be recorded on the case 
report form (CRF) including all prescription, over-the-counter (OTC), 
herbal supplements, and IV medications and fluids.  If changes occur 
during the trial period, documentation of drug dosage, frequency, route, 
and date must also be included on the CRF.
All concomitant medications received within 28 days before the first dose 
of trial treatment and 30 days after the last dose of trial treatment should 
be recorded.  Concomitant medications administered after 30 days after 
the last dose of trial treatment should only be recorded for SAEs and ECIs 
as defined in Section 7.
5.4.2 Prohibited Concomitant Medications
Subjects are prohibited from receiving the following therapies 
during the Screening and Treatment Phase (including retreatment 
for post-complete response relapse) of this trial:

Antineoplastic systemic chemotherapy or biological therapy 

Immunotherapy not specified in this protocol

Chemotherapy not specified in this protocol

Investigational agents other than pembrolizumab not 
specified in this protocol

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
Live vaccines within 30 days prior to the first dose of trial 
treatment and while participating in the trial.  Examples of 
live vaccines include, but are not limited to, the following: 
measles, mumps, rubella, varicella/zoster, yellow fever, 
rabies, BCG, and typhoid vaccine. 

Systemic glucocorticoids for any purpose other than to 
modulate symptoms from an event of clinical interest of 
suspected immunologic etiology.  The use of physiologic 
doses of corticosteroids may be approved after consultation 
with the Overall PI.

Strong inhibitors/inducers of selected CYP450 isoenzymes.  
Dabrafenib mesylate is a substrate for CYP 3A4, 2C8, p-
glycoprotein (Pgp), and breast carcinoma resistance protein 
(Bcrp). These enzymes and transporters are prohibited for 
eligibility and during the study. Because the lists of these 
agents are constantly changing, it is important to regularly 
consult 
a 
frequently-updated 
list 
such 
as 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx; medical 
reference texts such as the Physicians’ Desk Reference 
may also provide this information. 

Concomitant medications should be reviewed for the 
potential risk of inducing nephrotoxicity and, if so, should be 
modified if clinically possible (See 6.2.6)
If there is a clinical indication for one of these or other medications 
or 
vaccinations 
specifically 
prohibited 
during 
the 
trial, 
discontinuation from trial therapy or vaccination may be required.  
The investigator should discuss any questions regarding this with 
the Merck Clinical team.  The final decision on any supportive 
therapy or vaccination rests with the subject's primary investigator. 
Subjects may receive other medications that the investigator deems 
to be medically necessary.
The Exclusion Criteria describes other medications that are 
prohibited in this trial.
There are no prohibited therapies during the Post-Treatment 
Follow-up Phase.

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5.4.3 Concomitant Medications to be used with caution
The following therapies are to be used with caution during the Screening and 
Treatment Phase (including retreatment for post-complete response relapse) of 
this trial:

Mild or moderate inhibitors/inducers of CYP 3A4, 2C8, Pgp, and Bcrp 
should be used with caution as dabrafenib serum concentrations may be 
altered. Because the lists of these agents are constantly changing, it is 
important to regularly consult a frequently-updated list such as 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx; medical reference 
texts such as the Physicians’ Desk Reference may also provide this 
information.  

Dabrafenib may induce CYP 3A4, 2B6, and possibly 2C8/9 and 2C19.  
Use concomitant medications that are substrates of these isoenzymes 
with caution as there may be loss of efficacy. Substitute with other 
medications that are not affected if possible.

Because there is a low potential for interaction of trametinib with other 
concomitantly administered drugs through the cytochrome P450 system, 
the Principal Investigator should be alerted if the patient is taking any 
agent known to affect or with the potential to affect selected CYP450 
isoenzymes.  
5.4.4  Alerting  the Principal Investigator about specific agents and capturing the 
concurrent use of all drugs, over-the-counter medications, or alternative 
therapies in the case report form 

Because there is a potential for interaction of dabrafenib with other 
concomitantly administered drugs through the cytochrome P450 system, 
the case report form must capture the concurrent use of all other drugs, 
over-the-counter medications, or alternative therapies.  The Principal 
Investigator must be alerted if the patient is taking any agent known to 
affect or with the potential to affect selected CYP450 isoenzymes.  

Because there is a low potential for interaction of trametinib with other 
concomitantly administered drugs through the cytochrome P450 system, 
the case report form must capture the concurrent use of all other drugs, 
over-the-counter medications, or alternative therapies.  The Principal 
Investigator should be alerted if the patient is taking any agent known to 
affect or with the potential to affect selected CYP450 isoenzymes.  

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5.4.5 Rescue Medications & Supportive Care
5.4.5.1 Supportive Care Guidelines
Subjects should receive appropriate supportive care measures as 
deemed necessary by the treating investigator.  Suggested 
supportive care measures for the management of adverse events 
with potential immunologic etiology are outlined below and in 
greater detail in the ECI guidance document. Where appropriate, 
these guidelines include the use of oral or intravenous treatment 
with corticosteroids as well as additional anti-inflammatory agents if 
symptoms do not improve with administration of corticosteroids.   
Note that several courses of steroid tapering may be necessary as 
symptoms may worsen when the steroid dose is decreased. For 
each disorder, attempts should be made to rule out other causes 
such as metastatic disease or bacterial or viral infection, which 
might require additional supportive care. The treatment guidelines 
are intended to be applied when the investigator determines the 
events to be related to pembrolizumab. 
Note: if after the evaluation the event is determined not to be 
related, the investigator is instructed to follow the ECI reporting 
guidance but does not need to follow the treatment guidance (as 
outlined in the ECI guidance document). Refer to Section 6 for dose 
modification. 
It may be necessary to perform conditional procedures such as 
bronchoscopy, endoscopy, or skin photography as part of 
evaluation of the event. Suggested conditional procedures, as 
appropriate, can be found in the ECI guidance document.

Suggestions for Pneumonitis: 
o
For Grade 2 events, treat with systemic corticosteroids. 
When symptoms improve to Grade 1 or less, steroid taper 
should be started and continued over no less than 4 weeks.
o
For Grade 3-4 events, immediately treat with intravenous 
steroids.  Administer additional anti-inflammatory measures, 
as needed.
o
Add prophylactic antibiotics for opportunistic infections in the 
case of prolonged steroid administration.

Suggestions for Diarrhea/Colitis: 
Subjects should be carefully monitored for signs and symptoms 
of enterocolitis (such as diarrhea, abdominal pain, blood or 
mucus in stool, with or without fever) and of bowel perforation 
(such as peritoneal signs and ileus).  

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o
Advise all subjects who experience diarrhea/colitis to drink 
liberal quantities of clear fluids.  If sufficient oral fluid intake 
is not feasible, substitute fluid and electrolytes via IV 
infusion.  For Grade 2 or higher diarrhea, consider GI 
consultation and endoscopy to confirm or rule out colitis.
o
For Grade 2 diarrhea/colitis that persists greater than 3 
days, administer oral corticosteroids. 
o
For Grade 3 or 4 diarrhea/colitis that persists > 1 week, 
treat with intravenous steroids followed by high dose oral 
steroids.  
o
When symptoms improve to Grade 1 or less, start steroid 
taper and continue over no less than 4 weeks.

Suggestions for Type 1 diabetes mellitus (if new onset, 
including diabetic ketoacidosis [DKA]) or ≥ Grade 3 
Hyperglycemia, if associated with ketosis (ketonuria) or 
metabolic acidosis (DKA)
o
For T1DM or Grade 3-4 Hyperglycemia

Insulin replacement therapy is recommended for Type I 
diabetes mellitus and for Grade 3-4 hyperglycemia 
associated with metabolic acidosis or ketonuria. 

Evaluate patients with serum glucose and a metabolic 
panel, urine ketones, glycosylated hemoglobin, and C-
peptide. 

Suggestions for Hypophysitis:
o
For Grade 2 events, treat with corticosteroids. When 
symptoms improve to Grade 1 or less, start and continue 
steroid taper over no less than 4 weeks. Replacement of 
appropriate hormones may be required as the steroid dose 
is tapered.
o
For Grade 3-4 events, treat with an initial dose of IV 
corticosteroids followed by oral corticosteroids. When 
symptoms improve to Grade 1 or less, start and continue 
steroid taper over no less than 4 weeks. Replacement of 
appropriate hormones may be required as the steroid dose 
is tapered.

Suggestions for Hyperthyroidism or Hypothyroidism: 
Thyroid disorders can occur at any time during treatment. 
Monitor patients for changes in thyroid function (at the start of 

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treatment, periodically during treatment, and as indicated based 
on clinical evaluation) and for clinical signs and symptoms of 
thyroid disorders.
o
Grade 2 hyperthyroidism events (and Grade 2-4 
hypothyroidism):

In hyperthyroidism, non-selective beta-blockers (e.g. 
propranolol) are suggested as initial therapy.

In hypothyroidism, thyroid hormone replacement therapy, 
with levothyroxine or liothyroinine, is indicated per 
standard of care.
o
Grade 3-4 hyperthyroidism 

Treat with an initial dose of IV corticosteroid followed by 
oral corticosteroids. When symptoms improve to Grade 1 
or less, steroid taper should be started and continued 
over no less than 4 weeks. Replacement of appropriate 
hormones may be required as the steroid dose is 
tapered.

Suggestions for Hepatic Events:
o
For Grade 2 events, monitor liver function tests more 
frequently until returned to baseline values (consider 
weekly).

Treat with IV or oral corticosteroids
o
For Grade 3-4 events, treat with intravenous corticosteroids 
for 24 to 48 hours. 
o
When symptoms improve to Grade 1 or less, a steroid taper 
should be started and continued over no less than 4 weeks.

Suggestions for Renal Failure or Nephritis:
o
For Grade 2 events, treat with corticosteroids.
o
For Grade 3-4 events, treat with systemic corticosteroids.
o
When symptoms improve to Grade 1 or less, steroid taper should 
be started and continued over no less than 4 weeks. 

Suggestions for Management of Infusion Reactions: Signs 
and symptoms usually develop during or shortly after drug 
infusion and generally resolve completely within 24 hours of 
completion of infusion. 
Table 5.4 below shows treatment suggestions for subjects who experience an 
infusion reaction associated with administration of pembrolizumab (MK-3475).
Table 5.4 Infusion Reaction Treatment Suggestions

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NCI CTCAE Grade
Treatment
Premedication at subsequent 
dosing
Grade 1
Mild reaction; infusion interruption 
not indicated; intervention not 
indicated
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of the 
investigator.
None
Grade 2
Requires infusion interruption but 
responds promptly to symptomatic 
treatment (e.g., antihistamines, 
NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated 
for < =24 hrs
Stop Infusion and monitor symptoms.
Additional appropriate medical therapy may 
include but is not limited to:
IV fluids
Antihistamines
NSAIDS
Acetaminophen
Narcotics
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of the 
investigator.
If symptoms resolve within one hour of 
stopping drug infusion, the infusion may be 
restarted at 50% of the original infusion rate 
(e.g., from 100 mL/hr to 50 mL/hr).  
Otherwise dosing will be held until symptoms 
resolve and the subject should be 
premedicated for the next scheduled dose.
Subjects who develop Grade 2 toxicity 
despite adequate premedication should 
be permanently discontinued from further 
trial treatment administration.
Subject may be premedicated 
1.5h (± 30 minutes) prior to 
infusion of pembrolizumab (MK-
3475) with:
Diphenhydramine 50 mg po (or 
equivalent dose of 
antihistamine).
Acetaminophen 500-1000 mg 
po (or equivalent dose of 
antipyretic).
Grades 3 or 4
Grade 3:
Prolonged (i.e., not rapidly 
responsive to symptomatic 
medication and/or brief interruption 
of infusion); recurrence of 
symptoms following initial 
improvement; hospitalization 
indicated for other clinical sequelae 
(e.g., renal impairment, pulmonary 
infiltrates)
Grade 4:
Life-threatening; pressor or 
ventilatory support indicated
Stop Infusion.
Additional appropriate medical therapy may 
include but is not limited to:
IV fluids
Antihistamines
NSAIDS
Acetaminophen
Narcotics
Oxygen
Pressors
Corticosteroids
Epinephrine
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of the 
investigator.
Hospitalization may be indicated.
Subject is permanently discontinued from 
further trial treatment administration.
No subsequent dosing
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period 
of drug administration.
5.5
Criteria for Taking a Participant off Protocol Therapy
Duration of therapy will depend on individual response, evidence of disease 
progression and tolerance. In the absence of treatment delays due to adverse 
events, treatment may continue until one of the following criteria applies:

Completion of two years of pembrolizumab therapy

Disease progression, unless patient meets criteria for treatment beyond 
progression in Section 5.5.1

Intercurrent illness that prevents further administration of treatment,

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
Unacceptable adverse event(s),

Participant demonstrates an inability or unwillingness to comply with the oral 
medication regimen and/or documentation requirements

Participant decides to withdraw from the study, or

General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the opinion of the treating investigator.
5.5.1
Treatment Beyond Progression
Following initial disease progression, if a participant is treated beyond progression per 
the criteria outlined below, tumor assessments must be repeated > 4 weeks after initial 
disease progression in order to confirm disease progression. The tumor assessment 
must not be repeated any sooner than 4 weeks after initial disease progression. 
Treatment beyond progression will be allowed. In general, patients who develop disease 
progression (per RECIST1.1) will remain on trial.  Since this trial potentially involves four 
specific treatments “zones”, namely 1) MTT induction; 2) concomitant MTT plus 
pembrolizumab; 3) pembrolizumab single-agent; and 4) follow up after pembrolizumab 
discontinuation in setting of CR, the specific treatment beyond progression will be 
dependent on which “zone” the patient is in when progression occurs as described 
below.
5.5.1.1
MTT Induction (Targeted Therapy Lead-In)
Patients who develop clinical progression or radiographic progression 
(e.g. if non-planned imaging is performed) during MTT induction, then 
patients will be allowed to move onto the concomitant MTT plus 
pembrolizumab phase of the therapy.
5.5.1.2
Concomitant MTT plus pembrolizumab (Combined Targeted Therapy Plus)
Patients who develop clinical progression during or radiographic during 
(e.g. if non-planned imaging is performed) or on routine imaging 
performed at the end of the concomitant MTT plus pembrolizumab phase 
will be allowed to be treated with single-agent pembrolizumab beyond 
progression as long as the following criteria are met:
A. Absence of signs and symptoms (including worsening of laboratory 
values) indicating disease progression.
B. No decline in ECOG performance status.
C. Absence of rapid progression of disease.
D. Absence of progressive tumor at critical anatomical sites (e.g., 
cord compression) requiring urgent alternative medical 
intervention.

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5.5.1.3
Pembrolizumab single-agent
Patients who develop progression of disease on the 
pembrolizumab single-agent phase will be allowed to be treated 
beyond progression as long as the following criteria are met:
A. Absence of signs and symptoms (including worsening of 
laboratory values) indicating disease progression.
B. No decline in ECOG performance status.
C. Absence of rapid progression of disease.
D. Absence of progressive tumor at critical anatomical sites (e.g., 
cord compression) requiring urgent alternative medical 
intervention.
5.5.1.4
Follow up after discontinuation of pembrolizumab in setting of a CR 
Discontinuation of treatment may be considered for subjects who 
have attained a confirmed CR that have been treated for at least 24 
weeks with pembrolizumab and had at least two treatments with 
pembrolizumab beyond the date when the initial CR was declared.  
Subjects who discontinue treatment and then experience 
radiographic disease progression may be eligible for up to one year 
of additional treatment with single-agent pembrolizumab at the 
discretion of the investigator if no cancer treatment was 
administered since the last dose of pembrolizumab, the subject 
meets the safety parameters listed in the Inclusion/Exclusion 
criteria, and the trial is open.  Subjects will resume therapy at the 
same dose and schedule at the time of initial discontinuation. 
5.6
Duration of Follow Up
If treatment is discontinued for completion of two years of pembrolizumab, or 
for disease progression, or for withdrawal of consent, participants will be 
followed for adverse events. All adverse events encountered from time of the 
first dose of study treatment up until 90 days after the last dose of study 
treatment will be followed until one of the following occurs: 
-
The event resolves,
-
The participating investigator assesses the event as stable,
-
The participating investigator determines the event to be irreversible,
-
The participant is lost to follow-up,
-
The participant dies. 
 If the subject is not seen in clinic after the off-study visit, required Adverse Event 
details must be collected over the phone. 

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If treatment is discontinued for a reason other than disease progression, study 
discontinuation, or withdrawal of consent, participants will be seen every 12 weeks 
(+/- 2 weeks) for imaging until progressive disease or death, whichever comes first. 
If there are any adverse events that have not resolved, or been assessed by the 
participating investigator as stable or irreversible at the time of progressive disease, 
the participant will be followed until the adverse events resolve, or are assessed by 
the participating investigator as stable or irreversible. 
5.7
Criteria for Taking a Participant Off Study
Participants will be removed from study when any of the criteria listed in 
Section 5.6 applies. The reason for study removal and the date the 
participant was removed must be documented in the study-specific case 
report form (CRF). Alternative care options will be discussed with the 
participant.
In the event of unusual or life-threatening complications, participating 
investigators must immediately notify the Principal Investigator, Ryan 
Sullivan at 617-724-4000.
5.8
Contraception
Pembrolizumab may have adverse effects on a fetus in utero.  Furthermore, it 
is not known if pembrolizumab has transient adverse effects on the 
composition of sperm.  For this trial, male subjects will be considered to be of 
non-reproductive potential if they have azoospermia (whether due to having 
had a vasectomy or due to an underlying medical condition).  
Female subjects will be considered of non-reproductive potential if they are 
either: 
(1) Postmenopausal (defined as at least 12 months with no menses without an 
alternative medical cause; in women < 45 years of age a high follicle 
stimulating hormone (FSH) level in the postmenopausal range may be used to 
confirm a post-menopausal state in women not using hormonal contraception 
or hormonal replacement therapy. In the absence of 12 months of amenorrhea, 
a single FSH measurement is insufficient.); 
OR 
(2) Have had a hysterectomy and/or bilateral oophorectomy, bilateral 
salpingectomy or bilateral tubal ligation/occlusion, at least 6 weeks prior to 
screening; 
OR 

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(3) Has a congenital or acquired condition that prevents childbearing.
Female and male subjects of reproductive potential must agree to avoid 
becoming pregnant or impregnating a partner, respectively, while receiving 
study drug and for 120 days after the last dose of study drug by complying with 
one of the following:  
Female subjects of childbearing potential and male subjects with partners of 
childbearing potential must:
(1) Practice abstinence† from heterosexual activity; 
OR 
(2) Use (or have their partner use) acceptable contraception during 
heterosexual activity.  
Acceptable methods of contraception are:
Single method (one of the following is acceptable):
• Intrauterine device (IUD)
• Vasectomy of a female subject’s male partner 
• Contraceptive rod implanted into the skin
Combination method (requires use of two of the following):
• Diaphragm with spermicide (cannot be used in conjunction with cervical 
cap/spermicide)
• Cervical cap with spermicide (nulliparous women only)  
• Contraceptive sponge (nulliparous women only) 
• Male condom or female condom (cannot be used together)
• Hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or 
progestin-only pill), contraceptive skin patch, vaginal contraceptive ring, or 
subcutaneous contraceptive injection
†Abstinence (relative to heterosexual activity) can be used as the sole method 
of contraception if it is consistently employed as the subject’s preferred and 
usual lifestyle and if considered acceptable by local regulatory agencies and 
ERCs/IRBs.  Periodic abstinence (e.g., calendar, ovulation, sympto-thermal, 
post-ovulation methods, etc.) and withdrawal are not acceptable methods of 
contraception. 
‡If a contraceptive method listed above is restricted by local 
regulations/guidelines, then it does not qualify as an acceptable method of 
contraception for subjects participating at sites in this country/region.
Subjects should be informed that taking the study medication may involve 

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unknown risks to the fetus (unborn baby) if pregnancy were to occur during the 
study.  In order to participate in the study subjects of childbearing potential 
must adhere to the contraception requirement (described above) from the day 
of study medication initiation (or 14 days prior to the initiation of study 
medication for oral contraception) throughout the study period up to 120 days 
after the last dose of trial therapy.  If there is any question that a subject of 
childbearing potential will not reliably comply with the requirements for 
contraception, that subject should not be entered into the study.
6. DOSING DELAYS/DOSE MODIFICATION CRITERIA
Dose delays and modifications must be made using the following criteria. 
Toxicity assessments will be done using the CTEP Active Version of the NCI 
Common Terminology Criteria for Adverse Events (CTCAE) which is identified 
and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
If possible, symptoms should be managed symptomatically. In the case of 
toxicity, appropriate medical treatment should be used (including anti-emetics, 
anti-diarrheals, etc.).
6.1
Pembrolizumab Dose Modifications
Pembrolizumab will be withheld for drug-related Grade 4 hematologic 
toxicities, non- hematological toxicity ≥ Grade 3 including clinically 
significant laboratory abnormalities despite appropriate replacement 
therapies when appropriate, and severe or life-threatening AEs as per 
Table 6.1.
Table 6.1 Pembrolizumab dose modification requirements for drug-related adverse 
events
Toxicity
Hold 
Treatmen
t For 
Grade
Timing for Restarting Treatment
Discontinue Subject
2-3
Toxicity resolves to Grade 0-1.
Toxicity does not resolve within 12 weeks of last dose or 
inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks.
Diarrhea/Colitis
4
Permanently discontinue
Permanently discontinue
2
Toxicity resolves to Grade 0-1
Toxicity does not resolve within 12 weeks of last dose.
AST, ALT, or 
Increased 
Bilirubin
3-4
Permanently discontinue
(see exception below)1
Permanently discontinue
Type 1 Diabetes 
Mellitus (if new 
onset) or 
Hyperglycemia
T1DM or 
3-4
Hold pembrolizumab for new onset 
Type 1 diabetes mellitus or Grade 3-4 
hyperglycemia associated with 
evidence of beta cell failure. 
Resume pembrolizumab when patients are clinically and 
metabolically stable.
Hypophysitis
2-3
Toxicity resolves to Grade 0-1
Toxicity does not resolve within 12 weeks of last dose or 
inability to reduce corticosteroid to 10 mg or less of 

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Toxicity
Hold 
Treatmen
t For 
Grade
Timing for Restarting Treatment
Discontinue Subject
prednisone or equivalent per day within 12 weeks.
4
Permanently discontinue
Permanently discontinue
3
Toxicity resolves to Grade 0-1
Toxicity does not resolve within 12 weeks of last dose or 
inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks.
Hyperthyroidism 
4
Permanently discontinue
Permanently discontinue
Hypothyroidism
2-4
Therapy with pembrolizumab can be 
continued while treatment for the 
thyroid disorder is instituted
Therapy with pembrolizumab can be continued while 
treatment for the thyroid disorder is instituted.
Infusion Reaction
3-4
Permanently discontinue
Permanently discontinue
2
Toxicity resolves to Grade 0-1
Toxicity does not resolve within 12 weeks of last dose or 
inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks.
Pneumonitis
3-4
Permanently discontinue
Permanently discontinue
2
Toxicity resolves to Grade 0-1
Toxicity does not resolve within 12 weeks of last dose or 
inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks.
Renal Failure or 
Nephritis
3-4
Permanently discontinue
Permanently discontinue
Hematologic 
Toxicity
4
Toxicity resolves to Grade 0-1 or 
baseline
Toxicity does not resolve within 12 weeks of last infusion. 
Permanent discontinuation should be considered for any 
severe or life-threatening event.
3 or Severe
Toxicity resolves to Grade 0-1
Toxicity does not resolve within 12 weeks of last dose or 
inability to reduce corticosteroid to 10 mg or less of 
prednisone or equivalent per day within 12 weeks.
All Other Drug-
Related 
Toxicity2,3
4
Permanently discontinue
Permanently discontinue
Note: Permanently discontinue for any severe or Grade 3 drug-related AE that recurs or any life-threatening event.
1 For patients with liver metastasis who begin treatment with Grade 2 AST or ALT, if AST or ALT increases by greater than or equal to 50% relative 
to baseline and lasts for at least 1 week then patients should be discontinued.
2 Patients with intolerable or persistent Grade 2 drug-related AE may hold study medication at physician discretion.  Permanently discontinue study 
drug for persistent Grade 2 adverse reactions for which treatment with study drug has been held, that do not recover to Grade 0-1 within 12 
weeks of the last dose.  
3 Exception to be treated similar to grade 1 toxicity: Grade 2 alopecia, grade 2 fatigue
6.1.1 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). In 
these cases only, subjects must be placed back on study therapy within 2 
weeks of the scheduled interruption, unless otherwise discussed with the 
PI of the study. The reason for interruption must be documented in the 
patient's study record.

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6.2
Dabrafenib + Trametinib Dose Modifications
The table below outlines the dose levels to be used for any necessary 
dabrafenib and trametinib dose modifications in studies which include the 
combination:
Current Dose 
Dabrafenib
If Dose Reduction Required
Reduce To
150mg BID

150 mg QAM, 75 mg 
QPM
150 mg QAM, 75 mg 
QPM

75mg BID
75mg BID

Discontinue dabrafenib
Current Dose 
Trametinib
If Dose Reduction Required
Reduce To
2mg QD

1.5mg QD
1.5mg QD

1.0mg QD
1.0mg QD

Discontinue trametinib
If an AE resolves to grade 1 or baseline at the reduced dose level, and no 
additional toxicities are seen after 4 weeks of study treatment at the reduced 
dose, the dose may be increased to the previous dose level.  A dose 
reduction below 75 mg BID for dabrafenib and 1 mg once daily for trametinib 
is not allowed.  If a dose reduction below 75 mg BID is required, dabrafenib 
will be permanently discontinued, but the patients will be allowed to continue 
trametinib.  If a dose reduction below 1.0 mg once daily for trametinib is 
required, then trametinib will be permanently discontinued, but these patients 
will be allowed to continue pembrolizumab and/or dabrafenib.
The dose modifications may involve one or both agents, and should be based 
on the nature, severity and attributions of the AEs.  General guidelines are 
provided below. 
In the event that trametinib and pembrolizumab need to be discontinued due 
to toxicity reasons, treatment with dabrafenib may continue at the discretion 
of the investigator until time of disease progression.
6.2.1 Dabrafenib +/or Trametinib Dose Modification Requirements for drug-related 
adverse events Not Specified in Subsequent Sections

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Table 6-2:  Dabrafenib +/or Trametinib Dose Modification Requirements 
for drug-related adverse events 
Not Specified in Subsequent Sections
CTCAE Grade
Action and Dose Modification
Grade 1 
Continue study treatment at same dose level (no dose 
modification).
Monitor closely.
Provide supportive care according to institutional standards.
Grade 2 (Tolerable)
Interrupt study treatment if clinically indicated.
Monitor closely.
Provide supportive care according to institutional standards.
When toxicity resolves to grade 1 or baseline, restart study 
treatment at current dose level.
Grade 2 (Intolerable)
Grade 3
Interrupt study treatment.
Monitor closely.
Provide supportive care according to institutional standards.
When toxicity resolves to grade 1 or baseline, restart study 
treatment reduced by one dose level.
If the grade 3 toxicity recurs, interrupt study treatment.
When toxicity resolves to grade 1 or baseline, restart study 
treatment reduced by another dose level.
Grade 4
Interrupt study treatment.
Monitor closely.
Provide supportive care according to institutional standards.
Restart with study treatment reduced by one dose level once 
toxicity resolves to grade 1 or baseline.
If the grade 4 toxicity recurs, either permanently discontinue 
study treatment or, if the patient is clinically benefiting, discuss 
continuation of study treatment with the overall PI.
*If the AEs are thought to be due to one of the two agents, resumption of the other agents may 
be considered if the first agent is discontinued due to toxicities and treatment interruption is <21 
days.  Overall PI should be consulted for resumption of single agent.  
** In the event of abdominal pain or suspected pancreatitis, amylase and lipase laboratory 
samples should be collected for confirmation of the diagnosis.
6.2.2 Dabrafenib + Trametinib Dose Modification Requirements for Pyrexia

Pyrexia is defined as a body temperature equal to or above 38.5○ 
Celsius or 101.3○ Fahrenheit 

Pyrexia is an adverse event associated with dabrafenib.  In a minority 
of cases, pyrexia was accompanied by symptoms such as severe 
chills/rigors, dehydration, hypotension, dizziness or weakness and 
required hospitalization. 

Subjects should be instructed on the importance of immediately 
reporting febrile episodes.  

Pyrexia accompanied by hypotension, dehydration, renal insufficiency 
and/or severe (grade 3) rigors/chills in the absence of an obvious 
infectious cause should be reported as an SAE.

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Table 6-2:  Dabrafenib + Trametinib dose Modification and Management 
Requirements for Pyrexia
Event
Management Guideline
Dose Modification
Work up:
Clinical evaluation for infection and hypersensitivity, especially if pyrexia is complicated by rigors, 
severe chills, dehydration, etc. 
Laboratory work-up (recommend  include full-blood-count, electrolytes, creatinine, BUN, CRP, 
liver-function tests, blood and urine culture).
Management: 
Anti-pyretic treatment should be started immediately at the first occurrence.  Anti-pyretic treatment 
may include acetaminophen (paracetamol), ibuprofen, or suitable anti-pyretic medication per 
institutional standards.
Oral hydration is encouraged in subjects without evidence of dehydration.  Intravenous hydration is 
recommended if pyrexia is complicated by dehydration/hypotension.
In subject experiencing pyrexia complicated by rigors, severe chills, etc., which cannot be 
controlled with anti-pyretic medication, recommend oral corticosteroids be started.
Prophylactic anti-pyretic treatment is recommended after the 2nd event.  
1st Event:

Clinical evaluation for infection 
and hypersensitivity

Laboratory work-up

Hydration as required

Administer anti-pyretic treatment 
if clinically indicated and 
continue prophylactic treatment
Interrupt dabrafenib.
Continue trametinib.
Upon recovery to baseline, restart 
dabrafenib at the same dose level.  If fever 
was associated with dehydration or 
hypotension, reduce dabrafenib by one 
dose level.
2nd Event
Clinical evaluation for infection 
and hypersensitivity
Laboratory work-up
Hydration as required
Within 3 days of onset of pyrexia:
Optimize anti-pyretic therapy.
Consider oral corticosteroids 
(i.e., prednisone 10 mg) for at 
least 5 days or as clinically 
indicated.
Interrupt dabrafenib.
Continue trametinib.
Upon recovery to baseline, restart 
dabrafenib at the same dose level.  If fever 
was associated with dehydration or 
hypotension, reduce dabrafenib by one 
dose level.

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Table 6-2:  Dabrafenib + Trametinib dose Modification and Management 
Requirements for Pyrexia
Event
Management Guideline
Dose Modification
Subsequent 
Events: 
Clinical evaluation for infection 
and hypersensitivity
Laboratory work-up
Hydration as required
Blood sample for cytokine 
analysis
Within 3 days of onset of pyrexia:
Optimize oral corticosteroid 
dose as clinically indicated for 
recalcitrant pyrexia.
If corticosteroids have been 
tapered and pyrexia recurs, 
restart steroids.
If corticosteroids cannot be 
tapered, consult medical 
monitor.
Interrupt dabrafenib.
Continue trametinib.
Once pyrexia resolves to baseline, restart 
dabrafenib reduced by one dose level.h
If dabrafenib must be reduced to <75 mg 
BID, permanently discontinue dabrafenib.
h  Dabrafenib should be reduced by one dose level after three episodes of pyrexia which cannot be 
managed by best supportive care and increasing doses of oral steroids.  Escalation of dabrafenib is 
allowed if no episode of pyrexia is observed in the 4 weeks subsequent to dose reduction.
6.2.3 Dabrafenib +/or Trametinib Dose Modification for Drug-Related Rash
Rash is a frequent AE observed in patients receiving trametinib, 
dabrafenib, or the combination of both therapies.  
Recommendations for supportive care and guidelines for dose 
modifications for rash are based on experience with other MEK 
inhibitors and EGFR inhibitors (Balagula et al., 2010; Lacouture et 
al., 2011).
The institutional standards for the management of skin-related AEs 
can differ from these guidelines.  In this case, best clinical judgment 
should be applied and a consultation with the study overall PI may 
be required.

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Table 6-3:  Dabrafenib +/or Trametinib Supportive care and Dose Modification 
Requirements for Drug-Related Rash
CTCAE Grade
Adverse Event Management
Action and Dose Modification
Recommended supportive care:
Prevention:  Promote sunscreen use and avoid unnecessary sun exposure, use alcohol-free 
emollient creams, topical steroids and antibiotics as needed.
Pruritic lesions:  cool compresses and oral antihistamines.
Fissuring lesions:  Monsel’s solution, silver nitrate or zinc oxide cream.
Desquamation:  thick emollients and mild soap.
Paronychia:  antiseptic bath, local potent corticosteroids, antibiotics, surgery as needed.
Infected lesions:  topical or systemic antibiotics.
Grade 1

Initiate prophylactic and 
symptomatic treatment measures.1
Use moderate strength topical 
steroid.2
Reassess after 2 weeks.
Continue study treatment.
If rash does not recover to baseline within 2 
weeks despite best supportive care, 
reduce study treatment by one dose 
level.3
Grade 2

Initiate prophylactic and 
symptomatic treatment measures.1
Use moderate strength topical 
steroid.2
Reassess after 2 weeks.
Reduce study treatment by one dose 
level.
If rash recovers to ≤ grade 1 within 2 
weeks, increase dose to previous dose 
level.
If no recovery to ≤ grade 1 within 2 weeks, 
interrupt study treatment until recovery to ≤ 
grade 1.
Restart study treatment at reduced dose 
level.3
Grade ≥3

Use moderate strength topical 
steroids PLUS oral methyl-
prednisolone dose pack.2
Consult dermatologist.
Interrupt study treatment until rash 
recovers to ≤ grade 1.
Restart with study treatment reduced by 
one dose level.3,4
If no recovery to ≤ grade 2 within 21 days, 
permanently discontinue study treatment.
1.  Rash prophylaxis is recommended for the first 6 weeks of study treatment.
2.  Moderate-strength topical steroids:  Hydrocortisone 2.5% cream or fluticasone propionate 0.5% 
cream.
3.  Approval of overall PI is required to restart study treatment after >21 days of interruption.
4.  Study treatment may be escalated to previous dose level if no rash is evident 4 weeks after 
restarting study treatment.

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6.2.4 Dabrafenib +/or Trametinib Dose Modification for Hand-Foot Skin Reaction 
(HFSR)
Table 6-4:  Dabrafenib + /or Trametinib Dose Modification for HFSR
CTCAE Grade
Adverse Event Management
Action and Dose Modification
Grade 1a
Lifestyle changes recommended.b
Initiate symptomatic treatment if 
clinically appropriatec
Continue study treatment at current dose 
level.
Grade 2
Lifestyle changes recommended.b
Initiate symptomatic treatment.c
Interrupt study treatment until recovery to 
≤ grade 1.d
Recovery to ≤ grade 1 within 7 days:  
restart study treatment at previous dose 
level.
If no recovery to ≤ grade 1 within 7 days or 
≥ 2nd occurrence:  restart with study 
treatment reduced by one dose level.
Grade ≥3
Lifestyle changes recommended.b
Initiate symptomatic treatment.c
Consult dermatologist.
Interrupt study treatment until rash 
recovers to ≤ grade 1.d
Restart with study treatment reduced by 
one dose level.e
If 3rd occurrence, discontinue study 
treatment permanently.
a  A full-body skin examination and removal of pre-existing calluses and keratotic skin is 
recommended prior to initiation of study treatment.
b  Life-style changes:  (1) reduce exposure of hands and feet to hot water; (2) avoid traumatic activity 
including vigorous exercise especially in the first 4 weeks after start of study treatment; (3) avoid 
constrictive footwear; (4) avoid excessive friction on the skin when applying topical treatments; (5) 
wear thick cotton socks and gloves, and shoes with padded insoles.
c  Symptomatic treatments:  (1) use moisturizing creams frequently and especially on hands and feet; 
(2) consider topical keratolytics:  urea 20-40% cream, or salicylic acid 6%, or tazarotene 0.1% cream, 
or fluorouracil 5% cream; (3) erythematous areas:  clobetasol propionate 0.05% ointment; (4) pain:  
topical lidocaine 2%, and/or systemic pain medication such as nonsteroidal anti-inflammatory drugs, 
codeine, and pregabalin.
d  Approval of overall PI is required to restart study treatment after ≥21 days of interruption.
e  escalation of study treatment to the previous dose level is allowed if no HFSR is observed in the 4 
weeks subsequent to dose reduction.
6.2.5 Dabrafenib + Trametinib Dose Modification for Squamous Cell Carcinoma
Cutaneous squamous cell carcinoma (SCC) has been observed in patients 
treated with dabrafenib and the combination of dabrafenib and trametinib.  
These treatment-related SCC should be surgically removed according to 
institutional practice; dose modifications or interruptions of the study 
treatment are not required.  Occurrence of SCC must be reported as an SAE.

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6.2.6 Dabrafenib +/or Trametinib Dose Modification for Renal Insufficiency
Cases of renal insufficiency have occurred in patients receiving the 
combination of dabrafenib and trametinib.  Prior to start of study 
treatment, concomitant medications should be reviewed for the 
potential risk of inducing nephrotoxicity and, if so, should be 
modified if clinically possible.
Table 6-5: Dabrafenib +/or Trametinib Treatment Modification Requirements 
for Renal Insufficiency
Serum Creatinine Level
Management Guideline
Action and Dose 
Modification
Serum creatinine increase
>0.2 mg/dL (18 mcmol/L)
BUT
≤0.5 mg/dL (44 mcmol/L) 
above baseline
Recheck serum creatinine within 1 
week.
Serum creatinine increase >1 week:  
contact Overall PI.
If pyrexia is present, treat pyrexia as 
per guidelines.a
Continue study treatment at 
the same dose level.
Serum creatinine increase
>0.5 mg/dL (44 mcmol/L)
OR
>2 mg/dL (>177 mcmol/L)
Monitor serum creatinine ≥2-times per 
week.
Hospitalization may be necessary if 
serum creatinine cannot be monitored 
frequently.
If pyrexia is present, treat pyrexia per 
guidelines.
Consult nephrologist if clinically 
indicated.
Perform renal biopsy if clinically 
indicated, for example:
Renal insufficiency persists despite 
volume repletion.
Patient has new rash or signs of 
hypersensitivity (such as elevated 
eosinophil count).
Interrupt study treatment 
until serum creatinine 
recovers to baseline.
Restart study treatment.b
 
a  NSAIDs can induce renal insufficiency, especially in patients with dehydration; encourage oral 
fluids or consider IV fluids as clinically indicated.
b  Investigator may restart at either the same or a reduced dose level.  Escalation of study treatment 
to previous dose level is allowed if another episode of renal insufficiency does not occur after 4 
weeks of dose reduction.  Consultation with the overall PI is required before restarting study 
treatment if there is evidence of thrombotic microangiopathy.

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6.2.7 Dabrafenib +/or Trametinib Dose Modification for Reduced Left Ventricular 
Ejection Fraction
Decreases of the left ventricular ejection fraction (LVEF) have been 
observed in patients receiving trametinib.  Therefore, ECHOs must 
be performed at intervals outlined in the Study Calendar.  The 
same procedure (either ECHO or MUGA, although ECHO is 
preferred) should be performed at baseline and at Week 9.  
Table 6-6:  Dabrafenib +/or Trametinib Treatment Modification and 
Management Requirements for LVEF Decrease
Clinic
LVEF-drop (%) or
CTCAE grade
Dose Modification
Asymptomatic
Absolute decrease of >10% in 
LVEF compared to baseline and 
ejection fraction below the 
institution’s LLN.
Interrupt study treatment and repeat ECHO 
within 2 weeks.a
If the LVEF recovers within 4 weeks (defined 
as LVEF ≥LLN and absolute decrease ≤10% 
compared to baseline):
Consult with the overall PI and request 
approval for restart.
Restart trametinib and dabrafenib (if cohort 
1) at reduced doses by one dose level.
Repeat ECHO 2, 4, 8, and 12 weeks after re-
start; continue in intervals of 12 weeks 
thereafter.
If LVEF does not recover within 4 weeks:
Consult with cardiologist.
Permanently discontinue trametinib. 
Resumption of dabrafenib (if cohort 1) may 
be considered after consultation with the 
overall PI.
Repeat ECHO after 2, 4, 8, 12, and 16 
weeks or until resolution.
Symptomaticb
Grade 3:  resting LVEF 39-
20% or >20% absolute 
reduction from baseline
Grade 4:  Resting LVEF ≤20%.
Permanently discontinue trametinib.  
Consult overall PI for continuation of 
dabrafenib (if cohort 1). Consult with 
cardiologist.
Repeat ECHO after 2, 4, 8, 12, and 16 weeks 
or until resolution.
a If ECHO does not show LVEF recovery after 2 weeks, repeat ECHO 2 weeks later.
b Symptoms may include:  dyspnea, orthopenea, and other signs and symptoms of pulmonary 
congestion and edema.
6.2.8 Dabrafenib +/or Trametinib Dose Modification for Hypertension
Increases in blood pressure (BP) have been observed in patients 
receiving trametinib.  Recommendations for BP monitoring and 

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management are provided below.
Monitoring:  All BP assessments are to be performed as follows:

In subjects with an initial BP reading within the hypertensive 
range, a second reading should be taken at least 1 minute later, 
with the two readings averaged to obtain a final BP 
measurement.  The averaged value should be recorded in the 
eCRF.

Visits to monitor increased blood pressure can be scheduled 
independently from the per-protocol visits outlined in the study 
calendar.  Ideally, subsequent blood pressure assessments 
should be performed within 1 week.

Persistent hypertension is defined as an increase of systolic BP 
(SBP) >140 mmHg and/or diastolic BP (DBP) >90 mmHg in 
three consecutive visits with blood pressure assessments from 
two readings.

Asymptomatic hypertension is defined as an increase of SBP 
>140 mmHg and/or diastolic BP (DBP) >90 mmHg in the 
absence of headache, light-headedness, vertigo, tinnitus, 
episodes of fainting, or other symptoms indicative of 
hypertension.

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Table 6-7:  Dabrafenib +/or Trametinib Treatment Modification and Management 
Requirements for Hypertension
Event
Management Guideline
Dose Modification
(Scenario A)
Asymptomatic and persistenta 
SBP of ≥140 and <160 mmHg, 
or DBP ≥90 and <100 mmHg
OR

linically significant increase in 
DBP of 20 mmHg (but still 
below 100 mmHg)
Adjust current or initiate new 
antihypertensive 
medication(s).
Titrate antihypertensive 
medication(s) during the 
next 2 weeks to achieve 
well-controlled BP.  If BP is 
not well-controlled within 2 
weeks, consider referral to a 
specialist and go to scenario 
(B).
Continue protocol therapy.
If BP is not well-controlled within 2 
weeks, consider referral to a specialist 
and go to scenario (B).
(Scenario B)
Asymptomatic SBP ≥160 
mmHg, or DBP ≥100 mmHg, 
OR

Failure to achieve well-
controlled BP within 2 weeks 
in Scenario A.
Adjust current or initiate new 
antihypertensive 
medication(s).
Titrate antihypertensive 
medication(s) during the 
next 2 weeks to achieve 
well-controlled BP.
Interrupt trametinib  if clinically 
indicated.
Once BP is well-controlled, restart 
trametinib reduced by one dose level.
Dabrafenib (if cohort 1) may be 
continued
(Scenario C)

Symptomatic hypertension 
OR

Persistent SBP ≥160 
mmHg, or DBP ≥100 mmHg, 
despite antihypertensive 
medication and dose reduction 
of study treatment
Adjust current or initiate new 
antihypertensive 
medication(s).
Titrate antihypertensive 
medication(s) during the 
next 2 weeks to achieve 
well-controlled BP.
Referral to a specialist for 
further evaluation and 
follow-up is recommended.
Interrupt trametinib.
Once BP is well controlled, restart 
trametinib reduced by one dose level.
Dabrafenib (if cohort 1) may be 
continued.
(Scenario D)
Refractory hypertension 
unresponsive to above 
interventions or hypertensive 
crisis.
Continue follow-up per 
protocol.
Discontinue trametinib.
Hold dabrafenib until BP is controlled.  
If the treatment delay is >21 days, 
overall PI should be consulted for 
resumption of dabrafenib.

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6.2.9 Dabrafenib +/or Trametinib Dose Modification Requirements for QTc 
Prolongation
Table 6-8:  Dabrafenib +/or Trametinib Withholding and Stopping Criteria for 
QTc Prolongation
Prolongation
Action and Dose Modification

QTcB ≥501 msec, or

Uncorrected QT >600 msec, or

QTcB >530 msec for subjects 
with bundle branch block
Interrupt dabrafenib and trametinib (cohort 1) or trametinib 
(cohort 2) until QTcB prolongation resolves to grade 1 or 
baseline.
If the event resolves, restart dabrafenib and trametinib 
(cohort 1) or trametinib (cohort 2) treatment at current dose 
level.
If the event does not resolve, permanently discontinue 
dabrafenib and trametinib treatment. 
If the event recurs, permanently discontinue study 
treatment.
Abbreviations:  msec = milliseconds; QTcB = QT interval on electrocardiogram corrected using the 
Bazett’s formula
6.2.10 Dabrafenib +/or Trametinib Dose Modification for Diarrhea
Episodes of diarrhea have been observed in patients receiving dabrafenib, 
trametinib, or both therapies in combination.  Other, frequent causes for 
diarrhea including concomitant medications (e.g., stool softeners, laxatives, 
antacids, etc.), infections caused by C. difficile or other pathogens, partial 
bowel obstruction, etc., should be clinically excluded.
Table 6-9:  Dabrafenib +/or Trametinib Treatment Modification and 
Management Requirements for Diarrhea
CTCAE Grade
Management 
Action and Dose Modification

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Table 6-9:  Dabrafenib +/or Trametinib Treatment Modification and 
Management Requirements for Diarrhea
CTCAE Grade
Management 
Action and Dose Modification
Uncomplicated 
Diarrhea,1
Grade 1 or 2
Diet:  Stop all lactose containing products; 
eat small meals, BRAT-diet (banana, rice, 
apples, toast) recommended.
Hydration:  8-10 large glasses of clear 
liquids per day (e.g., Gatorade or broth).
Loperamide3:  Initially 4 mg, followed by 2 
mg every 4 hours or after every unformed 
stool; maximum 16 mg/day.  Continue until 
diarrhea-free for 12 hours.
Diarrhea >24 hours:  Loperamide 2 mg 
every 2 hours; maximum 16 mg/day.  
Consider adding oral antibiotics.
Diarrhea >48 hous:  Loperamide 2 mg 
every 2 hours; maximum 16 mg/day.  Add 
budesonide or other second-line therapies 
(otreotide, or tincture of opium) and oral 
antibiotics.
Continue study treatment.
If diarrhea is grade 2 for > 48 
hours, interrupt study treatment 
until diarrhea resolves to grade 
≤1.
Restart study treatment at the 
same dose level.
Uncomplicated 
Diarrhea,1
Grade 3 or 4
Any Complicated 
Diarrhea2
Clinical evaluation mandatory.
Loperamide3:  Initially 4 mg, followed by 2 
mg every 4 hours or after every unformed 
stool; maximum 16 mg/day.  Continue until 
diarrhea-free for 12 hours.
Oral antibiotics and second-line therapies if 
clinically indicated
Hydration:  Intravenous fluids if clinically 
indicated.
Antibiotics (oral or intravenous) if clinically 
indicated.
Intervention should be continued until the 
subject is diarrhea-free for ≥24 hours.
Intervention may require hospitalization for 
subjects at risk of life-threatening 
complications.

Interrupt study treatment 
until diarrhea resolves to ≤ 
grade 1.
Restart with study treatment 
reduced by one dose level.4

If 3 dose reductions of 
study treatment are clinically 
indicated, permanently 
discontinue study treatment.
1.  Uncomplicated diarrhea defined by the absence of symptoms such as cramping, 
nausea/vomiting, ≥ grade 2, decreased performance status, pyrexia, sepsis, neutropenia ≥ grade 3, 
frank bleeding, and/or dehydration requiring intravenous fluid substitution.
2.  Complicated diarrhea defined by the presence of symptoms such as cramping, 
nausea/vomiting, ≥ grade 2, decreased performance status, pyrexia, sepsis, neutropenia ≥ grade 3, 
frank bleeding, and/or dehydration requiring intravenous fluid substitution.
3.  Loperamide should be made available prior to start of study treatment so loperamide 
administration can begin at the first signs of diarrhea.
4.  Escalation of study treatment to previous dose level is allowed after consultation with the medical 
monitor and in the absence of another episode of complicated or severe diarrhea in the 4 weeks 
subsequent to dose reduction.
6.2.11 Dabrafenib +/or Trametinib Dose Modification for Vision Changes
Episodes of vision changes have been observed in patients 

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receiving dabrafenib, trametinib, or the combination of both 
therapies and can be caused by central serous retinopathy (CSR) with 
retinal pigment epithelial detachments (RPED), or Retinal Vein 
Occlusion (RVO).  Patients are required to have a standard ophthalmic 
exam performed by an ophthalmologist at baseline, within 1 week prior 
to doing on week 9, and any time patients report visual disturbance.  
For Grade 2 visual changes or greater, this exam must occur within 24 
hours of onset (or study team knowledge of the event).  The exam will 
include indirect fundoscopic examination, visual acuity (corrected), 
visual field examination, tonometry, and direct fundoscopy.  Special 
attention should be given to retinal (e.g., CSR, RPED) or retinal vein 
abnormalities (e.g., RVO).
Guidelines regarding event management and dose reduction for visual changes considered to 
be related to study treatment are provided in the table below.
Table 6-10: Dabrafenib +/or Trametinib Treatment Modification Requirement 
for Vision Changes
CTCAE Grade
Management 
Action and Dose Modification
Grade 1
Asymptomatic or 
symptomatic but not 
limiting ADL; intervention 
not indicated.
Consult ophthalmologist any time 
when patient reports visual 
disturbance.  If there is visual loss 
or significant visual changes, 
consult ophthalmologist 
immediately (within 24 hours of 
study team awareness)
Workup to rule out CSR, RPED or 
RVO.  Consult retinal specialist in 
case of CSR or RVO.

Report CSR and RVO as 
SAE.
Continue follow up examination(s) 
(by retinal specialist if available) for 
CSR, RPED and RVO.

Continue study 
treatment at the same dose 
level until ophthalmologic 
examination can be 
conducted.*
If ophthalmologic examination 
cannot be performed within 7 
days of onset, interrupt study 
treatment until CSR and RVO 
can be excluded and symptoms 
resolve.
If CSR and RVO excluded, 
restart study treatment at same 
dose level.
If CSR:  Interrupt study 
treatment until symptoms 
resolve and exam by retinal 
specialist shows resolution.  
May restart study treatment 
with one dose level reduction 
of trametinib.

If RVO:  Permanently 
discontinue trametinib.  

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Table 6-10: Dabrafenib +/or Trametinib Treatment Modification Requirement 
for Vision Changes
CTCAE Grade
Management 
Action and Dose Modification
Grade 2 and Grade 3
Grade 2 defined as:  
Symptomatic with 
moderate decrease in 
visual acuity (20/40 or 
better); limiting 
instrumental ADL; local or 
non-invasive intervention 
indicated.  
Grade 3 defined as:  
Symptomatic with marked 
decrease in visual acuity 
or marked visual field 
defect (worse than 20/40 
but better than 20/200); 
severe pain or medically 
significant; operative 
intervention indicated.

Consult ophthalmologist 
immediately (within 24 hours of 
study team awareness).
Workup to rule out CSR, RPED or 
RVO.  Consult retinal specialist in 
case of CSR or RVO.

Report CSR and RVO as 
SAE.
Continue follow up examination(s) 
(by retinal specialist if available) for 
CSR, RPED and RVO.

Interrupt study treatment 
until signs and symptoms have 
resolved to baseline.

If CSR and RVO 
excluded and symptoms 
resolved to baseline, restart 
study treatment reduced by one 
dose level.
If CSR:  Interrupt study 
treatment until symptoms 
resolve and exam by retinal 
specialist shows resolution.  If 
CSR resolves restart study 
treatment with trametinib 
dose reduced by one dose 
level.
If RVO:  Permanently 
discontinue trametinib.
Grade 4
Sight-threatening 
consequences; urgent 
intervention indicated; 
blindness (20/200 or 
worse).

Consult ophthalmologist 
immediately (within 24 hours of 
study team awareness).
Workup to rule out CSR, RPED or 
RVO.  Consult retinal specialist in 
case of CSR or RVO.

Report CSR and RVO as 
SAE.
Continue follow up examination(s) 
(by retinal specialist if available) for 
CSR, RPED and RVO.
Permanently discontinue 
study treatment. 
Abbreviations:  CSR = central serous retinopathy; RVO = retinal vein occlusion; SAE = 
serious adverse event
* If visual changes are clearly unrelated to study treatment (e.g., allergic conjunctivitis), 
monitor closely but ophthalmic examination is not required.
**If ocular toxicities do not resolve within 21 days, permanently discontinue trametinib.
6.2.12 Dabrafenib +/or Trametinib Dose Modification for Pneumonitis
Pneumonitis has been observed in patients receiving trametinib.  
To reduce the risk of pneumonitis, patients will be monitored 
closely for symptoms, evaluated with imaging and functional tests 
when appropriate.  

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Table 6-11: Dabrafenib + Trametinib Treatment Modification Requirements for 
Pneumonitis
CTCAE Grade
Management 
Action and Dose Modification
Grade 1
CT scan (high-resolution with lung 
windows) recommended.
Clinical evaluation and laboratory 
work-up for infection.
Monitoring of oxygenation via pulse-
oximetry recommended.

 Consultation with 
pulmonologist recommended.
Continue study treatment  at current 
dose.
Grade 2
CT scan (high-resolution with lung 
windows).
Clinical evaluation and laboratory 
work-up for infection.
Consult pulmonologist.
Pulmonary function tests:  If < 
normal, repeat every 8 weeks until ≥ 
normal.
 Symptomatic therapy including 
corticosteroids if clinically indicated.
Interrupt study treatment until 
recovery to grade ≤1.
Restart with study treatment 
reduced by one dose level.
Escalation to previous dose level 
after 4 weeks and consultation 
with the overall PI may be 
considered.
If no recovery to grade ≤1 within 4 
weeks, permanently discontinue 
study treatment.
Grade 3
CT scan (high-resolution with lung 
windows).
Clinical evaluation and laboratory 
work-up for infection.
Consult pulmonologist.
Pulmonary function tests:  If < 
normal, repeat every 8 weeks until ≥ 
normal.
Bronchoscopy with biopsy and/or 
BAL if possible.

 Symptomatic therapy 
including corticosteroids as clinically 
indicated.
Interrupt study treatment until 
recovery to grade ≤1.
After consultation with the overall 
PI, study treatment may be 
restarted reduced by one dose 
level.

If no recovery to grade ≤1 
within 4 weeks, permanently 
discontinue study treatment.
Grade 4
Same as Grade 3.
Permanently discontinue study 
treatment.
6.2.13 Dabrafenib +/or Trametinib Dose Modification for Liver Chemistry Changes
Table 6-12:  Dabrafenib +/or Trametinib Dose Modification Requirements for 
Liver Chemistry Changes
Stopping Criteria and Action

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Table 6-12:  Dabrafenib +/or Trametinib Dose Modification Requirements for 
Liver Chemistry Changes
Stopping Criteria and Action
Liver chemistry stopping criteria are defined as follows.  When any of the liver chemistry 
stopping criteria are met, immediately discontinue study treatment, perform liver event follow-up 
assessments, and monitor the patient until liver chemistries resolve, stabilize, or return to baseline 
values.

ALT ≥3x ULN and bilirubin ≥2x ULN (>35% direct bilirubin) (or ALT ≥3x ULN and international 
normalized ratio [INR] >1.5, if INR measured).  NOTE:  If serum bilirubin fractionation is not 
immediately available, study treatment should be discontinued if ALT ≥3x ULN and bilirubin ≥2x 
ULN.  Serum bilirubin fractionation should be performed if testing is available.  If testing is 
unavailable, record presence of detectable urinary bilirubin on dipstick, indicating direct 
bilirubin elevations and suggesting liver injury.

ALT ≥8x ULN.

ALT ≥5x ULN but <8x ULN persists for 2 weeks.

ALT ≥3x ULN if associated with the appearance or worsening of symptoms of hepatitis or 
hypersensitivity such as fatigue, nausea, vomiting, right upper quadrant pain or tenderness, 
fever, rash, or eosinophilia.

ALT ≥5x ULN but <8x ULN and cannot be monitored weekly for >2 weeks.

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7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS
An adverse event is any untoward medical occurrence associated with the use of the 
study drug(s), whether or not considered drug related. An adverse event (AE) can 
therefore be any unfavorable and unintended sign (including an abnormal laboratory 
finding, for example), symptom, or disease temporally associated with the use of a 
medicinal product, whether or not considered related to the study drug(s).
7.1
Expedited Adverse Event Reporting to the Overall PI and Merck
Investigators must report to the DF/HCC Overall Principal Investigator (PI) any 
serious adverse event (SAE) that occurs from the time of the first dose of study 
treatment up until 90 days after the last dose of study treatment. The report 
should be submitted on the MedWatch 3500A form. 
A serious adverse event is any adverse event that is any of the following:
Fatal (i.e., the adverse event actually causes or leads to death)
Life threatening (i.e., the adverse event, in the view of the investigator, 
places the patient at immediate risk of death)
Requires or prolongs inpatient hospitalization
Results in persistent or significant disability/incapacity (i.e., the adverse 
event results in substantial disruption of the patient’s ability to conduct 
normal life functions)
A congenital anomaly/birth defect in a neonate/infant born to a mother 
exposed to the investigational product
Considered a significant medical event by the investigator (e.g., may 
jeopardize the patient or may require medical/surgical intervention to 
prevent one of the outcomes listed above)
Pyrexia accompanied by hypotension, dehydration, renal insufficiency 
and/or severe (grade 3) rigors/chills in the absence of an obvious 
infectious cause should be reported as an SAE.
Occurrence of Cutaneous squamous cell carcinoma (SCC) must be 
reported as an SAE.
Central serous retinopathy (CSR) and Retinal Vein Occlusion (RVO) must 
be reported as an SAE.
All adverse events that do not meet any of the criteria for serious should be 
regarded as nonserious adverse events
Investigators must report each serious adverse event to the Overall PI within 24 
hours of learning of the occurrence. In the event that the participating investigator 
does not become aware of the serious adverse event immediately (e.g., 

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participant sought treatment elsewhere), the participating investigator is to report 
the event within 24 hours after learning of it and document the time of his or her 
first awareness of the adverse event. Report serious adverse events by 
telephone, email or facsimile using the MedWatch 3500A form to:
Ryan J. Sullivan, MD
Phone: 617-724-4000
Email:   rsullivan7@mgh.harvard.edu
Fax:   617-726-1949
The participating investigator must provide follow-up information on the serious 
adverse event. Follow-up information should describe whether the event has 
resolved or continues, if and how the event was treated, and whether the 
participant will continue or discontinue study participation.
In addition, the participating investigator will be responsible for reporting these 
serious adverse events to Merck via the MedWatch 3500A form. 
 The contact for Merck is listed below:
Alicia M. Schneider
Scientific Leadership & Research Manager - Oncology
Merck Investigator Studies Program/Scientific Engagements
Global Center for Scientific Affairs| Merck Research Laboratories
Phone: 267-305-0191
Email: Alicia.Schneider@merck.com
Fax: 267-305-6534
7.2
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 must report to the FDA any suspected adverse reaction to study 
treatment (i.e., including active comparators) that is both serious and 
unexpected.  
7.3
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. 

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7.4
Routine Adverse Event Reporting
All Adverse Events must be reported in routine study data submissions to the 
Overall PI on the toxicity case report forms.  AEs reported through expedited 
processes (e.g., reported to the IRB, FDA, etc.) must also be reported in 
routine study data submissions.
7.5
Monitoring of Adverse Events and Period of Observation
All adverse events, both serious and non-serious, and deaths that are 
experienced by participants will be collected from the time of the first dose of 
study treatment up until 90 days after the last dose study treatment, or until 
death if death occurs first. The presence and resolution of AEs and SAEs (with 
dates) should be documented on the appropriate case report form and 
recorded in the participant’s medical record to facilitate source data verification. 
For some SAEs, the Overall PI or designee may follow-up by telephone, fax, 
and/or monitoring visit to obtain additional case details deemed necessary to 
appropriately evaluate the SAE report (e.g., hospital discharge summary, 
consultant report, or autopsy report). 
8. PHARMACEUTICAL INFORMATION
A list of the adverse events and potential risks associated with the agents administered 
in this study can be found in the investigative drug brochure.
8.1
Pembrolizumab
8.1.1 Description
Pembrolizumab (MK-3475) is a humanized anti-PD-1 mAb of the IgG4/kappa 
isotype with a stabilizing S228P sequence alteration in the fragment crystallizable 
(Fc) region. MK-3475 binds to human PD-1 and blocks the interaction between 
PD-1 and its ligands. The theoretical molecular weight of the polypeptide is 
146,288 Da and its theoretical pI is 7.5. The parental murine anti-human PD-1 
antibody (hPD-1.09A) was produced by immunizing mice with hPD-1 DNA. The 
MK-3475 antibody was generated by humanization of the parental antibody by 
the Medical Research Council (Cambridge, UK) using complementarily-
determining region (CDR) grafting technology (U.S. Patent No. 5,225,539). The 
gene segments encoding the variable heavy and light chains of MK-3475, as well 
as human IgG4, were codon-optimized, synthesized, and ligated into a vector. 
A single expression plasmid, pAPD11V1-GA was constructed for the expression 
of both the heavy and light antibody chains of MK-3475. The nucleotide 
sequences encoding the heavy and light chains, along with their respective 

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promoters and poly A signal sequences have been confirmed by DNA sequence 
analysis. The pAPD11V1-GA expression vector was subsequently used to 
transfect CHO-DXB-11 cells for the development of the MK-3475-producing cell 
line.
The theoretical molecular weight of the polypeptide is 146,288 Da and its 
theoretical pI is 7.5. Pembrolizumab exhibits linear pharmacokinetics at dose 
levels of clinical relevance (1-10 mg/kg). It exhibits low clearance and limited 
volume of distribution that is typical for therapeutic antibodies. Mean estimated 
t1/2 values are 14.1-21.6 days.
The nomenclature of pembrolizumab is provided in the table below:
The nomenclature of pembrolizumab is provided in the table below:
Code Name 
MK 3475 (Anti-PD-1)
Other Code Name 
SCH 900475 (Anti-PD-1)
Chemical Name 
Humanized X PD-1_mAb (H409A11) IgG4
CAS Number
1374853-91-4
CAS Name
Anti-(human protein PDCD1 (programmed cell death 1))
immunoglobulin G4 (human-Mus musculus monoclonal heavy
chain) disulfide with human-Mus musculus monoclonal light
chain, dimer
Generic Name
Not available
Commercial Name
Pembrolizumab
8.1.2 Form
The investigator shall take responsibility for and shall take all steps to 
maintain appropriate records and ensure appropriate supply, storage, 
handling, distribution and usage of investigational product in accordance 
with the protocol and any applicable laws and regulations.
Pembrolizumab is supplied as a clear to opalescent solution that is 
essentially free of extraneous particles and may contain proteinaceous 
particulates. One dosage form of pembrolizumab will be provided by 
Merck in Type I glass vials intended for single use only as summarized in 
the following table:
Product Name & Potency
Dosage Form
Pembrolizumab 100 mg/ 4mL
Solution for Injection
Pembrolizumab solution for infusion is a sterile, non-pyrogenic, aqueous, 
preservative-free solution. Pembrolizumab solution for infusion contains 
an excess fill of 6.25 mg (equivalent to 0.25 mL solution) to ensure the 
recovery of label claim of 100 mg pembrolizumab per vial (equivalent to 

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4.0 mL of solution).
8.1.3 Storage and Stability
As specified in the Pharmacy Manual for pembrolizumab as provided by 
the Overall PI. 
Clinical supplies must be stored in a secure, limited-access location under 
the storage conditions specified on the label.  
8.1.4 Compatibility
The following infusion set materials are compatible with Pembrolizumab

PVC infusion set that is plasticized using Di-2-ethylhexyl 
Terephthalate DEHP 

PVC and tri-(2-ethylhexyl) trimellitate (TOTM) infusion set 

Polyethylene lined PVC infusion set 

Polyrethane 

Plybutadiene  A sterile, non-pyrogenic, low-protein binding 0.2 to 5 
μm in-line filter made of polyethersulfone (PES) or polysulfone must 
be used during administration to remove any adventitious particles. 
If the infusion set does not contain a 0.2 to 5 μm in-line filter, it is 
recommended to use a 0.2 to 5 μm add-on filter which may contain 
an extension line (the materials of the extension line and filter 
should be as mentioned above). 
A sterile, non-pyrogenic, low-protein binding 0.2 to 5 μm in-line filter made 
of polyethersulfone (PES) or polysulfone must be used during 
administration to remove any adventitious particles. If the infusion set 
does not contain a 0.2 to 5 μm in-line filter, it is recommended to use a 0.2 
to 5 μm add-on filter which may contain an extension line (the materials of 
the extension line and filter should be as mentioned above).
8.1.5 Handling
Receipt and dispensing of trial medication must be recorded by an authorized 
person at the trial site.
Clinical supplies may not be used for any purpose other than that stated in 
the protocol.

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8.1.6 Availability
Pembrolizumab will be supplied free-of-charge from Merck.
8.1.7 Administration
Pembrolizumab will be administered as a 30 minute IV infusion using an 
infusion pump (treatment cycle intervals may be increased due to toxicity as 
described in Section 6). Sites should make every effort to target infusion 
timing to be as close to 30 minutes as possible. However, given the variability 
of infusion pumps from site to site, a window of -5 minutes and +10 minutes is 
permitted (i.e., infusion time is 30 minutes: -5 min/+10 min). Attach the 
infusion line to the pump and prime the line, either with normal saline (at least 
25 mL) or with infusion solution as per local SOP, before starting the infusion. 
Maximum infusion rate should not exceed 6.7 ml/min through a peripheral or 
indwelling catheter. Use 30 mL normal saline to flush the infusion line at the 
end of the infusion if institutional guidelines allow.
Unused infusion solution should not be used for another infusion of the same 
participant or different participant.
DO NOT administer the product as an intravenous push or bolus.
DO NOT combine, dilute or administer it as an infusion with other medicinal 
products.
A central line is not required for Pembrolizumab administration, but may be 
used if available.
8.1.8 Ordering
Participating Institutions will order their own investigational agent 
(Pembrolizumab) directly from Merck using the Drug Supply Request Form. 
Please allow for 3 weeks for drug to arrive after the order is submitted. The 
Participating Institution will ensure that the pharmacy will be able to receive 
and store the agent according to state and federal guidelines. The local IRB 
should be kept informed of who will supply the agent (i.e., Merck 
pharmaceuticals Inc.) so that any regulatory responsibilities can be met in a 
timely fashion.
  
8.1.9 Accountability
The investigator is responsible for keeping accurate records of the clinical 
supplies received from Merck or designee, the amount dispensed to and 
returned by the subjects and the amount remaining at the conclusion of the 
trial. 

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8.1.10 Destruction and Return
Upon completion or termination of the study, all unused and/or partially used 
investigational product will be destroyed at the site per institutional policy. It is 
the Investigator’s responsibility to arrange for disposal of all empty containers, 
provided that procedures for proper disposal have been established 
according to applicable federal, state, local and institutional guidelines and 
procedures, and provided that appropriate records of disposal are kept.
8.2
Dabrafenib mesylate (GSK2118436B) (NSC 763760)
8.2.1 Chemical Name:  N-{3-[5-(2-Amino-4-pyrimidinyl)-2-(1,1-dimethylethyl)-1,3-
thiazol-4-yl]-2-fluorophenyl}-2,6-difluorobenzene sulfonamide, methanesulfonate 
salt
8.2.2 Other Names:  GSK2118436, GSK2118436A (free base), Tafinlar
8.2.3 Classification:  BRAF inhibitor
8.2.4 CAS Registry Number:  1195768-06-9
8.2.5 Molecular Formula:  C23H20F3N5O2S2 • CH4O3S
8.2.6 M.W.:  615.68 (mesylate salt)
8.2.7 Mode of Action:  Dabrafenib mesylate (GSK2118436B) is a potent and selective 
BRAF kinase inhibitor.  This inhibition suppresses downstream activity of pERK, 
a biomarker, and has antiproliferative activity against BRAF mutant tumors.  The 
mode of action is consistent with ATP-competitive inhibition.
8.2.8 How Supplied:  Dabrafenib mesylate (GSK2118436B) capsules will be supplied 
commercially.
•
50 mg capsule is Swedish orange, size 2 with markings of four black 
bars.
•
75 mg capsule is pink, size 1 with markings of four black bars.
Capsule excipients include microcrystalline cellulose, magnesium stearate 
(vegetable source), colloidal silicon dioxide.  Shell composition consists of 
an opaque hypromellose capsule, composed of red iron oxide (E172), 
titanium dioxide (E171), and hypromellose (E464).  Four black bars are 
printed on the hypromellose capsules using black ink.  The black ink 
contains black iron oxide (E172), shellac, propylene glycol, and 
ammonium hydroxide.

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8.2.9 Storage:  Store between 15°C to 30°C (59°F to 86°F).
8.2.10 Stability:  Shelf-life studies of dabrafenib mesylate (GSK2118436B) are ongoing.
8.2.11 Route of Administration:  Oral administration.  Take dabrafenib mesylate 
(GSK2118436B ) 1 hour prior or 2 hours after a meal.  If a dose is missed, it 
should not be taken if it is less than 6 hours until the next dose.
8.2.12 Potential Drug Interactions:  In vitro studies show that dabrafenib mesylate 
(GSK2118436B) induces CYP3A4, 2B6, 2C9,8, 2C9, and 2C19 enzymes.  Use 
caution in patients who are taking substrates that are metabolized in these 
enzyme pathways.
Dabrafenib mesylate (GSK2118436B) metabolism appears to be mediated 
by CYP3A4 and CYP2C8.  Use caution if strong inducers or inhibitors of 
CYP2C8 or 3A4 are co-administered with dabrafenib.
Patients should avoid ingesting the fruit or juice of Seville oranges, 
grapefruit, pummelos, exotic citrus fruits, or grapefruit hybrids for at least 
24 hours prior to the start of dosing because of inhibition of intestinal 
CYP3A4.
Dabrafenib solubility is pH-dependent and experiences decreased 
solubility at higher pH.  Use caution in patients who are taking drugs that 
elevate gastric pH due to the theoretical risk of decreasing oral 
bioavailability of dabrafenib.
8.2.13 Availability
Dabrafenib mesylate (GSK2118436B) is FDA-approved for the treatment 
of unresectable or metastatic BRAF-mutant melanoma. It will be used at 
its standard dose and schedule for its indicated purpose. Commercial 
dabrafenib will be used throughout the study and obtained from specialty 
pharmacies and with coverage provided by participant’s individual health 
insurance.
8.3
Trametinib dimethyl sulfoxide (GSK1120212B) (NSC 763093) 
8.3.1
Chemical Name (IUPAC): equimolecular combination of N-(3-{3-cyclopropyl-5-
[(2-fluoro-4-iodophenyl)amino]-6,8-dimethyl-2,4,7-trioxo-3,4,6,7-
tetrahydropyrido[4,3-d]pyrimidin-1(2H)-yl}phenyl)acetamide with 
(methylsulfinyl)methane
8.3.2 Other Names:  trametinib, GSK1120212, JTP-74057, JTP-78296, JTP-75303, 
Mekinist

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8.3.3 CAS Registry Number:  1187431-43-1
8.3.4 Classification:  MEK inhibitor
8.3.5 Molecular Formula:  C26H23FIN5O4 • C2H6OS
8.3.6 M.W.:  693.54 (dimethyl sulfoxide solvate), 615.41 (anhydrous parent)
8.3.7 Approximate Solubility:  Trametinib dimethyl sulfoxide is almost insoluble in 
water (<0.0001 mg/mL at 25° C)
8.3.8 Mode of Action:  Trametinib dimethyl sulfoxide is a reversible, highly selective, 
allosteric inhibitor of mitogen-activated extracellular signal regulated kinase 1 
(MEK1) and MEK2.  Tumor cells commonly have hyperactivated extracellular 
signal-related kinase (ERK) pathways in which MEK is a critical component.  
Trametinib dimethyl sulfoxide inhibits activation of MEK by RAF kinases and 
MEK kinases.
8.3.9 Description:  Trametinib dimethyl sulfoxide is a white to almost white powder.
8.3.10 How Supplied:  Tablets will be supplied commercially.
The tablet core contains mannitol, microcrystalline cellulose, 
hypromellose, croscarmellose sodium, magnesium stearate (non-animal), 
colloidal silicon dioxide, and sodium lauryl sulfate.
• 0.5 mg tablets are white or yellow, modified oval, biconvex and film-
coated. Aqueous film coating consists of Opadry Yellow 03B120006 
(hypromellose, titanium dioxide, polyethylene glycol, iron oxide yellow).
• 2 mg tablets are pink, round, biconvex and film-coated. Aqueous film 
coating consists of Opadry Pink YS-1-14762-A, hypromellose (titanium 
dioxide, polyethylene glycol, polysorbate 80, iron oxide red).
8.3.11 Storage:  Store tablets at 2°C - 8°C (36°F - 46°F) in the original bottle.  Bottles 
should be stored in the manufacturer’s package carton for light protection.  
Protect from moisture. For additional storage instructions, please refer to 
package insert. 
8.3.12 Stability:  Shelf life studies of trametinib dimethyl sulfoxide are ongoing.
8.3.13 Route of Administration:  Oral. Take by mouth on an empty stomach, either 1 
hour before or 2 hours after a meal. If a dose is missed, it should not be taken if it 
is less than 12 hours until the next dose.
8.3.14 Potential Drug Interactions

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In vitro studies suggest that trametinib dimethyl sulfoxide is not a substrate 
of CYP enzymes or of human Pgp, BCRP, OATP1B1 or OATP1B3 
transporters. 
Trametinib dimethyl sulfoxide is a weak CYP2C8 inhibitor and weak 
CYP3A4 inducer. Drug-drug interactions with sensitive substrates of 2C8 
and 3A4 are not anticipated. 
8.3.15 Availability
Trametinib dimethyl sulfoxide (GSK1120212B) is FDA-approved for the 
treatment of unresectable or metastatic BRAF-mutant melanoma.  It will 
be used at its standard dose and schedule for its indicated purpose. 
Commercial trametinib will be used throughout the study and obtained 
from specialty pharmacies and with coverage provided by participant’s 
individual health insurance. 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES
9.1
Collection of Specimen(s)
Tumor biopsies are required be performed in all patients for both cohorts at four 
time points (as all patients are enrolled onto the first Stage of the Simon 2-
stage design): 
1. Prior to commencing MTT
2. Following 2-week MTT lead-in
3. Following 6-weeks of combined pembrolizumab with MTT (if feasible)
4. A biopsy at the time of disease progression will also be performed (this is 
optional)
Multiple cores will be obtained and/or sufficient tumor excised at each biopsy 
time-point, assuming that it is safe to do so (e.g. patients with rapid responses 
may have very little tumor to biopsy safely at the latter time points).  Core 
biopsies or portions of the excised tumor will be processed with the following 
hierarchy in mind:
1. DNA/RNA/protein extraction
(Sullivan)
2. Disaggregation and flow cytometry
(Sharpe)
3. FFPE
(Sullivan)
4. Single-cell RNA seq of T cells
(Hacohen)
5. Single-cell RNA seq of tumor cells
(Sharpe)
Analysis will then be carried out to compare changes seen longitudinally and to 
determine if those changes are associated with improved outcomes to therapy 
with study treatment.  Most of this work will exploratory in nature, as analysis 

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such as the technology for single-cell sequencing of tumor and T-cells is 
emerging and no data is presently available to inform how these analyses might 
be used to help predict which patients are most likely to benefit from single-
agent or combination therapy.  However, based on previous work, there are two 
assays that will be incorporated into a predictive model, PD-L1 expression by 
immunohistochemistry (IHC) and immuno-sequencing (immunoSEQ) using the 
Adaptive Biotechnologies platform.
9.1.1 Handling of Specimens(s)
As described above, four cores will be obtained and fixed.  The SOP for 
collection, handling, and processing is attached (Appendix C). Samples 
will either be stored at the individual sites and sent in batch at the time of 
planned correlative study analysis or sent to and stored at the Sullivan 
Laboratory at MGH. FFPE samples will be stored at room temperature.  
Frozen samples will be stored in a -80 degree freezer.
9.1.2 Shipping of Specimen(s)
Samples may be sent at the time of collection or in batches via overnight 
shipping.  Frozen samples should be sent on dry ice; paraffin blocks may 
be sent at room temperature conditions.  Please email laboratory 
notification of shipment prior to sending. The address:
Sullivan/Flaherty Laboratory
c/o Michal Barzily, Ph.D.
55 Fruit Street; Jackson 9th Floor
Boston, MA 02114
Phone: 617-643-3614
Email: RSULLIVAN7@mgh.harvard.edu
Site(s) Performing Correlative Study  
All sites are expected to participate in these correlative studies.
9.2
PD-L1 Immunohistochemistry
Immunohistochemistry for PD-L1 and CD8 will be performed in Dr. Jeffrey 
Engelman’s laboratory using a monoclonal anti-PD-L1 antibody (Clone E1L3N, 
Cell Signaling Technologies; Danvers, MA) and a CD8 monoclonal antibody 
(4B11, RTU, Leica Biosystems, Buffalo Grove, IL), respectively, with an 
automated stainer (Bond Rx, Leica Microsystems, Buffalo Grove, IL).  As there 
is no recognized standard PD-L1 scoring protocol, we will define PD-L1 
positivity as membranous +/- cytoplasmic staining of tumor cells of any intensity 
using two different cut-offs (≥1% and ≥5 tumor cells) since both have been 
associated with clinical benefit to PD-1 pathway blockade in melanoma. 

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9.3
Adaptive Biotechnologies immunoSEQ
FFPE specimens (or isolated tumor DNA) and frozen PBMC samples will be 
shipped to Adaptive Biotechnologies. 
Samples sent to Adaptive will be handled in accordance with Adaptive SOPs.  
All arriving packages will be opened the same day they arrive and inspected 
thoroughly for correct labeling and packaging integrity.  Adaptive will perform 
“survey level” sequencing on each tissue sample and “deep level” sequencing 
on each of the PBMC derived gDNA samples provided.  As part of these 
analyses, Adaptive uses a proprietary assay for the amplification and massive 
parallel sequencing of millions of CDR3 regions in the T cell receptor beta gene 
(TCRB) using a multiplex PCR amplification across the VDJ junction of 
rearranged TCRB.
Using Adaptive’s unique capacity to perform next generation sequencing of T-
cell receptors for this study, a large amount of data will be generated using 
tissue specimens and PBMC samples from all collection time points. In addition 
to the immunoSEQ Analyzer software, which is available to all of Adaptive 
clients to aid in data analysis and visualization, Adaptive can directly involve its 
computational biology and biostatistics personnel in the data analysis.
9.4
Tumor Microenvironment Assessment
Tumor microenvironment assessment will be performed in collaboration with 
Dr. Arlene Sharpe.  At least two biopsies will be earmarked for this work and 
will be sent to Dr. Sharpe’s laboratory.
To determine how the tumor cells are modulated during MTT alone, anti-PD1 
plus MTT and anti-PD1 monotherapy combination, we will use single-cell and 
bulk RNA-seq, whole exome, etc. to assess the evolution of tumor cells during 
therapy. Sequential biopsies will provide a means to analyze evolution of tumor 
cell responsiveness and resistance to therapy
To determine how immune cells in the tumor microenvironment are modulated 
during MTT alone, anti-PD1 plus MTT and anti-PD1 monotherapy combination, 
we will use single-cell and bulk RNA-seq, and assays to compare immune cell 
function (e.g., T cell activation vs. exhaustion using cellular immunologic 
assays, as well as analysis of phosphoproteins and ubiquitination signaling) in 
temporal biopsies. These studies should reveal how anti-tumor immunity is 
modulated during the lead-in phase of the clinical trial with MTT, during MTT 
and anti-PD1 combination therapy and during subsequent anti-PD1 
monotherapy. 
9.5
Pharmacodynamic Studies

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9.5.1.1
MITF
Biopsies will be obtained in patients 
9.5.1.2
Blood-based BRAF assay
To explore the value of pretreatment BRAF level in predicting response to 
dabrafenib, trametinib, and Pembrolizumab, we will test isolated PBL and 
serum samples obtained prior to commencement of therapy.  RNA will 
then be isolated from PBL and serum and BRAFV600 analysis will be 
performed as described in Figure 2.4.1.  Quantitative analysis will be 
performed and levels will be reported in ng/uL.   Two categories of levels 
will be analyzed, based on our previous data, those with values >900 
ng/uL and  < 900 ng/uL.    
To explore the pharmacodynamic effects of dabrafenib, trametinib, and 
Pembrolizumab therapy on peripheral blood BRAFV600 mutation detection, 
we will serial test isolated PBL and serum samples. RNA will then be 
isolated from PBL and serum and BRAFV600 analysis will be performed as 
described in Figure 2.4.1.  Patients will have quantitative analysis before 
and baseline values will be in ng/uL. Peripheral blood will be drawn pre-
treatment, on Day 15 of the first cycle of treatment, and then on Day 1 of 
every subsequent cycle of therapy.  Pre- and on-treatment BRAFV600 
levels will be compared, and a blood-based response will be defined as a 
50% or more decrease in signal based on acrylamide gel analysis. A 
blood-based progression will be defined as a doubling in signal based 
compared with nadir level on acrylamide gel analysis. A comparison of 
blood-based response or progression (>50% improvement vs. < 50% 
improvement; or 100% increase vs. < 100% increase) with clinical 
response (CR/PR by RECIST1.1) and clinical progression (PD) will then 
be performed to assess concordance between changes over time with our 
assay and with imaging.
10.STUDY CALENDAR
Baseline evaluations are to be conducted within 2-weeks prior to start of protocol 
therapy. Scans must be done <4 weeks prior to the start of therapy.  All assessments 
must be performed prior to administration of any study medication. On days when TSH 
is required, TSH is not required to be resulted prior to administration of study 
medication. All study assessments and medications should be administered within + 3 
days of the protocol-specified date, unless otherwise noted.  Laboratory values do not 
need to re-meet eligibility criteria on Week 1, Day 1.

87
Targeted 
Therapy 
Lead-In
Combined Targeted 
Therapy plus Immune 
Therapy
Single-agent pembrolizumab
Pre- Study 
-14 to -1 
days
Wk 1
Wk 2
Wk 3
Wk  6
Wk 9
Wk 12
Wk 15
Wk 18
Wk 21
Wk 
24
Wk 27-107
Off-
Studym
Follow 
Up
 Dabrafeniba
 X------------------------------------------------------------X                                - - - - - - - - - - - - - - - - - - - - - - - - 
-  
- - - - - - - -
 Trametiniba
X-------------------------------------------------------------X                                 - - -  - - - - - - - - - - - - - - - - - - - - 
- 
- - - - - - - -
 Pembro
X
X
X
X
X
X
X
X
Xl
Informed consent
X
Historyb
X
X
X
X
X
X
X
X
X
X
X
Dermatology Examc
X
X
Ophthalmology Examd
X
X
Concurrent meds
X
X----------------------------------------------------------------------------------------------------------------------------X
X
Physical exam (Wt, BSAn, 
VSo)
X
X
X
X
X
X
X
X
X
X
        X
X
Height
X
ECGe
X
X
X
Performance Status
X
X
X
X
X
X
X
X
X
X
X
X
CBC w/diff, plts
X
X
X
X
X
X
X
X
X
X
X
X
Serum chemistryf
X
X
X
X
X
X
X
X
X
X
X
X
TSH
X
X
X
X
X
Xf
Adverse event evaluationP
X----------------------------------------------------------------------------------------------------------------------------X
X
XP
XP
Radiologic evaluationg
X
X
X
X
X
Xr
B-HCGh
X
X
X
X
X
X
X
Echo/MUGAi
X
X

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a.
MAPK targeted therapy (MTT): In cohort 1, participants will be treated with the combination of dabrafenib and trametinib. In 
cohort 2, participants will be treated with trametinib.  MTT will commence week 1, day 1 and be given continuously (except in the 
setting of toxicity) for two weeks in the lead-in phase and then 6-weeks in combination with pembrolizumab.  Only if patients 
develop symptomatic or radiographic progression at anytime AFTER initial MTT-phase completion, then MTT may be resumed at 
a previously tolerated dose in combination with ongoing pembrolizumab.  
b.
Participants will be seen on day 1 (+/-3 days) of week 1, week 3, and then every three weeks while remaining on therapy.  If 
treatment is discontinued for a reason other than disease progression, study discontinuation, or withdrawal of consent, patients 
will be seen every 12 weeks (+/- 2 weeks).
c.
Dermatological examination done at screening, and within 1 week prior to dosing on week 9. A full-body skin examination and 
removal of pre-existing calluses and keratotic skin is recommended prior to initiation of study treatment (See Table 6-4).
d.
Ophthalmological examination done at screening and within 1 week prior to treatment on week 9. For Grade 2 visual changes or 
greater, an exam must occur within 24 hours of onset (or study team knowledge of the event). Consult ophthalmologist any time 
when patient reports visual disturbance.  If there is visual loss or significant visual changes, consult ophthalmologist immediately 
(within 24 hours)
e.
Single EKG will be collected at screening and repeated on day 1 of weeks 3 and 6 in cohort 1.
f.
Albumin, alkaline phosphatase, total bilirubin, BUN, creatinine, calcium, chloride, glucose, HCO3, LDH, phosphorus, potassium, 
total protein, SGOT   [AST], SGPT [ALT], sodium.  TSH will be performed at baseline, week 3 and then every 6 weeks.
g.
Radiographic imaging will be performed within 4 weeks of lead-in therapy commencement, within 1 week prior to Week 9, every 
six weeks thereafter (within 1 week prior to W15, W21, W27) until week 27, and then every 12 weeks (+/- 2 weeks) through 48 
weeks of pembrolizumab therapy. Additionally, following initial disease progression, if a participant is treated beyond progression, 
tumor assessments must be repeated > 4 weeks after initial disease progression in order to confirm disease progression. The 
tumor assessment must not be repeated any sooner than 4 weeks after initial disease progression.
h.
Serum pregnancy test (women of childbearing potential).
i.
Ejection fraction measurement done at screening and within 1 week prior to dosing on week 9 .  The same modality (ECHO or 
MUGA) should be used at baseline and at follow-up; should be performed with increased frequency if clinically indicated.
BRAFj
X
X
X
X
X
X
X
X
X
Xj
PBMCk
X
X
X
(X)
Tumor Biopsiesk
X
X
X
(X)
Rash Prophylaxisq 
X q
X q
X q
X q

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CONFIDENTIAL
This document is confidential. Do not disclose or use except as authorized.
89
j.
Correlative blood analysis will be performed prior to MTT, prior to pembrolizumab therapy initiation, prior to every pembrolizumab 
dose through week 27, prior to every other pembrolizumab dose after week 27 (week 33, week 39, etc.), and at time of disease 
progression. BRAF samples will be collected in 1-10 mL green sodium heparin and 1-10 mL red top serum tubes
k.
Tumor biopsies and PBMC blood analysiswill be performed pretreatment, prior to pembrolizumab therapy initiation (up to 5 days 
prior), at the conclusion of combined targeted therapy plus pembrolizumab therapy (up to 5 days prior), and then at the time of 
disease progression. PBMC samples will be collected in 2-8 mL blue tiger top CPT tubes. 
l.
Pembrolizumab will be administered at a dose of 200 mg IV every three weeks.
m. Off-study evaluation visit is completed within 30 days after the last dose of study medication. If treatment is discontinued for a 
reason other than completion of two years of pembrolizumab, disease progression or withdrawal of consent, patients will be seen 
every 12 weeks (+/- 2 weeks) with imaging performed prior to these evaluations.  If patients have an ongoing response or stable 
disease 18 months  (+/- 2 months) after their last dose of pembrolizumab, patients will be followed every three-twelve months, 
based on investigator discretion, with imaging performed every 3-12 months.
n.
BSA should be calculated using the baseline height.
o.
Vitals signs include pulse, body temperature, blood pressure (BP), and respiratory rate. In subjects with an initial BP reading 
within the hypertensive range, a second reading should be taken at least 1 minute later per Section 6.2.8BRAD
p.
Adverse Event Reporting: All adverse events, both serious and non-serious, will be collected from the time of the first dose of 
study treatment up until 90 days after the last dose of study treatment, or until death if death occurs first. The adverse events are 
followed to their resolution, or until the participating investigator assesses them as stable, or the participating investigator 
determines the event to be irreversible, or the participant is lost to follow-up. If the subject is not seen in clinic after the off-study 
visit, required Adverse Event details must be collected over the phone. 
q.
Rash prophylaxis is recommended for the first 6 weeks of study treatment. See Table 6-3.
r.
If treatment is discontinued for a reason other than disease progression, study discontinuation, or withdrawal of consent, 
participants will be seen every 12 weeks (+/- 2 weeks) for imaging until progressive disease or death, whichever comes first.

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11.MEASUREMENT OF EFFECT
Although response is not the primary endpoint of this trial, participants with 
measurable and/or non-measurable disease will be assessed by RECIST 1.1. 
11.1
Antitumor Effect – Solid Tumors
Radiographic imaging will be performed within 4 weeks of lead-in therapy 
commencement, within 1 week prior to Week 9, every six weeks thereafter 
(within 1 week prior to W15, W21, W27) until week 27, and then every 12 
weeks (+/- 2 weeks) through 48 weeks of pembrolizumab therapy.
In addition to a baseline scan, confirmatory scans should also be obtained 
not less than 4 weeks following initial documentation of objective response.
If treatment is discontinued for completion of two years of pembrolizumab, or 
for a reason other than disease progression or withdrawal of consent, 
patients will be seen every 12 weeks (+/- 2 weeks) with imaging performed 
within 2 weeks prior to these evaluations.
Response and progression will be evaluated in this study using the new 
international criteria proposed by the Response Evaluation Criteria in Solid 
Tumors (RECIST) 1.1 guideline. (Eisenhauer et al., 2009).  Changes in 
the diameter (unidimensional measurement) of the tumor lesions are used 
in the RECIST criteria.
11.1.1 Definitions
Evaluable for Target Disease response.  Only those participants who have 
measurable disease 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. 
11.1.2 Disease Parameters
Measurable disease.  Measurable lesions are defined as those that can be 

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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 might or 
might not be 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 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 

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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. 
11.1.3 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 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 

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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 assessment to the next. If new lesions 
are identified by ultrasound in the course of the study, confirmation by CT or MRI 

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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.
11.1.4 Response Criteria
11.1.4.1
Evaluation of Target Lesions
Complete Response (CR):  Disappearance of all target lesions.  Any 
pathological lymph nodes (whether target or non-target) must have reduction 
in short axis to <10 mm.
Partial Response (PR):  At least a 30% decrease in the sum of the diameters 
of target lesions, taking as reference the baseline sum diameters.
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 

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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.
11.1.4.2
Evaluation of Non-Target Lesions
Complete Response (CR):  Disappearance of all non-target lesions and 
normalization of tumor marker level.  All lymph nodes must be non-
pathological in size (<10 mm short axis).
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response.
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits.
Progressive Disease (PD):  Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions.  Unequivocal 
progression should not normally trump target lesion status.  It must be 
representative of overall disease status change, not a single lesion increase.    
Although a clear progression of “non-target” lesions only is exceptional, the 
opinion of the treating physician should prevail in such circumstances, and 
the progression status should be confirmed at a later time by the review panel 
(or Principal Investigator).
11.1.4.3
Evaluation of New Lesions
The finding of a new lesion should be unequivocal (i.e. not due to difference 
in scanning technique, imaging modality, or findings thought to represent 
something other than tumor (for example, some ‘new’ bone lesions may be 
simply healing or flare of pre-existing lesions). However, a lesion identified on 
a follow-up scan in an anatomical location that was not scanned at baseline is 
considered new and will indicate PD. If a new lesion is equivocal (because of 
small size etc.), follow-up evaluation will clarify if it truly represents new 
disease and if PD is confirmed, progression should be declared using the 
date of the initial scan on which the lesion was discovered.
11.1.4.4
Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the 
treatment until disease progression/recurrence (taking as reference for 
progressive disease the smallest measurements recorded since the treatment 
started).  The patient's best response assignment will depend on the 

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achievement of both measurement and confirmation criteria.
For Participants with Measurable Disease (i.e., Target Disease)
Target 
Lesions
Non-Target 
Lesions
New 
Lesions
Overall 
Response
Best Overall Response 
when Confirmation is 
Required*
CR
CR
No
CR
>4 wks Confirmation**
CR
Non-CR/Non-
PD
No
PR
CR
Not evaluated
No
PR
PR
Non-CR/Non-
PD/not 
evaluated
No
PR
>4 wks Confirmation**
SD
Non-CR/Non-
PD/not 
evaluated
No
SD
Documented at least once 
>4 wks from baseline**
PD
Any
Yes or No
PD
Any
PD***
Yes or No
PD
Any
Any
Yes
PD
no prior SD, PR or CR

See RECIST 1.1 manuscript for further details on what is evidence of a new 
lesion.
**        Only for non-randomized trials with response as primary endpoint.
***      In exceptional circumstances, unequivocal progression in non-target lesions 
may be
            accepted as disease progression.
Note:  Participants with a global deterioration of health status requiring discontinuation 
of treatment without objective evidence of disease progression at that time 
should be reported as “symptomatic deterioration.”  Every effort should be made 
to document the objective progression even after discontinuation of treatment.
For Participants with Non-Measurable Disease (i.e., Non-Target Disease)
Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD

‘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
11.1.5 Duration of Response

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Duration of overall response:  The duration of overall response is measured from 
the time measurement criteria are met for CR or PR (whichever is first recorded) 
until the first date that recurrent or progressive disease is objectively documented 
(taking as reference for progressive disease the smallest measurements 
recorded since the treatment started, or death due to any cause. Participants 
without events reported are censored at the last disease evaluation).
Duration of overall complete response: The duration of overall CR is measured 
from the time measurement criteria are first met for CR until the first date that 
progressive disease is objectively documented, or death due to any cause. 
Participants without events reported are censored at the last disease evaluation.
Duration of stable disease:  Stable disease is measured from the start of the 
treatment until the criteria for progression are met, taking as reference the 
smallest measurements recorded since the treatment started, including the 
baseline measurements. 
11.1.6 Progression-Free Survival
Overall Survival: Overall Survival (OS) is defined as the time from randomization 
(or registration) to death due to any cause, or censored at date last known alive.
Progression-Free Survival: Progression-Free Survival (PFS) is defined as the 
time from randomization (or registration) to the earlier of progression or death 
due to any cause. Participants alive without disease progression are censored at 
date of last disease evaluation.
Time to Progression: Time to Progression (TTP) is defined as the time from 
randomization (or registration) to progression, or censored at date of last disease 
evaluation for those without progression reported.
11.1.7 Response Review
Independent, central review of the radiology assessment will be performed 
by through the Dana Farber Harvard Cancer Center Tumor Imaging 
Metrics Core (TIMC). 

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12.DATA REPORTING / REGULATORY REQUIREMENTS
Adverse event lists, guidelines, and instructions for AE reporting can be found in 
Section 7 (Adverse Events: List and Reporting Requirements).
12.1
Data Reporting
12.1.1 Method
The ODQ will collect, manage, and perform quality checks on the data for this 
study.
Note:  If your study has been assigned to CDUS-Complete reporting, all adverse 
events (both routine and expedited) that have occurred on the study and meet 
the mandatory CDUS reporting guidelines must be reported via the monitoring 
method identified above.  If your study has been assigned to CDUS-Abbreviated 
reporting, no adverse event reporting (routine or expedited) is required to be 
reported via CDUS.
12.1.2 Responsibility for Data Submission
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data 
and/or data forms to the ODQ according to the schedule set by the ODQ.
For CDUS and CMTS submissions:  
Participant institutions are responsible for submitting CDUS data and/or data 
forms to either the Coordinating Center or to the Lead Organization on the study 
quarterly.  The date for submission to the Coordinating Center or to the Lead 
Organization will be set by them.  CDUS does not accept data submissions from 
the participant institutions on the study.  When setting the dates, allow time for 
Coordinating Center compilation, Overall PI review, and timely submission to 
CTEP by the quarterly deadlines.  For trials monitored by CTMS, a quarterly 
report of data will be provided by Theradex to the Coordinating Center.
Either the Coordinating Center or the Lead Organization is responsible for 
compiling and submitting CDUS data to CTEP for all participant institutions and 
for providing the data to the Overall PI for review.  
12.2
Data Safety Monitoring
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 

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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. 
12.3
Regulatory Considerations 
12.3.1 Protocol Review and Amendments
This protocol, the proposed informed consent and all forms of participant 
information related to the study (e.g., advertisements used to recruit 
participants) and any other necessary documents must be submitted, 
reviewed and approved by a properly constituted IRB governing each study 
location. 
Any changes made to the protocol must be agreed upon by the DFHCC 
Overall Principal Investigator, shall be submitted as amendments, and must 
be approved by the IRB prior to implementation. Any changes in study 
conduct must be reported to the IRB. The DF/HCC Overall Principal 
Investigator (or Protocol Chair) will disseminate protocol amendment 
information to all participating investigators. 
All decisions of the IRB concerning the conduct of the study must be made 
in writing.
12.3.2 Informed Consent
All participants must be provided a consent form describing this study and 
providing sufficient information for participants to make an informed decision 
about their participation in this study. The formal consent of a participant, using 
the IRB approved consent form, must be obtained before the participant is 
involved in any study-related procedure. The consent form must be signed and 
dated by the participant or the participant’s legally authorized representative, 
and by the person obtaining the consent. The participant must be given a copy 
of the signed and dated consent document. The original signed copy of the 
consent document must be retained in the medical record or research file. 

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12.3.3 Ethics and Good Clinical Practice (GCP)
This study is to be conducted according to the following considerations, 
which represent good and sound research practice:

E6 Good Clinical Practice: Consolidated Guidance 
www.fda.gov/downloads/RegulatoryInformation/Guidances/UCM12951
5.pdf 

US Code of Federal Regulations (CFR) governing clinical study 
conduct and ethical principles that have their origin in the Declaration 
of Helsinki
o
Title 21 Part 11 – Electronic Records; Electronic Signatures 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr11_02.html
o
Title 21 Part 50 – Protection of Human Subjects 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr50_02.html 
o
Title 21 Part 54 – Financial Disclosure by Clinical 
Investigators 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr54_02.html 
o
Title 21 Part 56 – Institutional Review Boards 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr56_02.html 
o
Title 21 Part 312 – Investigational New Drug Application 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr312_02.html 

State laws

DF/HCC research policies and procedures        
http://www.dfhcc.harvard.edu/clinical-research-support/clinical-
research-unit-cru/policies-and-procedures/ 
It is understood that deviations from the protocol should be avoided, except 
when necessary to eliminate an immediate hazard to a research participant. 
In such case, the deviation must be reported to the IRB according to the 
local reporting policy. 
12.4
Study Documentation
The investigator must prepare and maintain adequate and accurate case 
histories designed to record all observations and other data pertinent to the 
study for each research participant. This information enables the study to be 
fully documented and the study data to be subsequently verified.

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Original source documents supporting entries in the case report forms include 
but are not limited to hospital records, clinical charts, laboratory and pharmacy 
records, recorded data from automated instruments, microfiches, photographic 
negatives, microfilm or magnetic media, and/or x-rays. 
12.5
Records Retention
All study-related documents must be retained for the maximum period 
required by applicable federal regulations and guidelines or institutional 
policies. 
13.STATISTICAL CONSIDERATIONS
This is a phase II trial to assess the effect of adding an abbreviated MAPK-targeted 
therapy to pembrolizumab in patients with unresectable or metastatic melanoma.  
Two cohorts of patients will be enrolled and analyzed separately: Patients with 
BRAFV600 mutant melanoma, and patients with BRAFV600 wild-type melanoma. The 
trial will be based on parallel Simon two-stage designs according to disease cohort and 
will provide preliminary estimates of toxicity and efficacy.  
13.1
Study Design/Endpoints
Primary Endpoint:  The rate of clinical benefit (CBR), defined as the proportion of 
patients who have CR/PR/SD at the week-24 scan while remaining off MAPK-targeted 
therapy (MTT) after induction.  To be evaluable for the primary endpoint, patients must 
receive at least one dose of pembrolizumab, any patient who is unevaluable for 
response will be classified as a non-responder.
Secondary Endpoints:
13.1.1 Overall Survival (OS):  The time between the first dose of targeted therapy and 
death from any cause.  For patients who are lost to follow-up or who have no 
documentation of death at the time of final analysis, follow-up will be censored at 
the date of last assessment of vital status.
13.1.2 Safety and tolerability:  Safety and toxicity will be monitored throughout the study.  
An early, comprehensive safety review will be conducted at the end of the first-
stage of the Simon two-stage design to review the data for unexpected severe 
toxicities due to the drug combination.
13.1.3 Describe temporal changes in the tumor microenvironment as a function of 
therapy.
Design:  For each disease cohort, the Simon two-stage design is based on a type-I 
error rate of 0.1, at least 85% power, and a total sample size of 25 subjects.  A 
complete safety assessment is planned to coincide with the review of clinical benefit at 
the end of the first stage.  
Within cohort, the null hypothesis of a true CBR of 0.50 will be tested against a one-

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sided alternative CBR of 0.75.  The benchmark CBR rate of 0.50 is based on the results 
of the Keynote 001 trial in patients with refractory or first-line malignant melanoma 
treated with pembrolizumab (Robert, ASCO 2016) that reported a CBR of 0.51 
regardless of BRAF mutation status. A short course of MAPK-targeted therapy in 
addition to pembrolizumab would be considered worthy of further investigation if there is 
evidence of an improvement in CBR to 0.75.  Fourteen (14) subjects that are evaluable 
for 
the 
primary 
endpoint 
(defined 
as 
receiving 
at 
least 
1 
dose 
of 
dabrafenib/trametinib/pembrolizumab 
combination 
therapy 
prior 
to 
treatment 
discontinuation for any reason.) will be enrolled in the first stage.  If 8 or fewer subjects 
with clinical benefit are observed, enrollment will stop. If there are 9 or more subjects 
with clinical benefit, then an additional 11 subjects will be enrolled for a total of 25. The 
null hypothesis will be rejected if 16 or more subjects with clinical benefit are observed 
in 25 subjects. This design yields power of 86% (target type II error of 0.15) when the 
CBR rate is 0.75.  If the null hypothesis is true, the probability is 0.79 that enrollment to 
a cohort will stop at the end of the first stage.  This high probability of stopping under the 
null was chosen to require strong evidence of benefit before opening the second stage.
13.2
Sample Size, Accrual Rate and Study Duration
The total sample size for this study is 50 patients (25 patients per cohort).  At an 
anticipated accrual rate of 2 patients per month, enrollment is expected to be completed 
in approximately two years.
13.3
Analysis of Primary Endpoints
Clinical benefit rates will be presented for each cohort with 90% confidence intervals 
based on the method of Atkinson and Brown, which allows for the two-stage design.  
For samples of size 25, each confidence interval will be no wider than 0.35.
13.4
Analysis of Secondary Endpoints
PFS and OS: The distributions of secondary endpoints of PFS and OS will be based on 
the method of Kaplan-Meier. Medians of the distributions of PFS and OS will be 
estimated and presented with 90% confidence intervals based on log(-log(endpoint)) 
methodology.  One-year estimates of OS will also be presented using the same 
methods. 
Early Safety Review:  An early, comprehensive safety review will occur at the end of the 
first stage of the Simon two-stage design and will take place when one cohort has 
reached the end of its respective first stage according to the Simon design. Since we do 
not anticipate that adverse events will differ according to BRAF mutation status, all 
available safety data will be combined from the two cohorts, resulting in an early safety 
review for up to 28 patients. All reported AEs will be summarized. 
For a sample of 28 patients, there is high probability of observing at least one event if a 
toxicity has an incidence of at least 5%. If the true incidence of an unexpected or severe 

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toxicity is 5% or greater, the probability is at least 0.75 that one or more patients out of 
28 will experience the toxicity during the early safety monitoring period. If the true 
incidence of unexpected or severe toxicity is 1% or less, the probability is 0.25 or less 
that at least one patient of 28 will experience the toxicity during the early safety 
monitoring period. 0 summarizes the probabilities of observing at least one patient with 
a severe or unexpected toxicity during the initial safety review for a range of true 
incidence rates.
Table 13.1. 
Operating Characteristics of Early Safety Monitoring
True Incidence of Unexpected or Severe 
Toxicity
Probability of Observing One or More 
Patients with Toxicity among First 28
1%
0.25 
3%
0.57 
5%
0.76 
8%
0.90 
9%
0.93 
10%
0.95 
15%
0.99 
13.5
Analysis of Correlative Measures
Analysis of MTT induced changes on T-cell clonality / PDL1 expression and 
correlation with clinical benefit.  To investigate whether MTT-associated changes 
following a brief course of MTT can predict who will benefit from the addition of 
anti-PD1 therapy, assessments will be based on: (a) clonality of tumor-infiltration 
lymphocytes (TILs), and (b) PD-L1 IHC. TIL clonality is a term used to quantify 
the diversity of clones and frequency of any given clone.  It is calculated by 
ImmunoSeq Adaptive Biotechnologies software using a clonality score, defined 
as [1-(entropy)/log2(# of productive unique sequences)], where the entropy term 
takes into account the varying clone frequencies of TILs.  A maximally diverse 
population, where every sequence is represented one time, is associated with a 
clonality score of zero, and a perfectly monoclonal population with a clonality 
score of one.  Assessment times will be pre-treatment and after the 2-week MTT 
lead-in. Each cohort will be investigated separately.  
To investigate the hypothesis that there will be an increase in TIL clonality after 
MTT lead-in, the overall changes in clonality of TILs after MTT will be expressed 
as a fold-change (2-week/pre) and compared with unity using a Wilcoxon signed-
rank test with 80% power, and a 0.1, two-sided significance level.  For a range of 
standard deviations of the fold-change between 0.8 and 1.2, we will be able to 
detect effect sizes between 1.4 and 1.65 for this comparison.  We will further 
refine this question to address whether increases in clonality are related to 
response. Clones that comprise the largest percentage of the total T-cell 
population after MTT lead-in will be identified and sorted by frequency.  The 
percentage of the overall T-cell population included in the top 5% of clones will 

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be compared according to response (achieving/not achieving clinical benefit) 
using Wilcoxon rank-sum tests.  If the observed CBR is 0.75, resulting in 19 
patients with clinical benefit and 6 without, a Wilcoxon rank-sum test with 0.1, 
two-sided significance level will have 80% power to detect a difference in 
percentage T-cells that is approximately 1.3 times the common standard 
deviation.  Similar analyses will be performed for the top 2.5% or 1% of clones.
To assess if changes in clonality after MTT lead-in are associated with infiltration 
by new TIL clones, we will compare pre-treatment and post-MTT biopsies to 
identify clones that were absent from the pre-treatment biopsies, and summarize 
the percentage of individual clones that were identified to be new.  This will be 
assessed for all patients in a cohort using Wilcoxon signed-rank tests, and 
according to clinical response using Wilcoxon rank-sum tests.   In additional 
analyses, the percentage of pre-existing clones, rather than new clones, will be 
compared according to response to see if patients with high proportions of pre-
existing clones after MTT lead-in exhibit a better response than patients with low 
proportions.
For PD-L1 expression, patients will be classified, retrospectively, into two 
subgroups defined by clinical benefit at 24 weeks.  Fold-changes in PD-L1 IHC 
(2-week/pre) will be compared for patients achieving/not achieving clinical benefit 
using Wilcoxon rank-sum tests.  If the observed CBR is 0.75, resulting in group 
sizes of 19 and 6, a Wilcoxon rank-sum test with 0.1, two-sided significance level 
will have 80% power to detect a difference in fold-changes that is approximately 
1.3 times the common standard deviation.
  
13.6
Analysis of Safety and Toxicity Data 
Analysis set and grouping for the analyses:  All patients who receive one or 
more doses of the drug combination will be included in the safety analysis. All 
listings and tables will be presented by treatment.
Adverse events (AEs):  All adverse events recorded during the study will be 
summarized. The incidence of treatment-emergent adverse events will be 
summarized by treatment according to primary system organ class, severity 
based on the National Cancer Institute’s Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0, type of adverse event, and relationship to 
treatment. Deaths reportable as SAEs and non-fatal serious adverse events will 
be listed by patient and tabulated by primary system organ class, type of adverse 
event, and dose level.
Laboratory abnormalities:  All laboratory values will be converted into SI units, 
as appropriate, and the severity grade calculated using CTCAE, version 4.0.  
Parameters for which a grading does not exist will be classified into 
low/normal/high group by means of laboratory normal ranges. For each 
laboratory test (e.g., hematology, biochemistry) a listing of laboratory values will 

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be provided by laboratory parameter, patient and treatment group. The frequency 
of notable lab abnormalities (i.e., newly occurring CTCAE grade-3 or -4 
laboratory toxicities), will be displayed by parameter, cycle, and dose level. 
Similarly, the frequency of all laboratory abnormalities will be displayed by 
parameter, worst CTCAE version 4.0 grade experienced and dose level. A 
separate listing will display notable laboratory abnormalities (i.e., newly occurring 
CTCAE grade-3 or -4 laboratory toxicities). Laboratory data will be summarized 
by presenting grade shift tables for those parameters for which CTCAE version 
4.0 allows classification. All remaining data will be summarized by presenting 
shift tables based on normal ranges.
Laboratory data will be also be displayed by presenting summary statistics of raw 
data and change from baseline values (means, medians, standard deviations, 
ranges).
13.7
Reporting and Exclusions
13.7.1 Evaluation of Toxicity
Evaluation of toxicity. Define “evaluable.” For example: All participants will be 
evaluable for toxicity from the time of their first treatment.
13.7.2 Evaluation of the Primary Efficacy Endpoint
Evaluation of response.  All participants included in the study must be 
assessed for response to treatment, even if there are major protocol treatment 
deviations or if they are ineligible. Each participant should be assigned one of the 
following categories: 1) complete response, 2) partial response, 3) stable 
disease, 4) progressive disease, 5) early death from malignant disease, 6) early 
death from toxicity, 7) early death because of other cause, or 9) unknown (not 
assessable, insufficient data). By arbitrary convention, category 9 usually 
designates the "unknown" status of any type of data in a clinical database.
             
All of the participants who met the eligibility criteria (with the possible exception of 
those who did not receive triplet therapy) should be included in the main analysis 
of the response rate. Participants in response categories 4-9 should be 
considered to have a treatment failure (disease progression). Thus, an 
incorrect treatment schedule or drug administration does not result in 
exclusion from the analysis of the response rate. Precise definitions for 
categories 4-9, and sometimes category 3, will be protocol specific.
All conclusions should be based on all eligible participants. Subanalyses 
may then be performed on the basis of a subset of participants, excluding those 
for whom major protocol deviations have been identified (e.g., early death due to 
other reasons, early discontinuation of treatment, major protocol violations, etc.). 
However, these subanalyses may not serve as the basis for drawing conclusions 

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concerning treatment efficacy, and the reasons for excluding participants from the 
analysis should be clearly reported. The 95% confidence intervals should also be 
provided.
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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REFERENCES
Divito, K. A., Charette, L. A., Rimm, D. L., and Camp, R. L. (2004). Long-term 
preservation of antigenicity on tissue microarrays. Lab Invest 84, 1071-8.
Fergenbaum, J. H., Garcia-Closas, M., Hewitt, S. M., Lissowska, J., Sakoda, L. C., and 
Sherman, M. E. (2004). Loss of antigenicity in stored sections of breast cancer 
tissue microarrays. Cancer Epidemiol Biomarkers Prev 13, 667-72.
Hewitt, S. M., Lewis, F. A., Cao, Y., Conrad, R. C., Cronin, M., Danenberg, K. D., 
Goralski, T. J., Langmore, J. P., Raja, R. G., Williams, P. M., et al. (2008). Tissue 
handling and specimen preparation in surgical pathology: issues concerning the 
recovery of nucleic acids from formalin-fixed, paraffin-embedded tissue. Arch 
Pathol Lab Med 132, 1929-35.
Research, N. C. I. O. O. B. a. B. (2007). National Cancer Institute Best Practices for 
Biospecimen Resources 
Riss, J., Khanna, C., Koo, S., Chandramouli, G. V., Yang, H. H., Hu, Y., Kleiner, D. E., 
Rosenwald, A., Schaefer, C. F., Ben-Sasson, S. A., et al. (2006). Cancers as 
wounds that do not heal: differences and similarities between renal 
regeneration/repair and renal cell carcinoma. Cancer Res 66, 7216-24.
Singh, B. (2007). Initial pathology assessment prior to preoperative therapy. In 
Preoperative Therapy in Invasive Breast Cancer: Reviewing the State of the 
Science and Exploring New Research Directions,  (Bethesda, Maryland).

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

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APPENDIX B:  INFORMATION ON POSSIBLE DRUG INTERACTIONS
Information on Possible Interactions with Other Agents for Patients and Their 
Caregivers and Non-Study Healthcare Team
The patient ____________________________ is enrolled on a clinical trial using the 
experimental agents, Dabrafenib plus Trametinib dimethyl sulfoxide or trametinib 
dimethyl sulfoxide.  This clinical trial is sponsored by the Dana Farber Harvard Cancer 
Center.  This form is addressed to the patient, but includes important information for 
others who care for this patient. 
Dabrafenib mesylate and trametinib dimethyl sulfoxide interact with many drugs that are 
processed by your liver.  Because of this, it is very important to tell your study doctors 
about all of your medicine before you start this study.  It is also very important to tell 
them if you stop taking any regular medicine, or if you start taking a new medicine while 
you take part in this study.  When you talk about your medicine with your study doctor, 
include medicine you buy without a prescription at the drug store (over-the-counter 
remedy), or herbal supplements such as St. John’s wort. 
Many health care prescribers can write prescriptions.  You must also tell your other 
prescribers (doctors, physicians’ assistants or nurse practitioners) that you are taking 
part in a clinical trial. Bring this paper with you and keep the attached information 
card in your wallet.  These are the things that you and they need to know: 
Dabrafenib mesylate interacts with certain specific enzymes in your liver. 
The enzymes in question are CYP450 3A4, 2C8, 2C9, 2C19, 2B6.  Dabrafenib 
mesylate levels are affected by some of these enzymes and can lower the levels of 
other medicines you take.
Dabrafenib mesylate must be used very carefully with other medicines that need 
these liver enzymes to be effective or to be cleared from your system.
Other medicines may also affect the activity of the enzyme.
o
Substances that increase the enzyme’s activity (“inducers”) could reduce 
the effectiveness of the drug, while substances that decrease the 
enzyme’s activity (“inhibitors”) could result in high levels of the active drug, 
increasing the chance of harmful side effects.  Dabrafenib mesylate 
should not be taken with any other drugs that are strong inducers or 
inhibitors of CYP 3A4 or 2C8.  Prohibited medications include azole 
antifungals, some antiepileptic drugs, some antibiotics and some 
immunosuppressants.  Please check with the study investigator before 
prescribing or dispensing strong inhibitors/inducers of CYP 3A4 or 2C8. 
Mild/moderate inhibitors/inducers should be used with caution.
o
Dabrafenib mesylate is considered an inducer of CYP 3A4, CYP2C8/9, 
2B6 and possibly 2C19 , meaning that it can decrease the levels of other 
drugs that are processed by these enzymes.  This can lead to harmful 

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side effects and/or reduce the effectiveness of those medications.   
You and healthcare providers who prescribe drugs for you must be careful about 
adding or removing any drug in this category.
Before you start the study, your study doctor will work with your regular prescriber 
to switch any prohibited medicines that are considered “strong inducers/inhibitors 
or substrates of CYP 3A4 and 2C8.”
Your prescribers should look at this web site 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx
 or consult a medical reference to see if any medicine they want to prescribe is on 
a list of drugs to avoid.
Please be very careful!  Over-the-counter drugs have a brand name on the label—
it’s usually big and catches your eye.  They also have a generic name—it’s 
usually small and located above or below the brand name, and printed in the 
ingredient list.  Find the generic name and determine, with the pharmacist’s help, 
whether there could be an adverse interaction.
Be careful:
o
If you take acetaminophen regularly:  You should not take more than 3 
grams a day if you are an adult or 2.4 grams a day if you are older than 65 
years of age.  Read labels carefully!  Acetaminophen is an ingredient in 
many medicines for pain, flu, and cold.
o
If you take herbal medicine regularly:  You should not take St. John’s wort 
while you are taking dabrafenib mesylate
Other medicines can be a problem with your study drugs. 

You should check with your doctor or pharmacist whenever you 
need to use an over-the-counter medicine or herbal supplement. 

Your regular prescriber should check a medical reference or call 
your study doctor before prescribing any new medicine for you.  
Your study doctor’s name is
_____________________________________
and he or she can be contacted at 
_____________________________________

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INFORMATION ON POSSIBLE DRUG INTERACTIONS 
You are enrolled on a clinical trial using the experimental agent 
__________________.  This clinical trial is sponsored by the NCI.  
__________________ interacts with drugs that are processed by your 
liver.  Because of this, it is very important to:
Tell your doctors if you stop taking regular medicine or if you start 
taking a new medicine.
Tell all of your prescribers (doctor, physicians’ assistant, nurse 
practitioner, and pharmacist) that you are taking part in a clinical 
trial.
Check with your doctor or pharmacist whenever you need to use 
an over-the-counter medicine or herbal supplement.
__________________ interacts with a specific liver enzyme called 
CYP______, and must be used very carefully with other medicines 
that interact with this enzyme. 
Before you start the study, your study doctor will work with your 
regular prescriber to switch any medicines that are considered 
“strong inducers/inhibitors or substrates of CYP______.”
Before prescribing new medicines, your regular prescribers should 
go to http://medicine.iupui.edu/clinpharm/ddis/table.aspx for a 
list of drugs to avoid, or contact your study doctor.  
Your study doctor’s name is _____________________________ 
and can be contacted at _________________________________. 

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APPENDIX C: BIOASSAY 
PROCESSING OF TISSUE SPECIMENS
Adapted from:
1. Leyland-Jones, B.R. et al.  Recommendations for collection and handling of 
specimens from group breast cancer clinical trials.  J Clinical Oncology, 26 (34): 5638-
5644, 2008.
-Full guidelines from that manuscript are referenced on the World Wide Web at 
http://ctep.cancer.gov/guidelines/spec_bc_grptrials.html 
2. University of Texas MD Anderson Cancer Center Institutional Tissue Bank Standard 
Operating Procedures, Version 7.0
MATERIALS/EQUIPMENT
Liquid Nitrogen in approved LN2 transport carrier
Surgical mask/eye protection
Safety glasses or face shield
Clean Laboratory coat
Freezer gloves
Clean protective shoes
Disposable latex gloves
Cryovials
Disposable scalpels or scalpel blades (or single 
edge razor blade)
Racks for cryovials
Forceps
Petri dish
Histoprep Marker
OCT cyro-compound
TissueTek cryomold
Kimwipes
10% Neutral Buffered formalin
100% Isopropanol 
95% Ethanol (alcohol)
HAZARDOUS MATERIALS
1. 10% Neutral Buffered Formalin
Formaldehyde : severe eye and skin irritant. Sensitizes by skin and respiratory 
contact. Toxic by ingestion and inhalation. Target organs effects on respiratory 
system. Corrosive. Carcinogen.
Emergency First Aid Procedures:  
Eye: Irrigate immediately with large quantity of 
water for a least 15 minutes. Get medical 
attention immediately
Skin: Flush with water for at least 15 minutes
Ingestion: Dilute immediately with water or 
milk. Induce vomiting. Call physician.

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Inhalation:  Remove to fresh air. Give artificial 
respiration if necessary.
If released or spilled: 
Use formaldehyde spill kit for small spills of 
1000ml; For larger spills contact Environmental 
Health & Safety
Waste Disposal Method 
Whatever cannot be saved for recovery or 
recycled should be disposed of according to 
local, state, and federal regulations.
Respiratory Protection 
If the exposure level is exceeded, wear a full 
facepiece respirator equipped with a 
formaldehyde cartridge.
Ventilation 
Work in well ventilated areas
Precautionary Labeling 
Label with formaldehyde label
Handling and Storage 
Considerations 
Wash hands thoroughly after handling. Avoid 
eye contact. Protect from freezing and physical 
damage.  Store at controlled room 
temperature, 15-30 C.
2. Liquid Nitrogen
Emergency First Aid 
Procedures: 
For Cold Liquid Frostbite:
If any liquefied atmosphere gas contacts the skin or 
eyes, remove any clothing that may constrict blood 
circulation to the frozen area. Immediately flood or 
submerge the affected body area with large quantities of 
clean, unheated water and then apply cold compresses. 
A source of water should be nearby and easily 
accessible wherever liquid nitrogen activities are being 
conducted. If the skin is blistered, or there is any chance 
that the eyes have been affected, get the patient to a 
physician immediately for treatment.
For Grogginess or Unconsciousness While Handling 
Liquid Nitrogen:
If a person seems to become groggy or loses 
consciousness while working with liquid nitrogen, get 
him to a well-ventilated area immediately. Use a self-
contained breathing apparatus if necessary. If breathing 
has stopped, apply artificial respiration. Whenever a 
person loses consciousness, call 911 immediately.
If released or spilled: 
Waste Disposal Method 
Respiratory Protection 
Ventilation 
Precautionary Labeling 
Handling and Storage 
Use only containers specifically designed for holding 

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Considerations 
liquefied gases
FRESH/FROZEN TISSUE PROCESSING
Processing Options for Fresh/Frozen Tissue:

OCT is especially useful for preserving histology, and may improve RNA 
recovery, and thus is recommended. A frozen section resulting from an OCT-
embedded specimen will provide important information on the presence and 
quantity of tumor. Moreover, OCT prevents the tissue from desiccation and 
crumbling and also acts as an insulator from thermal change and limits ice crystal 
formation.  If tissue samples are obtained by core (punch or needle) biopsies, 
each core should be separately embedded in the OCT.

If OCT processing is not possible, controlled snap-freezing in cooled isopentane 
or with a heat extractor is recommended over simple dry-ice freezing.  Snap-
frozen specimens should be placed in an appropriate container (e.g., cryovial or 
cassette) and transferred to -80°C or colder for storage
Some guiding principles for fresh/frozen tissue collection include the following

Do not slow-freeze. Samples should be snap-frozen. Slow freezing promotes the 
formation of ice crystals, which damage the nucleic acids (e.g., RNA) in the 
specimen. The slower a sample freezes, the larger the ice crystals. Older models 
of cryostats (bath/dewar or vacuum type) that require > one minute to freeze a 
specimen should be avoided.

Do not place the specimen directly in liquid nitrogen.  Instead, place the OCT-
filled cryomold onto a stable structure (i.e. Petri dish) that is on the surface of the 
liquid nitrogen.

If only dry ice is available, adding alcohol (e.g., isopropanol or ethanol) to the dry 
ice can make a slurry that will help freeze the specimen more effectively (the 
alcohol will increase the thermal conductivity of the dry ice). This, however, is not 
a preferred over liquid nitrogen for snap-freezing.

Do not add serum to the specimen

Do not touch the biopsy without sterile gloves

Sterile or disposable equipment should be used, including for dissection and for 
snap-freezing.

Instruments should be changed or cleaned between dissecting normal and tumor 
tissue.

If a pen is used to label cryovials or other receptacles that will be stored in 
freezing conditions, ensure that the pen is waterproof/solvent-proof and can 
withstand long-term freezing conditions.

Copies of any relevant pathology reports and material submission forms should 
be sent along with the specimens to the central bank. Reports should be coded 

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in a way they can be matched to the specimen(s) while also protecting patient 
confidentiality requirements.

If possible, representative adjacent normal tissue should be provided in addition 
to the tumor tissue. Normal tissue should be maximally distant from the tumor 
(minimum 2 cm).  Collection of germline DNA (i.e. from PBMCs) should be 
considered in all protocols that include the collection of tumor tissue for DNA 
isolation. 
Size/Number of fresh/frozen biopsies
Punch biopsies (4-6 mm preferred, 2 mm minimum) of cutaneous and subcutaneous 
lesions are preferable to core needle biopsies.  A single biopsy is generally sufficient for 
research purposes.
Core needle biopsies: It should be stressed that core biopsy – whether collected as 
fresh/frozen or FFPE – is superior to fine needle aspiration (FNA) (Singh, 2007). Cores 
are more representative than FNA, providing more accurate diagnostic information – 
including invasive versus in situ, grade, percent tumor, and other important 
histopathologic information.  The minimum size for fresh/frozen tissue collection is 
generally 0.25 cubic cm, which is generally achieved with approximately four passes of 
a 14-gauge needle. In the diagnostic setting, the collection of 2-4 fresh/frozen cores for 
research is recommended, in addition to 2 cores for diagnosis.  The fraction of cores 
that will contain viable tumor will decrease if/as the tumor shrinks in response to 
therapy. Therefore, fewer cores may be obtainable as lesions grow smaller.  
If a previous biopsy site is noted in the specimen to be sampled, biopsies should not be 
taken from near that site. Core biopsies alter the biology of tissue – e.g., they introduce 
inflammatory material from wound reaction and biomolecules involved in wound healing 
– which can be problematic if a subsequent core taken from that tissue is used for 
assay development. Notably, genes involved in wound healing are very similar to those 
involved in cancer progression (Riss et al., 2006).
Fresh/Frozen Tissue Collection in the Surgical Setting
During surgery, fresh/frozen tissue may be acquired by the transfer of the surgical 
specimen from the operating room to the pathology department in a tumor container 
without fixatives. Once it arrives in the pathology department, the sample may be 
sectioned, and then cores taken with a punch biopsy instrument and snap-frozen. This 
method is preferred if ischemia time can be limited to 30 minutes or less.  Note: use a 
sterile RNAse free container if RNA work will be done with any of the tissue.

Alternative: Taking cores and immediately freezing them in the operating room – 
i.e., a core biopsy is taken from the specimen immediately after the specimen is 
removed from the patient. Operating room acquisition of cores from the specimen 
right after excision helps keep ischemia time under 10 minutes, especially in 
situations where pathologists are some distance from the operating room.

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Time to Freezing and Storage Temperature for Fresh/Frozen Samples

Fresh tissue samples should be frozen as soon as possible. If they cannot be 
frozen immediately, they should be frozen within 30 minutes.

Once snap-frozen, samples should be immediately transferred either to liquid 
nitrogen (preferred) or to a -80°C freezer. Specimens should be carried to such 
freezers on dry ice.

Frozen samples should be stored long-term either in liquid nitrogen or in a locked 
freezer with a temperature of -80°C or colder. The freezer should be on electrical 
emergency power line and alarmed. If future uses of the tissue are unknown, 
storing the tissue in the vapor phase of liquid nitrogen will help to ensure long-
term viability.

Storage equipment may include small (2x3 inch) plastic, zip-top bags; mega-
cassettes (for example, with each tissue or cryomold wrapped in aluminum foil); 
and cryoboxes and plastic racks (cryovial storage).
Quality Assurance for Fresh/Frozen Samples
A frozen section should be cut from the OCT block and stained with H&E to confirm 
tumor presence, percent of tumor cells, preservation of morphology, and the presence 
of any undesirable material, such as necrotic or inflammatory material.  The H&E slide 
may be used as a guide to isolate specific portions of the sample for molecular analyses 
(i.e. viable tumor; adjacent normal tissue; etc).
Database Annotation for Fresh/Frozen Tissue Collection
When possible, the following should be recorded on the specimen submission form with 
respect to fresh/frozen tissue collection:

Time before freezing:  if >30 minutes, note time in 15-minute increments beyond 
30 minutes. 

Freezing temperature

If previous punch biopsy(ies) were performed on the patient or noted in the 
specimen

Time point of sample – e.g., after which cycle of therapy
LABELING
Vials, including cryovials, should be labeled with the study name or number, a specimen 
ID number that is linked to the subject’s study ID, contents of the vial, and date of 
collection. The subject’s study ID should not be on the vial unless patient confidentiality 
is determined to be secure according to the clinical trial protocol.  Specific procedures 
for labeling specimens should clearly be defined in the protocol. The central bank itself 
should have standardized labeling (printed or written) for archiving samples, such as 
unique sample IDs and or barcodes.  The information included on a sample label must 
not include patient-identifying information, and should be compliant with the Health 
Insurance Portability and Accountability Act (HIPAA). The information should be 
sufficiently specific such that the encoded information (e.g., tracking number) can be 
linked to the sample in the database.

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Recommended Procedures for OCT Embedding and Snap-Freezing
Specimen Preparation Prior to Fixation
-
Using universal precautions, remove any excess blood from the tissue using a 
paper towel or KimWipe. 
-
Tissue should be cut on a dissection board using a razor blade or scissors with at 
least one dimension at a maximum thickness of 0.5 cm. 
-
Discard any unused tissue according to procedures for disposing of biological 
waste material.
-
Discard the blade according to procedures for disposing of contaminating sharps.
-
Weigh each section of the specimen prior to fixation
-
For labeling, Markers specifically made for cryo temperatures are recommended 
(alcohol-based permanent markers will smudge).
-
Note: if any of the tissue will be used for RNA work later use RNAse free 
technique.
1. OCT Embedding
a. Pre-Procedure Preparation: label cryomolds with permanent marker or printed 
cryolabel, and prepare (preferably print) sticker labels for foil wrappers.  
Labels should include sample ID number, tissue type, and date.  Place 
cryomolds on a flat surface in a manner that will allow for easy differentiation 
of those intended for normal tissue and those for tumor tissue.
b. When sample is available, fill the bottom of each cryomold with a thin layer 
(less then 1 mm) of OCT by slowly and carefully filling the mold. It is important 
to avoid formation of bubbles and avoid uneven surfaces.
c. Weigh each section of the specimen prior to placing it in a cryoomold. Record 
the weight in appropriate log and database
d. If possible, pre-chill the prepared cryomold (step b). This can be done by: (1) 
setting on ice for 2-5 minutes, or (2) just prior to transferring specimen (step 
e) partially freezing by holding over liquid nitrogen until OCT starts to become 
cloudy.
e. Transfer the specimen to the OCT-filled cyromold using forceps.
f.
Cover the tissue with OCT; ensure the top surface of the OCT compound 
completely covers the tissue and is level. 
g. The OCT can be hardened by placing a Petri dish on the surface of liquid 
nitrogen and, using forceps, place the filled cryomold in the Petri dish. Avoid 
allowing the cryomold to come in direct contact with the liquid nitrogen.  
Specimen(s) are sufficiently frozen when the OCT has become completely 
white and hard.
h. After the OCT has hardened, place the mold in pre-labeled aluminum foil 
(heavy duty is best) with the appropriate label with the sample identification 
information.
i.
Place samples on dry ice until transferred to -80° freezer for storage.
2. Snap Freezing
a. Pre-Procedure Preparation: Label 1.8 ml cryovials using a permanent cryo-
marker (EtOH- and freezer-resistant).

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b. To determine specimen weight: record weight of the empty vial, add tissue, 
then re-weigh.  Subtract weights to determine the weight of the specimen, 
and record.
c. Place specimen in a 1.8ml cryovials using forceps. Use separate forceps for 
each type (tumor, normal) of specimen to avoid cross contamination.
d. Tightly secure the cap and submerged in liquid nitrogen for “snap freezing”. 
Use freezer gloves and a face shield during this procedure. Take precautions 
to avoid accidental spillage or spattering of liquid nitrogen.
e. Place samples on dry ice until transferred to -80° freezer for storage.
FFPE TISSUE PROCESSING
Fixation and paraffin infiltration
One fixative and one buffer type should be used across participating centers. All tissue 
samples should be fixed in 10% neutral phosphate-buffered formalin (i.e., 3.7% 
formaldehyde), pH 7.  Resection specimens should be grossly dissected 
(macrosectioned) prior to fixation, to ensure adequate penetration of the fixative; ideally, 
the sections should be approximately 3 to 5 mm thick prior to placement in tissue 
cassettes for fixation. It is essential that surgical margins are appropriately marked and 
that these steps are carried out by a pathologist or their designate. Different blades 
should be used when dissecting normal tissue vs. tumor tissue.  The time that elapses 
from resection to dissection and formalin fixation (the warm ischemia time) should be 
minimized, and typically should be no longer than 4 hours. Placing the specimen in 
fixative without dissection for overnight or longer is NOT adequate.
The following are recommended acceptable ranges of duration of fixation for FFPE 
specimens:

Biopsies (core, needle, and skin biopsies): 8-24 hours 

Excision specimens: 12-24 hours in formalin (36 hours -  absolute maximum)

Tissue sections (0.25-1.0 grams): Overnight-24 hours in formalin (36 hours -  
absolute maximum)

Weekend specimens:  Although fixing and shipping of specimens over the 
weekend (i.e., Friday-Monday) is discouraged, if specimens must be left in 
formalin over the weekend, they should be oriented, “blocked”, bread-loaf 
sectioned and placed in a large amount of formalin in closed containers.
If the collecting center is not associated with a pathology group and does not have 
access to a tissue processor, then the specimen should be either 1) shipped in formalin 
on the day of collection for next-day delivery to the central bank, or 2) fixed in formalin 
for no more than 24 hours and then transferred to 70% ethanol, then shipped to the 
central bank within a few days.  Samples should be protected from excessive heat when 
appropriate by packaging them in a styrofoam container (without ice packs).  See 
Shipping section for more detailed information about appropriate packaging of samples.

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The following are recommended ranges of time from formalin to paraffin on the 
processor (variable according to the specific manufacturer):

5-8 hrs for biopsies

6-14 hrs for other specimens (time depending on the instrumentation and tissue 
size)
Completion of the processes of dehydration with alcohols, clearing with xylene, and 
impregnation with paraffin is important. Some findings have suggested that extended 
processor times may result in higher-quality analytes, although which step should be 
prolonged has not yet been determined (Stephen Hewitt, personal communication, 
2006). Use of low-melt paraffins has been recommended. Contamination with beeswax 
should be avoided (Hewitt et al., 2008).
Storage of FFPE tissue
FFPE blocks should be stored at temperatures below 80ºF (below 26ºC) in an “office-
like” environment – i.e., a controlled-temperature environment with room temperature 
typical for an office, and protected from excessive heat (>28C), humidity (>70%), and 
dryness (<30% humidity). FFPE tissue should not be stored in basements (danger of 
water) or warehouses (danger of insects). Light exposure for FFPE tissue is a key 
problem and should be minimized.  Storage of unstained FFPE slides (whether from a 
single block or from a TMA block) should be discouraged due to antigen loss (DiVito et 
al., 2004; Fergenbaum et al., 2004). Biomarker analyses may best be carried out on 
freshly cut FFPE sections. 
Annotation of Laboratory Methods for FFPE samples
We recommend that fixative type, buffer type, and time from resection to dissection and 
formalin fixation should be reported and recorded in the central bank’s database.
Recommended Procedures for Formalin-Fixation of Tissues
1. Preserving the tissue in formalin enables the embedding of specimens into paraffin 
blocks. Neutral buffered formalin is used to stabilize protein in fresh tissue, and 
prevent autolysis and putrefaction. 
a. Specimens intended for formalin fixation should be processed after the 
completion of other fresh tissue procedures such as snap freezing, 
embedding in OCT compound, and submersion in RNA stabilizing reagent.
b. Minimize time interval
i. The time interval from of removal of tissues to fixation is very important 
in this procedure. The faster the tissue is placed in fixative, the better. 
Artifact will be introduced by drying, so if tissue is left out, please keep 
it moist with saline. The longer the interval between excision and 
fixation, the more cellular organelles will be lost and the more nuclear 
shrinkage and artifactual clumping will occur.

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c. The volume of formalin should be a minimum of 15-20 times the volume of 
the tissue sample – e.g., 20ml of formalin per 1cm3 of tissue.
d. Sectioning tissue for better penetration 
i. Penetration of tissues depends upon the diffusibility of each individual 
fixative, which is a constant. One way to get around this problem is 
sectioning the tissues thinly (3 to 5 mm). To preserve tissue and 
process for paraffin embedding, cut fresh tissue into appropriate size 
pieces. 
ii. NOTE: Tissues to be fixed and processed should be cut to a size no 
larger than 3-5 mm in thickness. Larger sized tissues will not permeate 
well with formaldehyde and will result in poor fixation and poor cellular 
morphology.
e. Record weight of each section
i. Weigh the specimen prior to placing it in a tissue cassette. Record the 
weight in appropriate log and database
f.
Labeling 
i. Place specimen in tissue cassette using proper orientation. Be sure to 
label the cassette using the cassette labeler. Include the tissue ID 
number and the tissue type on the cassette.
ii. Note: If the tissue is for a primary investigator, include their last name 
and protocol number on the side of the cassette.
g. Fixation
i. Place cassette in a specimen cup containing a 10:1 ratio of 10% 
Neutral buffered formalin to tissue. Let tissue fix in the 10% formalin at 
room temperature from a minimum of 16 hours up to 24 hr. 
ii. Note: If unable to embed after 24 hours of 10% formalin fixation, 
transfer specimen in specimen cassette to 70% alcohol and embed 
within 72 hrs.
SHIPPING
Shipping personnel must receive training and be current in certification for biological 
specimen shipping. International Air Transport Authority (IATA) requires recertification 
every 2 years.  For international studies, each country should consider identifying a 
tissue bank where tissue can be held before final shipping to a central bank across 
borders.  A site should consult the central bank to determine the best times to ship 
samples that are frozen. This will help to avoid inadvertent thawing due to the 
evaporation of dry ice.
Batch shipping of samples will help to reduce the time required for organizing shipments 
and, in the case of frozen samples, dry-ice shipping costs (see “Note on Nucleic Acid 
Extraction”, below.) A good guideline for the interval of time between procurement and 
shipment is one month.

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Packaging for All Specimens
Packaging should comply with International Air Transport Association (IATA) criteria 
(please see http://www.iata.org).  If ground overnight is used for FFPE samples, then 
shipment should conform to ground transportation standards (e.g., Department of 
Transportation packaging standards if in the US).  The shipping box should be secured 
and appropriate stickers should be placed, such as “Biological Substance, Category B 
UN 3373”, and the type of shipment, e.g., next-day. The IATA shipping category 
appropriate to the specimens collected should be used, both in labeling and in the 
training required for packaging. In addition to “Biological Substance, Category B, other 
IATA categories include “Exempt Human Specimens” and “Infectious Substance, 
Category A”.
Packaging for Shipping FFPE Specimens
Shipment of FFPE blocks requires that the blocks be protected from excessive heat. 
High outdoor temperatures are only one hazard: placement of an unprotected paraffin 
block on a warm surface can result in significant damage that could require re-
embedding.  Blocks should be individually wrapped or placed in small, jewelry-size, 
labeled plastic zip-top bags (not 2-10 blocks in a single sandwich bag). Blocks should 
then be placed in a Styrofoam shipping container, without dry ice or cold packs. 
Additional space should be filled with packing peanuts and other filler. Use of sealed 
bags with a desiccant can be used, if deemed necessary, to help control humidity.
Slides should be placed in appropriate slide carriers after the Permount has dried. At a 
minimum, the slide container should be wrapped in bubble wrap or placed in a padded 
envelope.
If alternative tissue block punchers are sent to a site for FFPE tissue collection, they 
should be shipped packed into a sleeve and in secured Styrofoam.
Packaging for Shipping Frozen Specimens
Multi-level, watertight packaging with the appropriate biohazard and dry ice labels 
should be used to ship frozen solid tissue and aliquoted serum or plasma. These 
specimens should be contained in non-breakable – i.e., non-glass – cryovials or tube 
containers.
For example:

Cryovial is placed into bubble-wrap, then into a plastic zip-top bag containing a 
sheet of absorbent material, for biohazard protection, then the bag and 
documentation into a watertight Styrofoam container packed with dry ice, the 
content list placed on top of Styrofoam container, then the Styrofoam container 
into a cardboard box with a biohazard label and a dry ice label.
Absorbent material, such as cotton balls, paper towels, or bubble wrap, should be used 
for additional cushioning as needed. Fragile containers should be wrapped with 
cushioning material. Again, though, plastic (not glass) vials should be used.

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Shipping containers should not be sealed airtight so that CO2 gas created from the 
evaporation of dry ice can escape the container. Pack dry ice and samples with paper, 
cardboard, or Styrofoam so that as the dry ice sublimates the samples will not move 
freely inside of the insulated box. The volume of air to which the dry ice is exposed 
should be minimized in order to slow the rate of sublimation. If there is any air space 
after filling the package with dry ice, it should be filled with packing peanuts or other 
material to reduce the volume of air space.
Temperature control for blood and fresh/frozen samples

Samples should be shipped overnight, and shipped only Monday through 
Thursday to ensure delivery on a workday. If shipment cannot be made 
immediately, the samples can be stored at the appropriate temperature (e.g., -
80°C for frozen tissue) until shipment can be made.

Notification of shipment to the central repository is encouraged to ensure that 
specimens are properly received and processed. Communication can avoid 
mishaps due to absence or closure of the repository or variations from region to 
region. Tracking numbers and carrier information should be included in the 
communications.

Dry ice should be used for shipping fresh/frozen tissue and aliquoted serum or 
plasma. The amount of dry ice needed will depend on the length of the trip and 
surrounding outside temperature, and should allow for a 24-hour delay in 
delivery. Discuss the amount required with the shipper in order to ensure that 
enough dry ice is added in order to maintain frozen specimens sufficiently to the 
destination.

EDTA tubes containing blood for germline DNA extraction should be shipped on 
the same day as the blood draw (if possible), unfrozen, on a cold pack 
conditioned to maintain refrigerated temperatures during shipment. Blood should 
NOT be transported frozen, and particularly not at -20ºC.

The amount of refrigerant or dry ice (depending on which type of specimen is 
being shipped) should allow for a 24-hour delay in transport.

A consideration for larger sites is the inclusion of temperature monitors within the 
shipping containers of frozen specimens to validate that temperature has been 
maintained and indicate if significant warming has taken place.
The “NCI Best Practices for Biospecimens Resources” (June 2007) provides further 
information on specimen storage, under Section B.1.4, “Biospecimen Storage”, pages 
4-5 of that document (Research, 2007).