Clinical trial NCT02636725
Conditions: Alveolar Soft Part Sarcoma Soft Tissue Sarcomas
Keywords: Advanced Alveolar Soft Part Sarcoma ASPS STS
Sponsor: Jonathan Trent, MD, PhD
Start date: 2016-04-19; Completion date: 2023-03-03
Enrollment: 33 participants; Allocation: NON_RANDOMIZED; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this research study is to test if Axitinib together with Pembrolizumab can slow tumor growth and know the side effects of the combination treatment.

Detailed description:
Arm 2, the Axitinib Plus Pembrolizumab Expansion Cohort, did not open.

Arms: arm 1: Participants in this group will receive combination treatment of Axitinib plus Pembrolizumab for up to 2 years followed by monotherapy of Axitinib until withdrawal of consent, disease progression and/or unacceptable toxicity as assessed by treating physician, whichever occurs first. arm 2: Expansion cohort for up to 10 additional patients with alveolar soft part sarcoma. Participants in this group will receive combination treatment of Axitinib plus Pembrolizumab for up to 2 years followed by monotherapy of Axitinib until withdrawal of consent, disease progression and/or unacceptable toxicity as assessed by treating physician, whichever occurs first.
Interventions: intervention 1: Axitinib intervention 2: Pembrolizumab
Intervention descriptions: intervention 1: 5 mg tablets twice daily oral dose administered for 7 consecutive weeks on Cycle 1. A safety lead-in consisting of the initial five patients, intrapatient dose escalation of Axitinib will be permitted based on the absence of predefined toxicities. Twice daily oral dose between 2 mg to 10 mg Axitinib tablets will be administered on subsequent 6 week cycles until withdrawal of consent, disease progression and/or unacceptable toxicity as assessed by treating physician, whichever occurs first. intervention 2: 200 mg intravenous infusion administered every 21 weeks beginning week 2 of Cycle 1 for a maximum of up to 2 years or until withdrawal of consent, disease progression and/or unacceptable toxicity as assessed by treating physician, whichever occurs first.

Protocol documents:
Prot_SAP_000.pdf: 
1
EProst # 20150932
NCT# NCT02636725
A Phase II Trial of Concurrent Axitinib and Pembrolizumab in Subjects with Advanced 
Alveolar Soft Part Sarcoma (ASPS) and Other Soft Tissue Sarcomas (STS)
VERSION #:
7.0
VERSION  DATE:
15 April, 2020
PRINCIPAL INVESTIGATOR:
Jonathan C. Trent, MD
Professor of Medicine
Medicine/ Hematology Oncology
Confidentiality Statement: The information contained in this document, especially unpublished 
data, is confidential property.  The information in this document may not be disclosed to others 
unless federal or state law or regulations require such disclosure.  Subject to the foregoing, this 
information may be disclosed only to those persons involved in the study who have a need to 
know, with the obligation not to further disseminate this information.       
      
 
 
        
 
 






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INVESTIGATOR AGREEMENT
I confirm that I have read this protocol, I understand it, and I will work according to this protocol 
and to the ethical principles stated in the latest version of the Declaration of Helsinki, the applicable 
ICH guidelines for good clinical practices, and the applicable federal, state, and local laws, rules, 
and regulations relating to the conduct of the protocol.  
I have read and understand the information in the Investigators’ Brochure (and/or other such 
pertinent safety information) regarding the risks and potential benefits.  
I agree to inform all those who assist/collaborate with me in the conduct of this study of their 
responsibilities and obligations. 
Once the protocol has been reviewed and approved by the Institutional Review Board (IRB) I 
understand that any change(s) made during the course of the study must also (first) be approved 
by the IRB prior to implementation, except when such modification is made to remove any 
immediate hazard(s) to the subject(s).  
I certify that I and the study staff responsible, have received the requisite training to conduct this 
research protocol.  
I agree to maintain adequate and accurate records in accordance with the University of Miami 
policies, federal, state and local laws and regulations.  
I agree to maintain the confidentiality of all information received and/or developed in connection 
with this protocol.
eProst Number:
Protocol Version Number:
Protocol Version Date:
Signature of Investigator:
Date:
Name of Investigator (printed):
Institution:
      
 
 
        
 
 


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PROTOCOL REVISION HISTORY
Version 
#
Summary of Changes
Version Date
1.1
(Pre-Approval Changes)

Administrative, editorial and formatting changes:
o
Clarification provided in Note under Figure 3.
o
Labels for Figure(s) 2, 3 and 4 corrected. 

Secondary Objectives and corresponding Endpoints modified 
to include clinical benefit rate (CBR), objective response rate 
(ORR) and progression-free survival (PFS); removing time to 
progression (TTP).

Section 7.1 Dose Escalation/Dose De-Escalation language 
modified to incorporate traditional 3+3 design.

Stopping Rules using objective response rate (ORR) and 
clinical benefit rate (CBR)

Section 16.0 (Statistical Considerations) language modified to 
clarify analysis
02/JUL/2015
1.2
(Pre-Approval Changes)

Administrative, editorial, numbering and formatting changes
o
Removed Sub-Investigator (John Goldberg, MD) who 
is no longer working at the Institution
o
Labels for Figures and Tables corrected

Phase II with safety lead-in
o
Single-arm survival design; axitinib intrapatient dose 
titration
o
Sample size adjusted from 38 patients to 30 patients 
(see Section 16.4 Patient Enrollment and Sample Size, 
for justification)

Primary Objective modified to determine recommended phase 
2 dose (RP2D); originally for progression-free survival (PFS) 
after 3 months

Ordering of Secondary Objectives modified

Exploratory Objectives modified and additional (exploratory) 
objectives added to identify further immunological 
associations with clinical status. 

Section 19.0 STUDY MONITORING, modified wording to 
incorporate applicable monitoring by UM CRORS and link. 

Addressed Merck comments 
o
Pembrolizumab dosing schedule changed to every 3 
weeks
30/JUL/2015
      
 
 
        
 
 


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o
Inclusion Criterion 6.1.3 clarified (as numbering was 
changed for administrative reasons 6.1.3 is now 
Inclusion Criterion #9.)
o
Prohibited concomitant medication information from 
Merck-provided template is missing partial information
o
Section 5.7.1 (Diet) from Merck-provided template is 
missing 
o
Section 7.2.3 (AST, ALT elevation) from Merck 
template is missing
o
Section 13.1 reference to Appendix D corrected
28/SEP/2015
1.3
(Pre-Approval Changes)

Section 4.0 Subject Recruitment & Screening
o
Added statement with regards to study recruitment of 
minors: "The intervention in the study holds out a 
prospect of direct benefit that is important to the health 
or well-being of minors and is available only in the 
context of the research.  Thus minors 16 years of age 
and older are included in the subject population."

Section 5.0 Patient Selection
o
Inclusion Criterion 3: Added “malignant 
myoepithelioma”.
o
Inclusion Criterion 17: Prior history of vasectomy does 
NOT replace requirement for contraceptive use.
o
Exclusion Criterion 1: Patients may have received prior 
PD-1/PD-L1 directed therapy.

Section 10.2 Dose Titration Guidelines for Axitinib
o
Management of Axitinib-related Hypertension: 
Clarified calcium channel blockers (CCB) and beta-
blocker examples

Appendix A: Expedited Adverse Event (AE) Reporting 
Requirements
o
Added Pfizer Expedited AE Reporting Requirements

Appendix F: Biomarker, Correlative and Special Studies (C.) 
Exploratory Objective 3: Measurement of circulating tumor 
cells pre- and post-treatment, and correlation with tumor 
response and time to progression 
o
Added statement to Approach (e): "Where appropriate, 
additional immunocytochemistry will be performed 
using cell surface vimentin or other marker based on 
specific histology."

Appendix K: Guidelines for Preparation and Administraton/ 
Keytruda for Injection (Lyophilized Powder) added
1.4
PRC Determination Letter dated 30/OCT/2015 
05/NOV/2015
      
 
 
        
 
 


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
Section 3.2 Evaluable Patients clarified for response and 
toxicity

PFS, OS and TTP will be evaluated from study treatment 
initiation

The statements incorporating the term “single arm survival 
design” have been retained/rephrased in the Study Design and 
Statistical Consideration sections, after discussion with 
Statistics 

Section 17.0 title corrected to Data and Safety Monitoring, 
Table 13: (last row) modified from 27 to 29

Section 16.3 Statistical Analysis (Analysis for Exploratory 
Endpoints) “summarized in endpoints” clarified

Inclusion criteria includes parental consent and assent 
requirement for minors 16 to 18 years of age 
2.0
Administrative/editorial changes for consistency:

Consistent language between Protocol Synopsis and body 
of the protocol

Consistent language between Section 12.0 "Schedule of 
Clinical and Laboratory Evaluations” and Section 12.7 
“Calendar of Clinical and Laboratory Evaluations”

Appendix I: Patient Dosing Diary adjusted for longer cycle 
and for Cycle 1
FDA Office of Hematology and Oncology Products Comments 
Email correspondence with FDA Division of Oncology Products 2 
Regulatory Project Manager dated 10/DEC/2015
Protocol:

Section 12.0 “Schedule of Clinical and Laboratory 
Evaluations”
o
Added weekly assessments of physical exams, 
performance status, vital signs, weight and labs 
through the first 2 cycles; 
o
Revised physical exam, performance status, vital 
signs, weight. every 6 weeks (i.e. Day 1 of each 
cycle) for cycle 3 and subsequent cycles and then 
labs every 3 weeks thereafter (i.e. Day 1 and 22);
o
Added comment that if a patient is dose-escalated 
(on axitinib) on day 1 of a cycle they should be 
evaluated at least once, on the week 4 (i.e. Day 22) 
visit, or as clinically indicated.
Main, Minors’ Assent and Parents of Minors’ Informed Consent 
Forms (ICFs) Version 2 (dated: 11/DEC/2015): 
11/DEC/2015
      
 
 
        
 
 


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
“Alternatives” to study treatment with specific examples 
provided and more detailed descriptions of known benefits

Revised wording on the schedule of Clinical and 
Laboratory Evaluations (as described above) to maintain 
consistency

Administrative/editorial changes for consistency
Sponsor-Designated (Merck)
Reference Safety Information as provided in Version 10 (date: 
31/AUG/2015) of Pembrolizumab Investigator's Brochure (IB) 
Section 9.1.4 (Management of Agent-Specific Adverse Events):

Updated safety information for patients with melanoma 
based on KEYNOTE-006 (i.e. AEs of Special Interest or 
AEOSI) 

“Clinical Trials Experience” 

“Immune-Related Adverse Reactions (irAEs)”

“Identification and Treatment of irAEs”

“Other Immune-Mediated Adverse Reactions”:
o
added Guillain-Barré syndrome and vitiligo

“Immune-Mediated Pneumonitis”
o
Updated “pneumonitis” text
Reference Risk Language as provided in Version 1.0 (date: 
03/SEP/2015) of Risk Language Template for MK-3475 
Main, Minors’ Assent and Parents of Minors’ Informed Consent 
Forms (ICFs) Version 2 (dated: 11/DEC/2015): 

Updated pembrolizumab side effects
3.0
Additional warnings on Keytruda® added after 
recommendation from drug sponsor (Merck)
Revisions after letter from sponsor indicated cases of Stevens-
Johnson syndrome, Toxic Epidermal Necrolysis and Immune-
mediated Myocarditis.
Descriptions were added to Section 9.2.4 Management of Agent-
Specific Adverse Events and to Section 10.3 Dose Modification 
Guidelines for Pembrolizumab.
Updated study enrollment number to 45 to account for screen 
failures consented as well as additional patients to replace non-
evaluable patients
26APR2017
      
 
 
        
 
 


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Updated windows for follow-up visits and safety visit for 
consistency throughout protocol 
Clarification regarding concomitant medication usage. Substrates 
are allowed, inhibitors and inducers should be avoided
4.0
Post Approval Amendment 
In response to Merck’s Dear Investigator Letter of Nov 28 2017  
to update the dose modification table 10 on page 67
Additional changes to this version include:
1. Expansion of clinical trial by 10 additional patients with ASPS 
only.
2. Addition and clarification of new exploratory endpoints and 
objectives, including outside collaborators requiring transfer of 
deidentified samples for analysis
3. Section 1.5, addition of rationale for expansion cohort in ASPS
4. Edited requirements for blood pressure (BP) log monitoring – 
patients will monitor BP daily during the entire first cycle., For 
subsequent cycles, if a dose escalation of axitinib is performed, 
patients will keep BP logs for 3 weeks until their day 22 visit 
for that cycle.  If stable, they do not need to continue to log BP 
for the duration of the cycle.  
5. Section 10.1 - Clarified management of grade 4 toxicities  – 
subjects with grade 4 adverse events are generally required to 
discontinue all study treatment except in the following 
conditions - 1) clear evidence that the toxicity was attributable 
to axitinib alone, resolved upon cessation of axitinib, and there 
is rationale to continuing pembrolizumab monotherapy OR 2) 
Grade 4 lab abnormalities that are not immune-related, where 
the patient is asymptomatic, and the abnormalities can be 
reversed with medical treatment. Example: grade 4 
hypertriglyceridemia that responds to antilipid drugs.
6. Modification of Table 9 - Changed management of axitinib-
related elevated liver enzymes or bilirubin.– For grade 3 LFTs, 
it is no longer required to discontinue axitinib, the drug will be 
held until LFTs resolve to grade 1 and then dose reduce 
axitinib. Grade 4 LFTs still requires discontinuation of axitinib.  
7. Management of proteinuria – Grade 1 proteinuria (1+) in the 
ABSENCE of infection or contaminated sample will require 
microalbuminuria or creatinine clearance at screening, without 
affecting eligibility.  Follow up urinalyses are decreased in 
frequency to day 1 of each cycle.  Repeat microalbumin or 
creatinine clearance in the absence of infection or contaminated 
sample, for grade 2 (2+ urine protein) or greater.
20 MAR 2018
      
 
 
        
 
 


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8. Added additional correlative peripheral blood sample collection 
on cycle 1 day 8 prior to Pembrolizumab dose (expansion 
patients only).  
9. Clarified requirements and timing for imaging studies in 
setting of treatment delays – if patient gets off schedule, as 
long as within three weeks, scans should be done at day 1 as 
normally scheduled based on pembrolizumab dosing.  If 
greater than three weeks of consecutive delays, scans should be 
done at the 12 week mark.  
10. Omitted day 22 telephone calls, patients are seen every visit so 
this was erroneous.
11.   12 lead EKGs are required on day 22 of each cycle ONLY if 
axitinib dose escalation was performed on day 1.
12. In table of assessments – deleted erroneous coagulation tests 
on C2D22, coagulation factors are only to be drawn on day 1 
of each cycle), removed D22 urinalysis and clarified 
requirements for microalbumin/Creatinine clearance as 
detailed above, EKGs corrected to D22 only if new dose of 
axitinib begun on day 1, corrected BP log requirements as 
above, added additional peripheral blood collection on Day 8, 
omitted day 22 telephone calls.
13. Section 13.0 – additions to the correlative 
evaluations.  Omitted transfer of a core to Dr. Trent lab for 
RNA analysis (insufficient tissue supplies). .
14. Section 16 – added additional language regarding correlative 
statistical analysis.  Edited sample size calculations for the 
larger number of patients.  
15. Revised references
16. Appendix F section A to reflect new correlative methodology 
and collaborations, added Figure F2.
Miscellaneous other formatting/grammatical corrections.
5.0
Change in PI
1. Replaced Breelyn Wilky, MD as Principal Investigator (PI) 
with Matteo Trucco, MD. 
2. Removed Matteo Trucco, MD as Sub-Investigator.
3. Added contact information for Matteo Trucco, MD.
4. Increased expected enrollment from 35 participants to 45 
participants. 
15OCT2018
6.0
Correlative Studies
1. Section 1.7- added language regarding samples being 
transferred to University of Colorado per collaboration 
agreement between University of Miami and University of 
Colorado.
2. Section 1.6.1 corrected to 1.7.1
      
 
 
        
 
 


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3. Section 1.6.2 corrected to 1.7.2
4. Section 1.6.3 corrected to 1.7.3
6.1
Change in PI
1. Replaced Matteo Trucco, MD as Principal Investigator 
(PI)
2. Removed Jonathan C. Trent, MD, PhD as Sub-
Investigator
3. Added contact information for Jonathan C. Trent, MD, 
PhD
18SEP2019
7.0 
1. Second course treatment: Added details for second course 
treatment (axitinib monotherapy and pembrolizumab re-
introduction) following the completion of the first two years of 
axitinib/pembrolizumab combination treatment. Changes reflected 
in sections 8.1 and 8.2
2. Section 8.0 was updated to reflect the length of cycles and 
schedule for axitinib monotherapy and pembrolizumab re-
introduction for patients who progress while on axitinib 
monotherapy.
3. Section 8.5 and 8.5.1 was updated to reflect axitinib 
dispensation during axitinib monotherapy and during the re-
introduction of pembrolizumab for patients that progress. 
4. Schedule of assessments was updated to reflect the assessments 
that will be performed during axitinib monotherapy (section 
12.2.18) and during pembrolizumab re-introduction (section 
12.2.19 and 12.2.20)
5. Descriptive superscripts were added to the study calendar in 
section 12.7.
6. The following warnings from the investigator’s brochure (IB) 
were added to section 9.1.4, Management of Agent-Specific 
Adverse Events:

Aneurysms and artery dissections

Arterial Thromboembolic Events

Venous Thromboembolic Events 

Elevation of Hemoglobin or Hematocrit

Hemorrhage

Gastrointestinal Perforation and Fistula Formation

Wound Healing Complications

Reversible Posterior Leukoencephalopathy 
Syndrome/Posterior Reversible Encephalopathy Syndrome

Hepatic Impairment
15 APR 2020
      
 
 
        
 
 


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TABLE OF CONTENTS
CONTACT INFORMATION .........................................................................................................2
INVESTIGATOR AGREEMENT ..................................................................................................4
PROTOCOL REVISION HISTORY ..............................................................................................5
TABLE OF CONTENTS ..............................................................................................................12
ABBREVIATIONS & DEFINITIONS .........................................................................................16
PROTOCOL SYNOPSIS ..............................................................................................................17
PROTOCOL SCHEMA.................................................................................................................24
1.0
BACKGROUND AND RATIONALE...............................................................................25
1.1
Soft Tissue Sarcomas (STS) ...........................................................................................25
1.2
PD-1/PD-L1 ....................................................................................................................25
1.3
Rationale for Combination Anti-PD-1 with anti-VEGFR Therapy in Sarcomas ...........26
1.4
Rationale for Intrapatient Dose Titration of Axitinib .....................................................30
1.5
Rationale for Expansion Cohort in Alveolar Soft Part Sarcoma ....................................31
1.6
Hypothesis.......................................................................................................................31
1.7
Correlative Studies..........................................................................................................31
2.0
OBJECTIVES.....................................................................................................................35
2.1
Primary Objective ...........................................................................................................35
2.2
Secondary Objectives......................................................................................................35
2.3
Exploratory Objectives ...................................................................................................35
3.0
ENDPOINTS ......................................................................................................................36
3.1
Primary endpoint.............................................................................................................36
3.2
Secondary endpoints .......................................................................................................37
3.3
Exploratory endpoints.....................................................................................................37
4.0
SUBJECT RECRUITMENT & SCREENING ..................................................................38
5.0
PATIENT SELECTION.....................................................................................................38
5.1
Inclusion Criteria.............................................................................................................38
5.2
Exclusion Criteria ...........................................................................................................41
6.0
ENROLLMENT PROCEDURES ......................................................................................43
6.1
Cancellation Guidelines ..................................................................................................43
6.2
Emergency Registration..................................................................................................43
6.3
Enrollment Procedure(s) .................................................................................................43
      
 
 
        
 
 


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7.0
STUDY DESIGN ...............................................................................................................43
7.1
Axitinib Dose Titration with Flat Dose of Pembrolizumab............................................44
7.2
Dose-Limiting Toxicity (DLT) .......................................................................................45
8.0
TREATMENT PLAN.........................................................................................................47
8.1
Second Course Axitinib (Inlyta®) ..................................................................................50
8.2
Second Course Pembrolizumab ......................................................................................50
8.3
Axitinib (Inlyta®) ...........................................................................................................50
8.4
Pembrolizumab (Keytruda®)..........................................................................................50
8.5
Treatment Dispensation, Compliance and Accountability .............................................51
8.6
Supportive Care Guidelines ............................................................................................52
8.7
Concomitant Medications/ Vaccinations ........................................................................54
8.8
Duration of Treatment.....................................................................................................55
8.9
Duration of Follow-Up....................................................................................................55
8.10
Telehealth ....................................................................................................................55
8.11
Shipping of Investigational Product............................................................................55
9.0
AGENTS (DRUG FORMULATION AND PROCUREMENT).......................................55
9.1
Axitinib ...........................................................................................................................55
9.2
Pembrolizumab ...............................................................................................................61
10.0
TREATMENT/ DOSE MODIFICATIONS ...................................................................70
10.1
Unacceptable Toxicity.................................................................................................70
10.2
Dose Titration Guidelines for Axitinib .......................................................................71
10.3
Dose Modification Guidelines for Pembrolizumab.....................................................74
11.0
TREATMENT DISCONTINUATION...........................................................................79
12.0
SCHEDULE OF CLINICAL & LABORATORY EVALUATIONS ............................80
12.1
Pre-Treatment Evaluation (Screening)........................................................................80
12.2
Evaluations on Treatment............................................................................................81
12.3
Off-Treatment Evaluations..........................................................................................89
12.4
End of Treatment (EOT) Safety Evaluations ..............................................................89
12.5
Follow-up Evaluations ................................................................................................90
12.6
Survival Assessment Evaluations................................................................................91
12.7
Calendar of Clinical and Laboratory Evaluations (continued on following page)......92
13.0
SCHEDULE OF CORRELATIVE EVALUATIONS....................................................96
      
 
 
        
 
 


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13.1
Pre-Treatment Specimen Collection ...........................................................................96
13.2
On Treatment Specimen Collection ............................................................................98
13.3
Off-Treatment Specimen Collection (End of Treatment or EOT visit) ......................99
13.4
Radiology correlative studies ....................................................................................100
13.5
Calendar of Specimen Collection for Correlative Studies ........................................101
13.6
Banking of Additional Specimens.............................................................................101
14.0
MEASUREMENT OF EFFECT...................................................................................101
14.1
Antitumor Effect in Solid Tumors.............................................................................101
14.2
Progression-Free Survival (PFS)...............................................................................108
14.3
Overall Survival (OS)................................................................................................108
15.0
ADVERSE EVENTS....................................................................................................108
15.1
Purpose ......................................................................................................................108
15.2
Adverse Event ...........................................................................................................108
15.3
Serious Adverse Events (see also Appendix A)........................................................109
15.4
Adverse Event Collection Period ..............................................................................110
15.5
Adverse Event Reporting Requirements ...................................................................111
15.6
Expedited Adverse Event Reporting Requirements..................................................112
16.0
STATISTICAL CONSIDERATIONS..........................................................................112
16.1
Overview ...................................................................................................................112
16.2
Definitions and Endpoints.........................................................................................112
16.3
Statistical Analysis ....................................................................................................114
16.4
Patient Enrollment and Sample Size .........................................................................116
17.0
DATA AND SAFETY MONITORING (Interim monitoring).....................................117
18.0
DATA REPORTING ....................................................................................................119
19.0
STUDY MONITORING...............................................................................................119
20.0
INVESTIGATOR RESPONSIBILITIES .....................................................................119
20.1
Investigator Responsibility/Performance ..................................................................119
20.2
Confidentiality...........................................................................................................119
20.3
Informed Consent and Permission to Use Protected Health Information .................119
20.4
Source Documentation and Investigator Files...........................................................120
20.5
Recording and Processing of Data ............................................................................120
20.6
Non-Protocol Research..............................................................................................121
      
 
 
        
 
 


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20.7
Ethics.........................................................................................................................121
20.8
Essential documents for the conduct of a clinical trial..............................................121
REFERENCES ............................................................................................................................122
APPENDIX A: EXPEDITED ADVERSE EVENT (AE) REPORTING REQUIREMENTS....125
APPENDIX B: DATA SUBMISSION SCHEDULE..................................................................128
APPENDIX C: PERFORMANCE STATUS SCALES ..............................................................129
APPENDIX D: NYHA CLASSIFICATION OF HEART DISEASE.........................................130
APPENDIX E: INFORMATION ON POSSIBLE DRUG INTERACTIONS [AXITINIB]......131
APPENDIX F: BIOMARKER, CORRELATIVE AND SPECIAL STUDIES ..........................134
APPENDIX G: PROTOCOL APPROVED METHODS OF CONTRACEPTION....................146
APPENDIX H: EVENTS OF CLINICAL INTEREST & SUPPORTIVE CARE GUIDELINES 
FOR PEMBROLIZUMAB..........................................................................................................148
APPENDIX I: PATIENT DOSING DIARY AND BLOOD PRESSURE LOG FOR AXITINIB
.....................................................................................................................................................153
APPENDIX J: CYP1A2, CYP2C8, CYP2C19, CYP3A4 SUBSTRATES, INHIBITORS & 
INDUCERS * ..............................................................................................................................159
APPENDIX K: GUIDELINES FOR PREPARATION AND ADMINISTRATION/ 
KEYTRUDA FOR INJECTION (LYOPHILIZED POWDER) .................................................162
Table 1.  Presence of PD-L1/PD-1 expression and tumor infiltrating lymphocytes in initial 
cohort of sarcoma patients.  NOTE: Bold/Italicized patients had paired biopsies evaluated.....30
Table 2. Adequate Organ Function Laboratory Values. .........................................................41
Table 3. Axitinib Dose Levels.  *Fixed dose based on simulations of population PK model for 
pembrolizumab suggesting consistency with previous 2 mg/kg dose (see Merck Investigator’s 
Brochure for pembrolizumab). ......................................................................................................46
Table 4. Summary of Lab DLTs.................................................................................................47
Table 5. Summary of Non-Lab DLTs. .......................................................................................47
Table 6. Treatment Schema: Axitinib and Pembrolizumab Concurrent Therapy ...............48
Table 7. Treatment Schema: Axitinib Monotherapy................................................................49
Table 8. Treatment Schema: Axitinib/Pembrolizumab Combination Treatment for Patients 
who Progress while on Axitinib Monotherapy..........................................................................49
Table 9. Axitinib and Pembrolizumab Regimen Description..................................................50
Table 10. Dose Titration of Axitinib .............................................................................................73
Table 11. Additional Dose Modification Guidelines for Axitinib............................................75
Table 12. Dose Modification and Toxicity Management Guidelines for Immune-Related 
AEs Associated with Pembrolizumab. .......................................................................................77
      
 
 
        
 
 


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Table 13. Correlative Studies' Timepoints ..............................................................................102
Table 14. RECIST 1.1 For Patients with Measurable Disease (i.e. Target Disease) ...........108
Figure 1. Representative staining for CD45/PD-1 on TIL and PD-L1..........................................27
Figure 2. Known signaling pathways of selected checkpoint molecules ......................................32
Figure 3. Schematic diagram of the study. ....................................................................................44
      
 
 
        
 
 


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ABBREVIATIONS & DEFINITIONS
Term
Abbreviation
Definition
Clinical Benefit Rate
CBR
The percentage of patients with advanced or 
metastatic cancer who have achieved complete 
response (CR), partial response (PR) and stable 
disease (SD) to a therapeutic intervention in clinical 
trials of anti-cancer agents. 
Dose-Limiting 
Toxicity
DLT
Describes side effects of a drug or other treatment that 
are serious enough to prevent an increase in dose or 
level of that treatment.   (DLTs are defined before 
beginning the trial and are protocol-specific.) 
Objective Response 
Rate
ORR
The percentage of patients with advanced or 
metastatic cancer who have achieved complete 
response (CR) or partial response (PR) to a 
therapeutic intervention in clinical trials of anti-cancer 
agents.
Overall Survival
OS
The length of time from either the date of diagnosis or 
the start of treatment for a disease, that patients 
diagnosed with the disease are still alive.  
Progression-Free 
Survival
PFS
The length of time during and after the treatment of a 
disease that a patient lives with the disease but it does 
not get worse.  
Time to Progression
TTP
The length of time from the date of diagnosis or the 
start of treatment for a disease until the disease starts 
to get worse or spread to other parts of the body.  
Reference: National Cancer Institute (NCI) Dictionary of Cancer Terms 
http://www.cancer.gov/dictionary 
      
 
 
        
 
 


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PROTOCOL SYNOPSIS 
Protocol Title 
A Phase II Trial of Concurrent Axitinib and Pembrolizumab in Subjects with Advanced Alve
Soft Part Sarcoma (ASPS) and Other Soft Tissue Sarcomas (STS)
Targeted 
Patient 
Population
Young adult and adult patients (age ≥ 16 years) with histologically confirmed sarcoma, who 
demonstrate either refractory disease, radiographic progression of disease and/or refusal of 
standard/routine care options.  Sarcoma(s) must be unresectable and measurable by RECIST 
Study Design 
This is an open-label, single-institution, non-randomized, Phase II study of concurrent axitini
with pembrolizumab therapy.  After a safety lead-in consisting of the initial five patients, 
intrapatient dose escalation of axitinib will be permitted based on the absence of predefined 
toxicities (Section 7.1, Table 3 and Section 10.2, Table 8, respectively).
Treatment 
Schema
Concurrent Axitinib and Pembrolizumab Treatment:
Treatment Schema: Axitinib Monotherapy
Cycle(s)
1
2
3, 4, 5, etc. until progression
Week(s)
1
2
3
4
5
6
7
1
2
3
4
5
6
1
2
3
4
5
6
Day(s)
1
8
1
5
2
2
2
9
3
6
4
3
1
8
1
5
2
2
2
9
3
6
1
8
1
5
2
2
2
9
36
Axitinib oral, 
BID 
continuously 
(uptitration 
permitted 
beginning in 
cycle 2)
X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X
Pembrolizumab 
IV q21 days
X
X
X
X
Imaging prior to every subsequent odd 
cycle (i.e. 3, 5, 7, 9, etc.)
X
X
Cycle(s)
1, 2, 3, etc. until progression
Week(s)
1
2
3
4
5
6
7
8
9
10
11
12
Day(s)
1
8
15
22
29
36
43
50
57
64
71
78
Axitinib oral, 
BID 
continuously 
X
X
X
X
X
X
X
X
X
X
X
X
Imaging every 12 weeks (+/- 7 days)
      
 
 
        
 
 


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Treatment Schema: Axitinib/Pembrolizumab Combination Treatment for Patients who
Progress while on Axitinib Monotherapy
Cycle(s)
1, 2, 3, etc. up to 17 cycles (approximately 1 year) 
Week(s)
1
2
3
4
5
6
Day(s)
1
8
15
22
29
36
Axitinib oral, BID 
continuously 
X
X
X
X
X
X
Pembrolizumab 
IV q21 days
X
X
Imaging prior to every subsequent 
odd cycle (i.e. 3, 5, 7, 9, etc.)
Duration of 
Treatment
Trial therapy will last until withdrawal of consent, disease progression and/or unacceptable 
toxicity, whichever occurs first.
Follow-up 
Required Post-
Treatment
All subjects will be followed at approximately 30-days (±5 days) after the last dose of trial 
treatment or before the initiation of a new anti-cancer treatment, whichever occurs first.  
Subjects who discontinue trial treatment for any reason other than disease progression will be
assessed every 12 weeks (±7 days) to monitor disease status.  
Following confirmed disease progression or initiation of new anti-cancer therapy, survival w
assessed (at a minimum) by telephone contact every 12 weeks (±7days).  
Objectives
Primary Objective:  To estimate progression-free survival rate at 3 months after concurrent 
axitinib and pembrolizumab therapy in patients with alveolar soft part sarcoma (ASPS) and o
advanced soft tissue sarcomas. 
Secondary Objectives:  

To estimate the objective response rate (ORR), clinical benefit rate (CBR), progression
survival (PFS) using RECIST 1.1, as well as overall survival (OS)  in patients with ASPS
other advanced soft tissue sarcomas treated with concurrent axitinib and pembrolizumab.

To describe the safety and toxicity profile of axitinib with intrapatient dose titration comb
with pembrolizumab therapy in patients with ASPS and other advanced soft tissue sarc
treated with concurrent axitinib and pembrolizumab.
Exploratory Objective(s):

To identify associations between clinical benefit status (CR/PR/SD vs. PD) and a) T
infiltration; b) immune markers including PD-1, PD-L1, PD-L2, TIM3, LAG3, and CT
expression categories in tumor tissue.  
      
 
 
        
 
 


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
To identify associations between progression-free status at 3 months (no progressio
progression) and a) T-cell infiltration; b) immune markers including PD-1, PD-L1, PD
TIM3, LAG3, and CTLA-4 expression categories in tumor tissue.

To identify associations between clinical benefit status (CR/PR/SD vs. PD) and the abs
change (baseline to cycle 3, baseline to off-study, and cycle 3 to off-study) in each o
following T-cell subsets in peripheral blood and tumor tissue: (CD8+, CD4+, T-regula
memory phenotype, naïve phenotype, Ki67+, PD-1+, TIM3+, LAG3+, CTLA4+).

To identify associations between progression-free status at 3 months (no progressio
progression) and the absolute change (baseline to cycle 3, baseline to off-study, and cycle
off-study) in each of the following T-cell subsets in peripheral blood and tumor tissue: (C
CD4+, T-regulatory, memory phenotype, naïve phenotype, Ki67+, PD-1+, TIM3+, LA
CTLA4+).

To describe the relationship between assessments of tumor response according to RECIS
and tumor response according to alternative radiologic methods including: a) Choi criter
immune-related response criteria (irRC), c) MRI volumetrics, and d) PERCIST 1.0.  

To identify associations between clinical benefit status (CR/PR/SD vs. PD) by RECIST 1.
the absolute change (baseline to cycle 3, baseline to off-study, and cycle 3 to off-stu
baseline) in quantity of circulating tumor cells (CTCs).

To identify associations between the progression-free status at 3 months (no progressio
progression) and the absolute change (baseline to cycle 3, baseline to off-study, and cycle
off-study at baseline) in quantity of circulating tumor cells (CTCs).

To identify associations between the progression-free status at 3 months (no progression v
progression) and the change in genomic expression of angiogenesis and immune-related 
genes, as assessed by RNA expression in tumor biopsies and peripheral blood samples.

To identify associations between the progression-free status at 3 months (no progression v
progression) and T cell clonality in an expansion cohort of ASPS tumor biopsies and 
peripheral blood cells

To identify associations between the progression-free status at 3 months (no progression v
progression) and baseline plasma angiogenic activity and the change in angiogenic activit
occurring with treatment
      
 
 
        
 
 


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Expected 
Number of 
Patients
45, including screen failures and non-evaluable patients
Expansion cohort: up to 10 additional patients with alveolar soft part sarcoma
Expected 
Number of 
Centers
Sylvester Comprehensive Cancer Center (SCCC)  
Note: SCCC is inclusive of the constituent satellite sites. 
Expected 
Duration of the 
Protocol
The estimated duration of the protocol is 3 years from screening/accrual to end of follow-up.
Inclusion 
Criteria
1. Patients must have histologically confirmed sarcoma with pathology review required for 
outside samples.  
2. The following histologies may be enrolled without prior treatment: 
a.
alveolar soft part sarcoma, (NOTE: expansion only permits patients with ASPS) 
b. clear cell sarcoma, 
c.
epithelioid hemangioendothelioma, and 
d. chordoma.
3. The following histologies may be enrolled ONLY if refractory to anthracycline-based 
chemotherapy or if the patient refuses to undergo standard of care treatment: 
a.
synovial sarcoma, 
b. rhabdomyosarcoma, 
c.
malignant peripheral nerve sheath tumors, 
d. dedifferentiated , pleomorphic, or myxoid/round cell liposarcoma, 
e.
leiomyosarcoma, 
f.
malignant phylloides tumor, 
g. high grade undifferentiated pleomorphic sarcomas (HGUPS/MFH), 
h. angiosarcoma, 
i.
spindle cell sarcoma NOS
j.
malignant myoepithelioma
4. The following histologies may be enrolled ONLY if refractory to at least one line of 
chemotherapy or if the patient refuses to undergo standard of care treatment:
a.
solitary fibrous tumor/hemangiopericytoma.
5. The following histologies may be enrolled ONLY if refractory to at least first-line targete
therapy or if the patient refuses to undergo standard of care treatment:
a.
gastrointestinal stromal tumors, 
b. extraskeletal myxoid chondrosarcoma, 
c.
PEComa
6. Primary tumors of bone including Ewing’s sarcoma, osteosarcoma, and dedifferentiated 
chondrosarcoma may only be enrolled if there are measurable target lesions occurring in 
tissue and they are refractory to standard of care anthracycline-based chemotherapy. 
      
 
 
        
 
 


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7. Any other histology or standard of care treatment not specifically addressed will be revie
by the principal investigator and pathologist for final determination of eligibility.  
8. Measurable disease as defined by RECIST v1.1 (provided in Section 14.0). 
9. Radiographic progression as defined by RECIST v1.1, based on comparison between two
radiographic studies no greater than 6 months apart.
10. Inability to undergo complete resection of the disease by surgery. 
11. Adequate organ function as defined below (Section 5.0, Inclusion Criterion 11).
System
Laboratory Value
Hematological
Absolute neutrophil count 
(ANC)
≥1,000 /mcL
Platelets
≥75,000 / mcL
Hemoglobin
≥8 g/dL without transfusion or EPO dependency 
(within 7 days of assessment)
Renal
Serum creatinine OR
Measured or calculateda 
creatinine clearance
(GFR can also be used in 
place of creatinine or 
CrCl)
≤1.5 X upper limit of normal (ULN) OR
≥60 mL/min for subject with creatinine levels > 1.5 X 
institutional ULN
Hepatic
Serum total bilirubin
≤ 1.5 X ULN OR
Direct bilirubin ≤ ULN for subjects with total bilirubin 
levels > 1.5 ULN
AST (SGOT) and ALT 
(SGPT)
≤ 2.5 X ULN  OR
≤ 5 X ULN for subjects with liver metastases
Albumin
>2.5 mg/dL
Coagulation
International Normalized 
Ratio (INR) or 
Prothrombin Time (PT)
Activated Partial 
Thromboplastin Time 
(aPTT)
≤1.5 X ULN unless subject is receiving anticoagulant 
therapy
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants
≤1.5 X ULN unless subject is receiving anticoagulant 
therapy
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants
a Creatinine clearance should be calculated per institutional standard.
12. Age ≥ 16 years.
      
 
 
        
 
 


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13. ECOG performance status of 0 or 1.
14. Patients must consent and be willing to undergo tumor core needle biopsies at three 
timepoints (1. baseline, 2. cycle 3, and 3. off-study).  At least one tumor site must be 
amenable to biopsy in the judgment of the interventional radiologist.  
15. Female subjects of childbearing potential should have a negative urine or serum pregnanc
within 72 hours prior to receiving the first dose of study medication.  If the urine test is 
positive or cannot be confirmed as negative, a serum pregnancy test will be required.
16. Females of child bearing potential that are sexually active must agree to either practice 2 
medically accepted highly effective methods of contraception at the same time or abstain
from heterosexual intercourse from the time of signing the informed consent through 120
days after the last dose of study drug. See Appendix G for protocol-approved highly effec
methods of contraceptive combinations. Subjects of childbearing potential are those who 
not been surgically sterilized or have not been free from menses for > 1 year.
a.
Negative test for pregnancy is required of females of child-bearing potential; A fe
of child bearing potential is any woman, regardless of sexual orientation or wheth
they have undergone tubal ligation, who meets the following criteria: 1. has not 
undergone a hysterectomy or bilateral oophorectomy; or 2. has not been naturally
postmenopausal for at least 24 consecutive months (i.e., has had menses at any tim
the preceding 24 consecutive months or 730 days). 
b. Conception while on treatment must be avoided
17. Male subjects should agree to use an adequate method of contraception starting with the f
dose of study therapy through 120 days after the last dose of study therapy. Prior history 
vasectomy does NOT replace requirement for contraceptive use.
18. Suitable venous access to allow for all study related blood sampling. 
19. Ability to understand and willingness to sign a written informed consent document.
20. For minors that are 16 to 18 years of age, assent and parental (or legally accep
representative) written informed consent must be obtained. 
Exclusion 
Criteria
1. Prior therapy with axitinib.  Patients are permitted to have received prior tyrosine kinase 
inhibitor (TKI) therapy including imatinib, sunitinib, pazopanib, or similar.  Patients may
have received prior PD-1 or PD-L1 directed therapy.  
2. Hypersensitivity to axitinib, pembrolizumab or any of its excipients. 
3. Patients may not be receiving any other investigational agents (within 4 weeks prior to C
1, day 1).
4. Prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to Cycle 1, day 1 or h
not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents administe
more than 4 weeks earlier.
5. Patient has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
within 2 weeks prior to Cycle 1, Day 1 or has not recovered (i.e., ≤ Grade 1 or at baseline
from adverse events due to agents administered more than 4 weeks earlier.  Subjects with
Grade 2 neuropathy are an exception to this criterion and may qualify for the study.  Note
      
 
 
        
 
 


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subject received major surgery, they must have recovered adequately from the toxicity an
complications from the intervention prior to starting therapy. 
6. Additional known malignancy that is progressing or requires active treatment.  Exception
include basal cell carcinoma of the skin, or squamous cell carcinoma of the skin that has 
undergone potentially curative therapy, or in situ cervical cancer.
7. Patients with end-organ dysfunction (detailed in Section 5.1, Inclusion Criterion 11). 
8. Patients with bone-only lesions. 
9. Patients with underlying immune deficiency, chronic infections including HIV, hepatitis,
tuberculosis (TB) or autoimmune disease. 
10. Patients with underlying hematologic issues including bleeding diathesis, known previou
bleeding requiring intervention within the past 6 months, active pulmonary emboli or DV
that are not stable on anticoagulation regimen.
11. Has known history of, or any evidence of active, non-infectious pneumonitis.
12. Has known active central nervous system (CNS) metastases, and/or carcinomatous menin
or leptomeningeal disease.  Subjects with previously treated brain metastases may partici
provided they are stable (without evidence of progression by imaging for at least four we
prior to the first dose of trial treatment and any neurologic symptoms have returned to 
baseline), have no evidence of new or enlarging brain metastases, and are not using stero
for at least 7 days prior to trial treatment.  This exception does not include carcinomatous
meningitis which is excluded regardless of clinical stability.
13. Concomitant (or receipt of) treatment with medications that may affect the metabolism of
pembrolizumab and/or axitinib within 7 days prior to Cycle 1, day 1 of axitinib. (CYP3A
substrates are not exclusionary)
14. Has received a live vaccine within 30 days of planned start of study therapy.  Note:  Seas
influenza vaccines for injection are generally inactivated flu vaccines and are allowed; 
however intranasal influenza vaccines (e.g., Flu-Mist®) are live attenuated vaccines, and
not allowed.
15. Is pregnant or breastfeeding, or expecting to conceive or father children within the projec
duration of the trial, starting with the pre-screening or screening visit through 120 days af
the last dose of trial treatment.
16. Any uncontrolled, intercurrent illness including but not limited to ongoing or active infec
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia
17. Prolonged QTc interval on Screening EKG >475 ms.
18. Ejection Fraction <40% by 2D ECHO at Screening. 
19. Any serious medical or psychiatric illness/condition including substance use disorders lik
in the judgment of the Investigator(s) to interfere or limit compliance with study 
requirements/treatment.
20. Has active autoimmune disease that has required systemic treatment in the past 2 years (i
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. 
      
 
 
        
 
 


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PROTOCOL SCHEMA 
The first cycle of treatment will be seven weeks, with one week of axitinib alone prior to initiation of pembrolizumab.  Subsequently, 
six-week cycles of treatment consist of twice daily oral doses of axitinib administered continuously with intravenous (I.V.) 
administration of pembrolizumab on day 1 and 22.  The first five evaluable patients will be considered a safety lead-in, and will not 
have axitinib dose escalation above 5 mg PO bid.  In subsequent cycles, patients will begin cycle 1 with axitinib 5 mg PO twice daily 
(BID) and be monitored for DLT; these patients may then have axitinib dose-escalated as tolerated for the individual patient starting 
with cycle 2.  Dose de-escalations may occur at any time for toxicity.  


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1.0 BACKGROUND AND RATIONALE
1.1 Soft Tissue Sarcomas (STS)
Soft tissue sarcomas (STS) are rare, heterogeneous and highly aggressive neoplasms that 
often affect young and otherwise healthy individuals.  Although aggressive 
chemotherapy has improved outcomes for pediatric histologies such as embryonal 
rhabdomyosarcoma, very few targeted therapies have been approved for refractory and 
metastatic STS; median overall survival is dismal at only 12-18 months.  Additionally, 
some histologies, such as alveolar soft part sarcoma (ASPS) and clear cell sarcoma (CCS) 
do not respond at all to traditional chemotherapy, and inevitably progress with distant 
metastases and death.  Gastrointestinal stromal tumors still ultimately develop resistance 
to imatinib and other tyrosine kinase inhibitors despite initial dependence on KIT, due to 
the development of escape mutations and alternative pathways.  Thus, novel treatment 
strategies are desperately needed for this challenging group of cancers. 
Sarcomas have long been suspected to have an immunogenic phenotype; as early as 1891, 
William Coley noted resolution of sarcoma after a severe bacterial infection (1).  
Although sarcoma’s rapid and aggressive course has limited the efficacy of most previous 
immunotherapy approaches, a few remarkable responses have been seen in synovial 
sarcomas expressing NY-ESO-1 antigens with adoptive T-cell immunotherapy (2-3). 
Unlike most solid tumors, some sarcomas can be “cured” by resection of all metastatic 
disease even after an incomplete response to chemotherapy, suggesting that immune 
surveillance and suppression may play a role in prevention of recurrence.  
1.2 PD-1/PD-L1
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 (TIL) in cancer tissue and favorable prognosis 
in various malignancies.  In particular, the presence of CD8+ T-cells and the ratio of 
CD8+ effector T-cells / FoxP3+ regulatory T-cells seems to correlate with improved 
prognosis and long-term survival in many solid tumors.
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress 
immune control.  The normal function of PD-1, expressed on the cell surface of activated 
T-cells under healthy conditions, is to down-modulate unwanted or excessive immune 
responses, including autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig 
superfamily member related to CD28 and CTLA-4 which has been shown to negatively 
regulate antigen receptor signaling upon engagement of its ligands (PD-L1 and/or PD-
L2).  The structure of murine PD-1 has been resolved.  PD-1 and family members are 
type I transmembrane glycoproteins containing an Ig Variable-type (V-type) domain 
responsible for ligand binding and a cytoplasmic tail which is responsible for the binding 
of signaling molecules.  The cytoplasmic tail of PD-1 contains 2 tyrosine-based signaling 
motifs, an immunoreceptor tyrosine-based inhibition motif (ITIM) and an 
immunoreceptor tyrosine-based switch motif (ITSM).  Following T-cell stimulation, PD-
      
 
 
        
 
 


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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.
1.3 Rationale for Combination Anti-PD-1 with anti-VEGFR Therapy in Sarcomas
Inhibitors of PD-1/PD-L1 interactions, including the anti-PD-1 antibody pembrolizumab, 
have been recently approved for melanoma and non-small cell lung cancer, but are 
largely unexplored in sarcomas.  However, recent studies have reported PD-L1 
expression in sarcomas, particularly GIST and osteosarcoma, as well as the presence of 
tumor-infiltrating T-cells that express PD-1 ((4-6), Figure 1.) The first single-agent trial 
of pembrolizumab for STS patients has just been initiated (NCT02301039).  However, 
many have questioned whether anti-PD-1 monotherapy will be sufficient in aggressively-
growing sarcomas; response to anti-PD-1 can take time to manifest.  It is recognized that 
therapy efficacy and prolongation of response are often enhanced by combining two or 
more treatments targeting compensatory signaling pathways, and given the complexity 
of immune checkpoint inhibition, many studies of combination treatments with PD-1 
targeted therapies are ongoing. 
      
 
 
        
 
 


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Figure 1. Representative staining for CD45/PD-1 on TIL and PD-L1. Performed 
on patient with recurrent alveolar rhabdomyosarcoma.  (Courtesy of Andrew Rosenberg, MD, 
University of Miami Department of Pathology, unpublished data.)
Studies of tumor immunology in melanoma and renal cell carcinoma cells have shown 
that HIF-1α and related angiogenic proteins contribute to the failure of the immune 
system to recognize and attack tumor cells.  These pro-angiogenic factors lead to 
suppression of dendritic cell maturation and antigen presentation, suppression of 
migration of lymphocytes across endothelium into tumor deposits, and encourage 
accumulation of myeloid derived suppressor cells (7-9).  Additionally, preclinical work 
has suggested that anti-VEGF treatment may increase PD-L1 expression in renal cell 
carcinoma cells, facilitating inhibitory interactions with PD-1 on tumor-infiltrating 
lymphocytes (10).  Based on these observations, a compelling rationale exists for 
combined therapy with immunostimulatory agents like checkpoint inhibitors, and anti-
VEGFR tyrosine kinase inhibitors (TKI).  A study of combination CTLA-4 blockade 
with ipilimumab and VEGF inhibitor bevacizumab produced a disease control rate of 
67.4% and mean overall survival of 25.1 months (11).  Tumor biopsies revealed marked 
trafficking of CD8+ T cells and dendritic macrophages across the tumor vasculature, and 
increased circulating memory T-cells in patients treated with the combination.  A phase 
1 study of combined sunitinib or pazopanib with PD-1 inhibitor nivolumab in renal cell 
carcinoma was recently reported (ASCO 2014, Abstract #5010).  Although the 
combination was toxic, with high rates of hepatic and renal failure leading to 
discontinuation of the pazopanib containing arm, response rates with both regimens were 
higher than previously reported with the TKI alone.  
A Phase I trial of combination axitinib, another pan-VEGFR TKI, and anti-PD-1 
antibody pembrolizumab in renal cell carcinoma is ongoing (NCT02133742).  The initial 
dose-finding cohort has been completed.    Remarkably, the combination of axitinib 5 
mg PO twice daily with pembrolizumab 2 mg/kg every three weeks was well-tolerated.  
      
 
 
        
 
 


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Three DLTs occurred in 10 evaluable patients, including one transient ischemic attack, 
one headache, and one patient with arthralgias, hypertension and fatigue (Atkins et al, 
Abstract #370, Society of Immunotherapy for Cancer 2015 Annual Meeting, National 
Harbor, MD).  An expansion cohort at the dose combination of axitinib 5 mg PO bid and 
pembrolizumab 2 mg/kg every three weeks, permitting intrapatient dose escalation of 
axitinib to 7 mg PO twice daily and 10 mg PO twice daily is ongoing.
The rationale for combined anti-angiogenic therapy and immunotherapy is similarly 
compelling in sarcomas.  Two of the most immunogenic sarcomas, ASPS and CCS, share 
marked similarity with melanoma based on pathologic translocations that activate 
members of the MITF transcription factor family.  Downstream targets of these aberrant 
fusion proteins include HIF-1α, the critical mediator of tumor angiogenesis.  High 
expression of pro-angiogenic factors including VEGF, PDGF, angiopoietin-1/2, and FGF 
have been implicated in sarcomas, portending worse prognosis and resistance to 
chemotherapy [1].  Interestingly, the most promising responses in ASPS and CCS to date 
have occurred with the pan-VEGF tyrosine kinase inhibitors cediranib and sunitinib [2, 
3].  Anti-angiogenic TKI have also been effective in other chemotherapy-resistant 
sarcomas, 
including 
gastrointestinal 
stromal 
tumor 
and 
solitary 
fibrous 
tumor/hemangiopericytoma, and pazopanib was recently approved by the FDA after 
improving overall survival in non-adipocytic STS refractory to chemotherapy.  However, 
most patients eventually develop resistance to anti-angiogenic therapy.
Goldberg et al recently reported the results of a Phase I trial of autologous GM-CSF-
secreting vaccines in patients with ASPS and CSS (15).  Interestingly, although no tumor 
regressions were seen, correlative studies did reveal intra-tumor influx of lymphocytes, 
T-regulatory cells, and dendritic cells.  Additionally, sera from vaccinated patients 
showed increased antibodies against angiogenic cytokines TIE1 and TIE2, suggesting 
that immune stimulation increased the host response to angiogenic factors thought to 
drive tumor growth.  In an exploratory analysis of vaccinated patients, 2 ASPS tumors 
showed expression of PD-1 by tumor-infiltrating lymphocytes as well as PD-L1 
expression by neighboring tumor cells.  This suggests that ASPS may express immune-
evading markers at baseline, or perhaps have the ability to upregulate PD-L1 in response 
to vaccination, preventing effective destruction.  Regardless, this would suggest a role 
for PD-1 blockade as a potential sensitizing strategy to permit immune recognition of 
ASPS, in combination with an anti-angiogenic strategy already shown to have activity in 
ASPS.
As a pilot investigation, we evaluated PD-1/PD-L1 expression and the presence of tumor 
infiltrating lymphocytes in 10 patients with sarcoma from our institution (Table 1.)  
Patient 10 is a current patient with alveolar soft part sarcoma who recently progressed on 
cediranib, a tyrosine kinase inhibitor similar to axitinib.  In the baseline biopsy, his tumor 
was negative for PD-L1 expression in the tumor tissue, but exhibited 2-5 TIL per 40X 
HPF, with a low fraction of the TIL positive for PD-1 expression.  However, on the post-
cediranib resection specimen, tumor cells were diffusely positive for PD-L1, with 
increased TIL and greater than 10% positivity for PD-1.  We also evaluated two other 
sarcoma patients from our institution with pre-and post-treatment biopsies.  Patient 9 
      
 
 
        
 
 


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(alveolar rhabdomyosarcoma) was biopsied upon recurrence several months after 
completion of adjuvant chemotherapy.  Patient 3 (Ewing’s sarcoma) was biopsied as part 
of an ongoing clinical trial combining a dendritic cell vaccine with tumor lysate injections 
(Eprost 20110462, PI, John Goldberg).  All of these patients showed upregulation of PD-
L1 on tumor cells and increased lymphocyte infiltration in the post-treatment biopsies 
relative to their own baseline, suggesting that exposure to chemotherapy or immune 
therapy increases expression of PD-L1 in resistant, viable cells, and increases 
lymphocyte infiltration.  
Patient 
ID
Tumor type
PD-L1 
expression
CD45+ TIL
PD-1 expression 
(% of TIL)
1
Osteosarcoma
Diffuse
Dense
Focal (1%)
2
Osteosarcoma
Focal
Positive
Negative
3
Ewing’s sarcoma 
(pre-treatment)
Diffuse
Scattered
Focal
Post-treatment (dendritic 
cell vaccine protocol)
Diffuse
Increased relative 
to baseline
Negative
4
Osteosarcoma
Weakly 
positive
Few 
intratumoral, 
greater 
peritumoral
Negative
5
Rhabdomyosarcoma 
(Alveolar)
Diffuse
Scattered
Negative
6
Ewing’s sarcoma
Diffuse
Scattered
Focal
7
Histiocytic sarcoma
Diffuse
Dense
10% positive
8
Rhabdomyosarcoma 
(Alveolar)
Diffuse
Positive
Scattered
9
Rhabdomyosarcoma 
(Alveolar) – initial
Weakly 
positive
Scattered
Negative
Rhabdomyosarcoma 
(Alveolar) – recurrence after 
chemotherapy
Diffuse
Scattered
Scattered
10
ASPS (initial)
Negative
Scattered
Focal
ASPS (progressing tumor 
on cediranib)
Diffuse
Positive
10% positive
Table 1.  Presence of PD-L1/PD-1 expression and tumor infiltrating lymphocytes in initial 
cohort of sarcoma patients.  NOTE: Bold/Italicized patients had paired biopsies evaluated.
Based on the compelling rationale for combined inhibition of immune checkpoints and 
tumor angiogenesis in sarcomas, we propose treatment of patients with ASPS, CCS and 
other soft tissue sarcomas with concurrent axitinib with pembrolizumab.  While the 
activity of pembrolizumab as monotherapy in sarcomas is currently being studied, 
      
 
 
        
 
 


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axitinib has shown activity in soft tissue sarcomas in early clinical trials.  Axi-STS, a 
phase II trial of axitinib at 5 mg PO twice daily in soft tissue sarcomas is ongoing in the 
UK and was reported at the NCRI conference in November 2014 (Abstract #B48) and 
CTOS 014 (Paper 031, Berlin, Germany).  Progression-free survival rates at 12 weeks 
were 47% in leiomyosarcoma, and 38% with other soft tissue sarcomas.  Results for the 
other cohorts studying synovial sarcoma and angiosarcoma are still pending.  Grade 3/4 
toxicities included fatigue (12/60 patients), hypertension (7/60 patients), arthralgia (2/60 
patients), diarrhea (6/60 patients), and hypercalcemia (Grade 4, 1/60 patients).  
We hypothesize that by using the anti-angiogenic agent axitinib to “prime” the 
sarcoma tumor microenvironment, producing an influx of immune cells into the 
area and possible upregulation of PD-L1 on the tumor cells, this may intensify the 
immune-directed cytotoxicity resulting from subsequent pembrolizumab therapy.   
This trial will provide pilot data for subsequent randomized trials should activity in the 
combination be observed.
1.4 Rationale for Intrapatient Dose Titration of Axitinib
Oral tyrosine kinase inhibitors are well-documented to show significant variability in 
plasma concentrations, pharmacodynamic on-target effects, toxicity, and tumor response 
in individual patients despite fixed dosing (16).  In particular, axitinib has been studied 
extensively with regards to pharmacokinetic variability in patients.  In renal cell 
carcinoma, increased axitinib AUC correlates with superior tumor response rate, (17) 
which has led to incorporation of dose escalation above the standard approved dose of 5 
mg twice daily in subsequent phase III clinical trials and inclusion on the FDA label as 
accepted practice.  As evidence of the variable tolerance of axitinib, in the phase III trial 
of axitinib vs. sorafenib, 31% of patients required at least one dose reduction of axitinib 
from the starting dose of 5 mg bid, while 37% of patients were treated above 5 mg bid 
(18).  However, the most commonly utilized dose titration schemes result in significant 
changes to expected AUC, which may result in undertreating or overtreating the 
individual patient.  Unlike standard chemotherapy which may be dose reduced by 10 or 
20%, the usual dose reductions for axitinib to either 3 mg bid or 2 mg bid leads to 60% 
and 40% respectively of the starting dose level.  Similarly, with the standard dose 
escalation to 7 mg bid followed by 10 mg bid patients receive 140% and 200% of the 
starting dose respectively.  A clinical trial of more stringent dose titration in smaller 
intervals is planned in renal cell carcinoma to better customize axitinib dosing, with the 
hypothesis that patients that can be treated closer to their optimal AUC will show 
improved toxicity profiles and superior clinical responses (Brian Rini, personal 
communication).  
The Axi-STS trial of axitinib in sarcoma did not utilize dose escalation above 5 mg bid 
but thus far has shown similar rates of grade 3 and 4 DLT to the larger studies in renal 
cell carcinoma.  Thus, we propose to include stringent titration guidelines and permit 
dose escalation in our patients to ensure optimal exposure to the anti-angiogenic effects.
      
 
 
        
 
 


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1.5 Rationale for Expansion Cohort in Alveolar Soft Part Sarcoma
We have completed accrual of the first 30 patients in this study, including 12 patients 
with ASPS. Out of 10 evaluable patients, all of whom enrolled on study with 
progressing disease, 5 patients achieved partial response, and 2 patients achieved minor 
responses and remain on study therapy. One patient had PD at 3 months and withdrew 
consent at that time. One patient progressed prior to 3 month imaging. Two patients 
progressed after the 3 month timepoint. One patient was discontinued for axitinib-
related toxicity.  The final patient has not yet reached 3 month assessments.
Based on the significant and largely durable responses in ASPS patients, we will 
expand the study to enroll up to 10 additional patients to obtain additional data 
regarding safety and efficacy. 
1.6 Hypothesis
We hypothesize that combination axitinib with pembrolizumab will prolong the time to 
tumor progression in patients with ASPS and other advanced soft tissue sarcomas, with 
favorable progression-free survival and clinical benefit rate relative to historical 
controls.
1.7 Correlative Studies
All samples collected will be transferred to the University of Colorado for assays and 
final analysis with clinical outcomes.  This is supported by a collaboration agreement 
between the University of Colorado and the University of Miami.  All samples will be 
de-identified prior to transfer and labeled only with the subject ID.
1.7.1 Characterization of immunomodulatory factors in patients treated with concurrent 
axitinib/pembrolizumab
Although the immune system is suspected to play a role in sarcoma development 
and recurrence, the specific mediators of immune surveillance and suppression of 
tumor growth are largely unknown.  Additionally, we have learned from analysis 
of patients treated thus far with PD-1-directed therapy that biomarkers of response 
to immunotherapy are extremely complex.  For example, in an elegant analysis of 
227 patients treated with MPDL3280A (anti PD-L1 antibody), treatment response 
appeared to correlate with high tumor PD-L1 expression, pre-existing tumor 
lymphocyte infiltration with PD-L1 expression, but also with CTLA4 expression, 
absence of fractalkine, and T-helper 1 gene expression (19).  Data from Taube et al 
in patients with multiple tumor types treated with nivolumab also suggested a 
geographic tendency for PD-L1 expression at the interface of lymphocyte-rich 
infiltrations, with PD-L1 expression linked to other markers, including PD-1 
expression on lymphocytes and PD-L2 expression (20).  Although PD-L1 
expression in tumor cells and the presence of lymphocyte infiltration with PD-
1/PD-L1 expression seem to be the best predictors of response, 10-15% of patients 
without tumor PD-L1 expression have responded to therapy, suggesting that other 
immunomodulatory factors must be playing a role.  In addition to CTLA4 
expression, other negative regulatory receptors have also been implicated, 
including LAG-3 and TIM-3, with pre-clinical blockade of some of these pathways 
      
 
 
        
 
 


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resulting in improved anti-tumor response (21, Figure 2).  Finally, the presence of 
myeloid-derived suppressor cells (MDSCs) and regulatory T-cells have been 
shown to negatively impact response to therapy in many cancers, though these are 
also understudied in sarcomas.  
Thus, a key correlative component of our study will be to profile sarcoma tumors 
and infiltrating tumor lymphocytes using pre- and post-treatment tumor biopsies, 
and analysis of circulating peripheral blood T-cells to better understand the 
immune environment in sarcoma patients.  We aim to define changes in intra-
tumoral and peripheral blood T-cell phenotypes, differentiation and 
activation status, and checkpoint ligand expression after treatment with 
axitinib/pembrolizumab, and correlate with progression-free survival and 
radiographic tumor response to therapy.
Figure 2. Known signaling pathways of selected checkpoint molecules and current 
therapeutics.
1.7.2 Assessment of tumor response using non-conventional radiologic criteria
Sarcomas often display atypical radiographic changes in response to treatment.  
Traditional size-based criteria, such as RECIST and WHO criteria, in 
      
 
 
        
 
 


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musculoskeletal tumors has been shown to be relatively insensitive to biological 
response as measured by other markers, such as histologic necrosis (22).  This is 
probably due the tendency of sarcomas to undergo internal hemorrhage and 
necrosis, and as a result enlarge in size (pseudoprogression) despite the fact that the 
tumor is actually exhibiting positive treatment response.  Comparable findings have 
been reported in other large STS treated with pazopanib (23).  With current 
advances in radiographic imaging, tumor responses or progression can be detected 
much earlier, and eliminate some of the clinical problems with RECIST.  For 
example, some patients may exhibit obvious three-dimensional progression, yet 
would be continued on ineffective therapy if the largest diameter does not reach 
20% increase.  Additionally, “stable disease” spans from 30% regression to 20% 
growth- generally requiring a waterfall plot or other description of response to get 
a sense of overall drug activity.  
To avoid erroneously classifying pseudoprogression as RECIST progression and 
premature discontinuation of therapy in clinical trials, alternative criteria for tumor 
response such as Choi criteria have been developed (24).  These criteria assess 
response in GIST tumors by measuring the degree of lesional enhancement; a 
modified approach has been proposed for assessment of enhancement pattern on 
conventional post-contrast MRI (25).  PET/CT has also been a useful modality in 
sarcomas that are initially FDG-avid, with a metabolic response (decrease in SUV) 
prior to radiographic changes in size (26).  PERCIST criteria for response have 
been developed and validated in solid tumors (27-28).  
Additionally, the use of novel functional MRI techniques, such as dynamic contrast 
enhanced imaging protocols, has been shown to be a useful non-invasive measure 
of response to therapy in sarcomas (29).  Recent advances have enabled functional 
MRI techniques to interrogate tissues at the cellular level.  This capability is 
particularly relevant in sarcomas since morphological parameters alone do not 
necessarily correlate with treatment response and prognosis.   Diffusion-weighted 
imaging (DWI) is based on the Brownian motion of molecules and of delineates 
areas of tissue with restricted diffusion; in general, areas of more restricted 
diffusion correlate to areas of higher cellularity.  DWI is particularly well suited to 
longitudinal evaluation of sarcomas with multiple studies in both osseous and soft 
tissue sarcomas showing significant decreases in restricted diffusion (30-31). 
Dynamic contrast-enhanced (DCE) MRI is based on rapid acquisition of post-
contrast sequences allowing for a map of tissue perfusion kinetics.  Recent trials 
have shown significant drops in DCE parameters after treatment of soft tissue 
sarcoma with targeted agents after two weeks of treatment (32); recent phase I trials 
have also confirmed corresponding drops in tumor with higher histologic necrosis, 
but these promising results have been based on very few subjects (n<10) (33).  In 
addition to more conventional measures of enhancing tumor fraction and kinetics, 
tissue heterogeneity has been shown to be a discriminator of responders from non-
responders (34-35).  Accurate quantification of these imaging parameters will 
likely require a volumetric approach to tumor segmentation, which will provide 
      
 
 
        
 
 


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optimal data for maximizing sensitivity for any real change in tumor composition 
or percentage necrosis.  Utilization of advanced MRI techniques will thus ensure 
that the most sensitive imaging parameters are those that will be employed to 
measure tumor response in this trial.
Interestingly, tumor imaging after the first weeks of anti-PD-1 therapy often shows 
an increase in tumor size, thought to be related to intra-tumor inflammation (36).  
In light of these paradoxical responses in the setting of checkpoint inhibitor therapy,  
immune-related response criteria (irRC) have been developed to more accurately 
account for early post-treatment changes in tumor size, and avoid erroneously 
discontinuing therapy in patients who will ultimately benefit.
While the official endpoint for this trial of concurrent axitinib/pembrolizumab in 
sarcomas will utilize RECIST v1.1, tumor response will also be assessed in parallel 
using Choi criteria and immune-related response criteria for patients utilizing CT 
for serial imaging, or modified Choi criteria and MRI volumetrics using dynamic 
contrast enhanced MRI sequences for patient being followed with MRI.  All 
patients will also have a pre-treatment PET/CT, and those patients with a positive 
PET at baseline will undergo additional on-treatment PET imaging.  The results 
from these non-traditional methods will be used to design future clinical trials in 
sarcoma in order to more accurately assess tumor response, particularly in the 
setting of immunotherapy.
1.7.3 Measurement of circulating tumor cells pre- and post-treatment, and correlation 
with tumor response and time to progression.  
Circulating tumor cells (CTC) have been detected in peripheral blood in patients 
with epithelial tumors, including metastatic breast, colon, and prostate cancer.  
Recent data suggests that the presence of CTC can be predictive and prognostic, 
and the CellSearch assay platform has been approved by the FDA to collect CTC 
before and after therapy, and assess response to treatment (37-38).  However, aside 
from high associated costs, this assay depends on enrichment of CTC based on their 
expression of EpCAM, a variably expressed cell surface marker, adversely 
affecting CTC enrichment. It is also likely that enumeration of CTCs alone may be 
inadequate as prognostic and predictive marker for clinical outcome and response 
to therapy; particular biomarkers expressed on CTCs may provide a wealth of 
additional information.
Importantly, although the utility of CTC analysis in other common malignancies 
has been widely demonstrated, very few studies have looked for circulating tumor 
cells in sarcoma patients and there are no studies evaluating their prognostic or 
predictive impact.  Previous reports have detected Ewing sarcoma CTC in blood 
and bone marrow using flow cytometry to isolate CD99+CD45- cells (39-40). Most 
recently, Satelli et al demonstrated that CTC with cell surface vimentin expression 
were detectable in human peripheral blood samples from patients with 
osteosarcoma, undifferentiated pleomorphic sarcoma, leiomyosarcoma, Ewing’s 
      
 
 
        
 
 


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sarcoma, and angiosarcoma (41).  Interestingly, patients with primary tumors had 
fewer CTC than patients with metastatic tumors.
Utilizing a unique, microfabricated parylene membrane-based device in 
collaboration with Ram Datar (42), we are currently collecting CTCs at various 
timepoints in sarcoma patients exploring whether CTC could serve as a marker of 
early micrometastatic disease in sarcomas, and may portend worse prognosis as 
seen in other tumor types.  Effects on circulating tumor cells are particularly 
interesting in light of immunotherapy, in hopes that a more effective CD8+ T-cell 
anti-tumor effect could decrease the presence of circulating tumor cells and 
decrease development of new metastatic sites.  Thus, peripheral blood samples will 
be drawn at selected timepoints and filtered to detect the numbers of circulating 
tumor cells using this technology.  The presence or absence of CTC will be 
correlated with tumor response.
2.0 OBJECTIVES
2.1 Primary Objective

To estimate progression-free survival rate at 3 months after concurrent axitinib and 
pembrolizumab therapy in patients with alveolar soft part sarcoma and other 
advanced soft tissue sarcomas.
2.2 Secondary Objectives

To estimate the objective response rate (ORR), clinical benefit rate (CBR), and 
progression-free survival (PFS) using RECIST 1.1, as well as overall survival (OS) 
in patients with ASPS and other advanced soft tissue sarcomas treated with 
concurrent axitinib and pembrolizumab.

To describe the safety and toxicity profile of axitinib with intrapatient dose titration 
combined with pembrolizumab therapy in patients with ASPS and other advanced 
soft tissue sarcomas.
2.3 Exploratory Objectives

To identify associations between clinical benefit status (CR/PR/SD vs. PD) and a) T-
cell infiltration; b) PD-1, PD-L1, PD-L2, TIM3, LAG3, and CTLA-4 expression 
categories in tumor tissue.  

To identify associations between progression-free status at 3 months (no progression 
vs. progression) and a) T-cell infiltration; b) PD-1, PD-L1, PD-L2, TIM3, LAG3, and 
CTLA-4 expression categories in tumor tissue.

To identify associations between clinical benefit status (CR/PR/SD vs. PD) and the 
absolute change (baseline to cycle 3, baseline to off-study, and cycle 3 to off-study) 
in each of the following T-cell subsets in peripheral blood and tumor tissue: (CD8+, 
      
 
 
        
 
 


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CD4+, T-regulatory, memory phenotype, naïve phenotype, Ki67+, PD-1+, TIM3+, 
LAG3+, CTLA4+).

To identify associations between progression-free status at 3 months (no progression 
vs. progression) and the absolute change (baseline to cycle 3, baseline to off-study, 
and cycle 3 to off-study) in each of the following T-cell subsets in peripheral blood 
and tumor tissue: (CD8+, CD4+, T-regulatory, memory phenotype, naïve phenotype, 
Ki67+, PD-1+, TIM3+, LAG3+, CTLA4+).

To identify associations between the progression-free status at 3 months (no 
progression vs. progression) and the change in genomic expression of angiogenesis 
and immune-related genes, as assessed by RNA expression in tumor biopsies and 
peripheral blood samples (collaboration with Nanostring, Simpatica Medicine).

In expansion cohort of ASPS patients, to identify associations between the 
progression-free status at 3 months (no progression vs. progression) with T cell clonal 
populations in tumor biopsies and peripheral blood cells.
To identify plasma angiogenic activity at baseline, cycle 1 day 8 representing axitinib monotherapy 
(ASPS expansion cohort only), and cycle 3 day 1. 

To describe the relationship between tumor response according to RECIST 1.1 and 
tumor response according to alternative radiologic methods including: a) Choi 
criteria, b) immune-related response criteria (irRC), c) MRI volumetrics, and d) 
PERCIST 1.0.  

To identify associations between clinical benefit status (CR/PR/SD vs. PD) by 
RECIST 1.1 and the absolute change (baseline to cycle 3, baseline to off-study, and 
cycle 3 to off-study) in quantity of circulating tumor cells (CTCs).

To identify associations between the progression-free status at 3 months (no 
progression vs. progression) and the absolute change (baseline to cycle 3, baseline to 
off-study, and cycle 3 to off-study) in quantity of circulating tumor cells (CTCs).
3.0 ENDPOINTS
3.1 Primary endpoint

The progression-free survival by RECIST v1.1 of sarcoma patients treated with 
concurrent axitinib/pembrolizumab therapy.  
Evaluable criteria:
Eligible subjects enrolled into the study that received 80% of scheduled axitinib doses 
and two infusions of pembrolizumab, have measurable disease at baseline and at least 
one post-baseline disease assessment.
      
 
 
        
 
 


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3.2 Secondary endpoints

The objective response (CR/PR), clinical benefit (CR/PR/SD), time to progression 
(TTP), and overall survival (OS) defined as time from study treatment initiation to 
first occurrence of progression by RECIST v1.1 or death of sarcoma patients treated 
with concurrent axitinib/pembrolizumab therapy.  
Evaluable criteria:
Eligible subjects enrolled into the study that received at least 80% of scheduled axitinib 
doses and two infusions of pembrolizumab, have measurable disease at baseline and at 
least one post-baseline disease assessment.

Adverse events, including dose-limiting toxicity and serious adverse events (grade 3 
or 4) will be graded using NCI CTCAE version 4.03.
Evaluable criteria: 
Eligible subjects enrolled into the study that receive at least one dose of both axitinib and 
pembrolizumab. Patients who withdraw from the study prior to week 2 for any reason 
other than DLT or other significant toxicity will not be considered evaluable for toxicity.
3.3 Exploratory endpoints

The quantity of CD3+ T-cells in peripheral blood and in tumor biopsies at each 
timepoint (baseline, cycle 3, and off-study).

The expression category in tumor tissue (none (0%), low (<5%), intermediate (5-
50%), or high (>50%) of PD-1, PD-L1, PD-L2, CTLA-4, TIM-3, LAG-3 at each 
timepoint (baseline, cycle 3, and off-study). 

The following T cell subsets will be studied in peripheral blood and tumor tissue:  
(CD4, CD8, T-reg, CTLA4, TIM3, LAG3, memory, naïve, PD-1, Ki67).  For each 
subset, the absolute change in the relevant marker(s) value will be calculated: 
o Cycle 3 marker value minus Baseline marker value
o Off-study marker value minus Cycle 3 marker value
o Off-study marker value minus Baseline marker value
Evaluable criteria:
Eligible subjects who receive at least one cycle of each study drug, and successfully 
undergo at least one post-treatment core biopsy and blood draw.  

Utilizing each of the alternative (non-RECIST) radiological criteria we will 
categorize clinical benefit status (CR/PR/SD vs PD).  CT and/or MRI with dynamic 
contrast enhanced sequences will be collected throughout the study at every disease 
evaluation and analyzed using Choi criteria, MRI volumetrics, and immune-related 
response criteria.  PET/CT will be obtained at baseline, Cycle 3, and off-study and 
tumor response determined by PERCIST 1.0.  
      
 
 
        
 
 


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Evaluable criteria:
Eligible patients who receive at least one cycle of each study drug and undergo at least 
one post-treatment radiographic imaging study.

The quantity of circulating tumor cells (CTCs) in peripheral blood will be measured 
at three timepoints:  1. Baseline, 2. Cycle 3, and 3. Off-study.  
Evaluable criteria:
Eligible patients who receive at least one cycle of each study drug and undergo at least 
one post-treatment blood sampling.

RNA expression of a panel of angiogenesis and immune related genes in tumor 
biopsies and peripheral blood samples. Expression profiles will be obtained at 
baseline and at Cycle 3 Day 1 on treatment. 
Evaluable criteria: Eligible patients who receive at least one cycle of study drug and 
undergo at least one post-treated radiographic imaging study.

T cell clonality indices in tumor and peripheral blood obtained at baseline and at 
Cycle 3 Day 1.  
Evaluable criteria: Eligible patients who receive at least one cycle of study drug and 
undergo at least one post-treated radiographic imaging study.

Plasma angiogenic activity at baseline and the ratio between on-treatment (either 
Cycle 1 Day 8 or Cycle 3 Day 1) and baseline.
Evaluable criteria:  Eligible patients who receive at least one cycle of study drug and 
undergo at least one post-treated radiographic imaging study.
4.0 SUBJECT RECRUITMENT & SCREENING
Subjects will be recruited at Sylvester Comprehensive Cancer Center via clinical practice 
offices.  Both men and women of all races and ethnic groups are eligible for this trial.  
Informed consent documents will be translated and available in English and Spanish.
The intervention in the study holds out a prospect of direct benefit that is important to the 
health or well-being of minors and is available only in the context of the research.  Thus 
minors 16 years of age and older are included in the subject population.
5.0 PATIENT SELECTION
5.1 Inclusion Criteria
1. Patients must have histologically confirmed sarcoma with pathology review required 
for any outside samples.  
2. The following histologies may be enrolled without prior treatment: 
      
 
 
        
 
 


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a.
alveolar soft part sarcoma, (NOTE: expansion only permits patients with 
ASPS)
b. clear cell sarcoma, 
c.
epithelioid hemangioendothelioma, and 
d. chordoma.
3. The following histologies may be enrolled ONLY if refractory to anthracycline-based 
chemotherapy or if the patient refuses to undergo standard of care treatment:
a.
synovial sarcoma, 
b. rhabdomyosarcoma, 
c.
malignant peripheral nerve sheath tumors, 
d. dedifferentiated, pleomorphic or myxoid/round cell liposarcoma, 
e.
leiomyosarcoma, 
f.
malignant phylloides tumor, 
g. high grade undifferentiated pleomorphic sarcomas (HGUPS/MFH),
h. angiosarcoma, 
i.
spindle cell sarcoma NOS
j.
malignant myoepithelioma.
4. The following histologies may be enrolled ONLY if refractory to at least one line of 
chemotherapy or if the patient refuses to undergo standard of care treatment:
a.
solitary fibrous tumor/hemangiopericytoma.
5. The following histologies may be enrolled ONLY if refractory to at least first-line 
targeted therapy or if the patient refuses to undergo standard of care treatment:
a.
gastrointestinal stromal tumors, 
b. extraskeletal myxoid chondrosarcoma, 
c.
PEComa.
6. Primary tumors of bone including Ewing’s sarcoma, osteosarcoma, and 
dedifferentiated chondrosarcoma may only be enrolled if there are measurable target 
lesions occurring in soft tissue and they are refractory to standard of care 
anthracycline-based chemotherapy.
7. Any other histology or standard of care treatment not specifically addressed will be 
reviewed by the principal investigator and pathologist for final determination of 
eligibility.  
8. Measurable disease as defined by RECIST v1.1 (provided in Section 14.0).  
9. Radiographic progression as defined by RECIST v1.1, based on comparison between 
two radiographic studies no greater than 6 months apart.
10. Inability to undergo complete resection of the disease by surgery.
11. Adequate organ function as defined in Table 2 (below): 
System
Laboratory Value
Hematological
Absolute neutrophil count 
(ANC)
≥1,000 /mcL
      
 
 
        
 
 


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Platelets
≥75,000 / mcL
Hemoglobin
≥8 g/dL without transfusion or EPO dependency 
(within 7 days of assessment)
Renal
Serum creatinine OR
Measured or calculateda 
creatinine clearance
(GFR can also be used in place 
of creatinine or CrCl)
≤1.5 X upper limit of normal (ULN) OR
≥60 mL/min for subject with creatinine levels > 1.5 X 
institutional ULN
Hepatic
Serum total bilirubin
≤ 1.5 X ULN OR
Direct bilirubin ≤ ULN for subjects with total bilirubin 
levels > 1.5 ULN
AST (SGOT) and ALT (SGPT) ≤ 2.5 X ULN  OR
≤ 5 X ULN for subjects with liver metastases
Albumin
>2.5 mg/dL
Coagulation
International Normalized Ratio 
(INR) or Prothrombin Time 
(PT)
Activated Partial 
Thromboplastin Time (aPTT)
≤1.5 X ULN unless subject is receiving anticoagulant 
therapy
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants
≤1.5 X ULN unless subject is receiving anticoagulant 
therapy
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants
a Creatinine clearance should be calculated per institutional standard.
Table 2. Adequate Organ Function Laboratory Values.
12. Age ≥ 16 years.
13. ECOG performance status of 0 or 1.
14. Patients must consent and be willing to undergo tumor core needle biopsies at three 
timepoints (1. baseline, 2. prior to starting Cycle 3, and 3. at off-study).  At least one 
tumor site must be amenable to biopsy in the judgment of the interventional 
radiologist.  
15. Female subject of childbearing potential should have a negative urine or serum 
pregnancy within 72 hours prior to receiving the first dose of study medication.  If 
the urine test is positive or cannot be confirmed as negative, a serum pregnancy test 
will be required.
16. Females of child bearing potential that are sexually active must agree to either 
practice 2 medically accepted highly effective methods of contraception at the same 
time or abstain from heterosexual intercourse from the time of signing the informed 
consent through 120 days after the last dose of study drug. See Appendix G for 
      
 
 
        
 
 


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protocol-approved highly effective methods of contraceptive combinations. Subjects 
of childbearing potential are those who have not been surgically sterilized or have not 
been free from menses for > 1 year.
a.
Negative test for pregnancy is required of females of child-bearing potential; A 
female of child bearing potential is any woman, regardless of sexual orientation 
or whether they have undergone tubal ligation, who meets the following criteria: 
1. has not undergone a hysterectomy or bilateral oophorectomy; or 2. has not 
been naturally postmenopausal for at least 24 consecutive months (i.e., has had 
menses at any time in the preceding 24 consecutive months or 730 days).
b. Conception while on treatment must be avoided
17. Male subjects 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.  
Prior history of vasectomy does NOT replace requirement for contraceptive use.
18. Suitable venous access to allow for all study related blood sampling 
19. Ability to understand and willingness to sign a written informed consent document.
20. For minors that are 16 to 18 years of age, assent and parental (or legally acceptable 
representative) written informed consent must be obtained. 
5.2 Exclusion Criteria
1. Prior therapy with axitinib.  Patients are permitted to have received prior tyrosine 
kinase inhibitor (TKI) therapy including imatinib, sunitinib, pazopanib, or similar.  
Patients may have received prior PD-1 or PD-L1 directed therapy.  
2. Hypersensitivity to axitinib, pembrolizumab or any of its excipients.
3. Patients may not be receiving any other investigational agents (within 4 weeks prior 
to Cycle 1, day 1).
4. Prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to Cycle 1, day 1 
or has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents 
administered more than 4 weeks earlier.
5. Patient has had prior chemotherapy, targeted small molecule therapy, or radiation 
therapy within 2 weeks prior to Cycle 1,  Day 1  or has not recovered (i.e., ≤ Grade 1 
or at baseline) from adverse events due to agents administered more than 4 weeks 
earlier.  Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and 
may qualify for the study.  Note:  If subject received major surgery, they must have 
recovered adequately from the toxicity and/or complications from the intervention 
prior to starting therapy. 
6. Additional known malignancy that is progressing or requires active treatment.  
Exceptions include basal cell carcinoma of the skin, or squamous cell carcinoma of 
the skin that has undergone potentially curative therapy, or in situ cervical cancer.   
7. Patients with end-organ dysfunction as defined in inclusion criterion (i.e. #11 above). 
8. Patients with bone-only lesions. 
9. Patients with underlying immune deficiency, chronic infections including HIV, 
hepatitis, or tuberculosis (TB) or autoimmune disease. 
      
 
 
        
 
 


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10. Patients with underlying hematologic issues including bleeding diathesis, known 
previous GI bleeding requiring intervention within the past 6 months, active 
pulmonary emboli or DVT that are not stable on anticoagulation regimen.
11. Has known history of, or any evidence of active, non-infectious pneumonitis. 
12. Has known active central nervous system (CNS) metastases and/or carcinomatous 
meningitis or leptomeningeal disease.  Subjects with previously treated brain 
metastases may participate provided they are stable (without evidence of progression 
by imaging for at least four weeks prior to the first dose of trial treatment and any 
neurologic symptoms have returned to baseline), have no evidence of new or 
enlarging brain metastases, and are not using steroids for at least 7 days prior to trial 
treatment.  This exception does not include carcinomatous meningitis which is 
excluded regardless of clinical stability.  
13. Concomitant (or receipt of) treatment with medications that may affect the 
metabolism of pembrolizumab and/or axitinib within 7 days prior to Cycle 1, day 1 
of axitinib.
14. Has received a live vaccine within 30 days of planned start of study therapy.  Note:  
Seasonal influenza vaccines for injection are generally inactivated flu vaccines and 
are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live 
attenuated vaccines, and are not allowed.
15. Is pregnant or breastfeeding, or expecting to conceive or father children within the 
projected duration of the trial, starting with the pre-screening or screening visit 
through 120 days after the last dose of trial treatment.
16. Any uncontrolled, intercurrent illness including but not limited to ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac 
arrhythmia
17. Prolonged QTc interval on Screening EKG >475 ms.
18. Ejection Fraction <40% by 2D ECHO at Screening. 
19. Any serious medical or psychiatric illness/condition including substance use 
disorders likely in the judgment of the Investigator(s) to interfere or limit compliance 
with study requirements/treatment.
20. 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.
      
 
 
        
 
 


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6.0 ENROLLMENT PROCEDURES
To enter a patient, the Investigator or Study Team will contact the Clinical Research Services’ 
(CRS) Representative.  All eligibility requirements must be reviewed prior to the patient 
entering the study.  The following information must be provided to the CRS Representative:
1) Completed and signed protocol-specific eligibility checklist;
2) All pages of the original signed informed consent form (ICF) including HIPAA Form 
B;
3) Relevant source documents including but limited to: subject medical history and 
physical exam, concomitant therapy, admission or discharge notes, diagnostic reports, 
pathologic confirmation of diagnosis, and relevant subject-specific written 
communication.
6.1 Cancellation Guidelines
If a patient does not receive protocol therapy, the patient may withdraw.  Contact the 
CRS Representative, or e-mail the information including the reasons for withdrawal 
within 10-business days. 
6.2 Emergency Registration
If an emergency registration takes place after business hours, the items listed above must 
be submitted by the next business day. 
6.3 Enrollment Procedure(s)
After all Enrollment Guidelines are met as described (above) a CRS Clinical Research 
Coordinator (CRC) will enroll the patient by entering the requisite information into the 
informatics software system (e.g. CIERRA) developed by the SCCC-Informatics Office 
to implement enrollment. This system will automatically generate a secure e-mail 
message to the appropriate study team members, i.e. CRC, CRORS, and the Research 
Pharmacist(s). 
Study treatment must be initiated within seven (7) days of enrollment.
7.0 STUDY DESIGN
The study will be a single-institution, open-label, single-arm phase II study. Since the primary 
endpoint is survival outcome (PFS) sample size calculation is based on a single-arm survival 
design. We will employ early stopping rules for lack of efficacy, based on previously reported 
historical controls (19% PFS at 3 months) and a large database suggesting that a progression-
free rate at 3 months of >40% correlates with an active drug in the second-line setting for 
patients with advanced sarcoma (43).  Patients will be treated with twice daily dosing of 
axitinib alone for the first 7 days, followed by concurrent axitinib administered twice daily at 
5 mg PO twice daily, plus intravenous administration of pembrolizumab every 21 days (Figure 
3).  Patients will be assessed every three weeks for toxicity.  After the first five patients are 
enrolled, we will assess safety of the combination.  If 2 or fewer patients exhibit DLT, we will 
      
 
 
        
 
 


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then proceed with intrapatient titration of axitinib dosing at each cycle based on the presence 
or absence of predefined toxicities (Section 7.1, Table 3).  Correlative studies characterizing 
T-cells in tumor tissue and in peripheral blood will be performed at three timepoints:  1. pre-
treatment, 2. on-treatment on cycle 3 day 1, and 3. off-study.  Additional exploratory imaging 
investigations, and assessment of circulating tumor cells are included for all patients (See 
Appendix F for complete description of correlative studies).
Figure 3. Schematic diagram of the study.  The first cycle of treatment will be seven weeks, with one 
week of axitinib alone prior to initiation of pembrolizumab.  Subsequently, six-week cycles of treatment consist 
of twice daily oral doses of axitinib administered continuously with intravenous (I.V.) administration of 
pembrolizumab on day 1 and 22.  The first five evaluable patients will be considered a safety lead-in, and will 
not have axitinib dose escalation above 5 mg PO bid.  If 2 or fewer patients in the safety lead-in develop DLT, 
axitinib will then be individually titrated based on toxicity beginning on cycle 2 day 1.  
7.1 Axitinib Dose Titration with Flat Dose of Pembrolizumab
In trials with dose escalation of pembrolizumab, no difference in response nor toxicity 
was noted in melanoma patients randomized to either 2 mg/kg every three weeks versus 
10 mg/kg every three weeks (44) [4].  Thus, this trial will utilize flat dosing of 
pembrolizumab based on equivalent pharmacokinetics with 200 mg flat dose compared 
to FDA approved dose of 2 mg/kg (Merck, Investigators Brochure).  However, increasing 
response rates were noted in patients who were escalated on axitinib therapy (17) [5].  
Given the younger age in general of sarcoma patients and lack of other comorbid medical 
conditions, we will incorporate individualized dose titration of axitinib based on toxicity 
to maximize exposure and likelihood of response.  Dose levels are summarized in Table 
3.  See Section 10.2 for toxicity criteria and dose titration rules.  
      
 
 
        
 
 


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Dose Level
Axitinib dose
Pembrolizumab dose 
-3
2 mg PO bid 
-2
3 mg PO bid
-1
4 mg PO bid
1 (Starting dose level)
5 mg PO bid (FDA-
approved)
2
6 mg PO bid
3
7 mg PO bid
4
8 mg PO bid
5
10 mg PO bid (maximum)
200 mg flat dose *
Table 3. Axitinib Dose Levels.  *Fixed dose based on simulations of population PK model for 
pembrolizumab suggesting consistency with previous 2 mg/kg dose (see Merck Investigator’s Brochure 
for pembrolizumab).
Based on the recently completed dose escalation trial of concurrent axitinib and 
pembrolizumab in renal cell carcinoma, estimated DLT rate is 30%.  Thus, we will 
conduct a safety review after the first 5 patients enrolled on the study during the first 
stage to ensure similar rates of DLT are noted in our patient population.
7.2 Dose-Limiting Toxicity (DLT) 
Dose-Limiting Toxicity (DLT) is defined as any one of the following Adverse Events 
(AEs) that occurs during the first cycle (49 days) and is considered by the Investigator to 
be related (possible, probable, or definite) to study drug, specifying attribution to axitinib, 
pembrolizumab, or both.  Management and dose modifications associated with the above 
AEs are outlined in Section 10.0 (Treatment/Dose Modifications). 
DLT is defined as any one of the following (Table 4 and 5): 
Lab Toxicity
AE
Patient Population 
Dose Limiting Toxicity 
Anemia 
(Hemoglobin)
All
<6.5 g/dl
Platelet count 
decreased
All
Grade 4 (<25,000mm3)
Febrile neutropenia 
All 
≥ Grade 3
Acute kidney injury
Does not resolve within 7 days
≥ Grade 3 (>3 x above baseline)
Proteinuria
Does note resolve within 7 days
≥ Grade 3
Liver function 
abnormalities 
(transaminitis/ 
hyperbilirubinemia)
If grade 2 (>1.5 - 3.0 x ULN ) at 
baseline, than any ≥50% increase 
from baseline that does not resolve 
within 7 days
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Table 4. Summary of Lab DLTs.
Non-Lab Toxicity 
AE
Patient Population 
Dose Limiting Toxicity 
Rash (acneiform or 
macro-papular)
All
≥ Grade 3 
Palmar-plantar 
erythrodysethesia 
syndrome
All
Grade 3
Hypertension
Uncontrollable to less than 150/90 
with maximal medical management 
within 7 days
≥ Grade 3 
Bronchopulmonary 
hemorrhage 
(hemoptysis)
All
≥ Grade 3
Mucositis oral 
(Stomatitis)
Non-responsive to maximal 
supportive medication within 7 days
≥ Grade 3
Other Non-Lab 
Toxicity 
All 
≥ Grade 3 with the 
EXCEPTION of the following: 
nausea, vomiting, diarrhea, 
constipation or edema 
controllable with medication 
within 7 days
grade 3 fever in the absence 
of infection or neutropenia
tumor flare defined as local 
pain, irritation or rash 
localized at sites of known or 
suspected tumor
transient grade 3 infusion 
reaction
grade 3 thromboembolic 
event IF patient is 
asymptomatic and initiated 
on anticoagulation – as there 
is a high prevalence in 
sarcomas, and this is difficult 
to attribute to study drug.
Table 5. Summary of Non-Lab DLTs.
      
 
 
        
 
 


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8.0 TREATMENT PLAN
A cycle of treatment will consist of concurrent axitinib and pembrolizumab therapy for 6 weeks 
(Figure 3, Table 6), except for cycle 1 which will be 7 weeks as detailed above.  Administration 
of axitinib shall occur continuously with pembrolizumab administered on day 8 and day 29 of 
the first cycle, and days 1 and 22 of the following cycles.  The first five patients will not be 
dose-escalated above 5 mg PO twice daily axitinib.  If these patients exhibit acceptable rates 
of DLT, starting with patient 6, dose-escalation of axitinib will be permitted.  No dose 
escalations will be permitted during cycle 1.  On day 1 of cycle 2 and the subsequent cycles, 
dose escalation of axitinib is permitted if toxicity is within the specified criteria.  No dose-
escalation will be conducted in the middle of any cycle.  Dose reduction or interruption is 
permitted in the case of toxicity at any time as per section 10.0.
Trial treatment should be administered after all procedures/assessments have been completed 
as detailed in Section 12.0.  Trial treatment may be administered up to 3 days before or after 
the scheduled Day 1 of each cycle due to administrative (e.g. scheduling) reasons.
Table 6. Treatment Schema: Axitinib and Pembrolizumab Concurrent Therapy
Cycle(s)
1
2
3, 4, 5, etc. until 
progression
Week(s)
1
2
3
4
5
6
7
1
2
3
4
5
6
1
2
3
4
5
6
Day(s)
1
8
1
5
2
2
2
9
3
6
4
3
1
8
1
5
2
2
2
9
36
1
8
1
5
2
2
2
9
3
6
Axitinib oral, 
BID 
continuously 
(uptitration 
permitted 
starting from 
cycle 2)
X
X X X X
X
X X X X
X
X
X
X X X X
X
X
Pembrolizuma
b IV q21 days
X
X
X
X
Imaging prior to every subsequent odd 
cycle (i.e. 3, 5, 7, 9, etc.)
X
X
      
 
 
        
 
 


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Once patients have completed two years of combination treatment with axitinib/pembrolizumab, 
pembrolizumab treatment will be stopped and patients will be treated with axitinib alone until 
progression. Each treatment cycle is 84 days (12 weeks) in length. Imaging will be performed 
every 12 weeks (±7 days). 
Table 7. Treatment Schema: Axitinib Monotherapy
For patients who progress while on axitinib monotherapy, pembrolizumab can be re-introduced 
and patients can be treated with the axitinib/pembrolizumab combination treatment for up to 17 
additional cycles (approximately 1 year). A cycle of treatment will consist of axitinib/ 
pembrolizumab combination therapy for 6 weeks (Table 8).  Administration of axitinib shall 
occur continuously with pembrolizumab administered on days 1 and 22.  
Once participants complete the additional year of axitinib/pembrolizumab treatment, they will 
continue with axitinib monotherapy indefinitely until they experience toxicity, withdrawal or 
consent, or as per the treating physician’s discretion. The indefinite axitinib monotherapy 
treatment schema will be the same as for the axitinib monotherapy (Table 7). 
Table 8. Treatment Schema: Axitinib/Pembrolizumab Combination Treatment for Patients 
who Progress while on Axitinib Monotherapy
Cycle(s)
1, 2, 3, etc. until progression
Week(s)
1
2
3
4
5
6
7
8
9
10
11
12
Day(s)
1
8
15
22
29
36
43
50
57
64
71
78
Axitinib oral, 
BID 
continuously 
X
X X
X
X
X
X
X
X
X
X
X
Imaging every 12 
weeks (+/- 7 days)
Cycle(s)
1, 2, 3, etc. up to 17 cycles (approximately 1 year)
Week(s)
1
2
3
4
5
6
Day(s)
1
8
15
22
29
36
Axitinib oral, 
BID 
continuously 
X
X
X
X
X
X
Pembrolizuma
b IV q21 days
X
X
Imaging prior to every subsequent 
odd cycle (i.e. 3, 5, 7, 9, etc.)
      
 
 
        
 
 


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First 2 years of 
combination 
Axitinib/Pembrolizu
mab treatment
Axitinib 
Monotherapy (until 
progression)
***
Combination 
Axitinib/Pembrolizumab 
treatment (Additional 
Year)
Agent
Premedications & Precautions
Dose
Route
Schedule
Cycle 
Length*
*
Schedule
Cycle 
Length
Schedule
Cycle 
Length
Axitinib
Premedicate with ondansetron 8 
mg orally if needed for nausea
Take daily doses 12 hours apart 
and swallow whole with or 
without food with a glass of water
*  5mg
PO BID
** Days 
1-42 
(week 1-
6)
Days 1-84 
(week 1-
12)
84 days 
(12 
weeks)
** Days 1-
42 (week 1-
6)
Pembrolizumab
Monitor for infusion reactions 
with hypersensitivity kit at 
bedside.
Grade 2 infusion reactions will be 
premedicated with 
diphenhydramine 50 mg IV and 
acetaminophen 1000 mg PO prior 
to subsequent infusions.
Diet: Subjects should maintain a 
normal diet unless modifications 
are required to manage an AE 
such as diarrhea, nausea or 
vomiting.
200 mg
IV 
infusion 
over 30 
minutes
(-5min/ 
+10min)
Cycle 1:  
Day 8, 29
Subseque
nt cycles:  
Day 1, 22
42 days
(6 
weeks) 
**
NA
NA
Each Cycle:  
Day 1, 22
42 days
(6 weeks) 
**
*Intrapatient dose escalation permitted after 5-patient safety lead-in as per protocol.
** Cycle 1 is 7 weeks with the first week consisting of axitinib alone.
*** Axitinib indefinite treatment will follow the same schedule as axitinib monotherapy
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8.1 Second Course Axitinib (Inlyta®)
All participants who complete the first two years of axitinib/pembrolizumab 
combination treatment may be eligible for axitinib monotherapy treatment until 
progression.
For participants who progress while on the axitinib monotherapy treatment, 
pembrolizumab can be re-introduced and participants will be treated with the 
axitinib/pembrolizumab combination treatment for up to 17 additional cycles 
(approximately 1 year). Once participants complete the additional year of 
axitinib/pembrolizumab treatment, they will continue with axitinib monotherapy 
indefinitely until they experience toxicity, withdrawal or consent, or as per the treating 
physician’s discretion.
This retreatment is termed the Second Course Phase of this study and is only available 
if the study remains open and the participant is receiving clinical benefit from 
treatment. 
8.2 Second Course Pembrolizumab
All participants who complete the first two years of axitinib/pembrolizumab 
combination treatment may be eligible for pembrolizumab retreatment if they progress 
while on axitinib monotherapy treatment. Pembrolizumab will be given as an 
axitinib/pembrolizumab combination treatment for up to 17 additional cycles 
(approximately 1 year).
Pembrolizumab re-introduction will be given for participants who progress while on 
axtinib monotherapy. This retreatment is termed the Second Course Phase of this study 
and is only available if the study remains open and the participant is receiving clinical 
benefit from treatment.
8.3 Axitinib (Inlyta®)
Axitinib shall be administered in the outpatient setting as either 5mg or multiple 1 mg 
tablets, orally (PO) twice a day (BID) continuously, with dose titration as per section 
10.0.  
Patients are to be advised that daily doses of axitinib shall be taken 12 hours apart with 
or without food and swallowed whole with a glass of water. 
For additional information on Axitinib including mechanism of action, drug metabolism, 
pharmacokinetics & toxicology, known side effects, composition, and storage 
recommendations, see [Section 9.1].
8.4 Pembrolizumab (Keytruda®)
Pembrolizumab 200 mg flat dose shall be administered in the outpatient setting as a 30 
minute intravenous (IV) infusion, once every 21 days.  The intravenous line should 
contain a sterile, non-pyrogenic, low-protein binding 0.2 micron to 5 micron in-line or 
      
 
 
        
 
 


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add-on filter. Do not co-administer other drugs through the same infusion line. Every 
effort to target infusion timing to be as close to 30 minutes as possible, should be made.  
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/+10min). 
For additional information on pembrolizumab including mechanism of action, drug 
metabolism, pharmacokinetics & toxicology, known side effects, composition, and 
storage recommendations, see [Section 9.2].
8.5 Treatment Dispensation, Compliance and Accountability
Concurrent administration of axitinib/pembrolizumab therapy will continue for each 
cycle until criteria for treatment discontinuation is/are met (See section 11.0). Once 
patients have completed two years of combination treatment with 
axitinib/pembrolizumab, pembrolizumab treatment will be stopped and patients will be 
treated with axitinib alone. For patients who progress while being on treatment with 
axitinib monotherapy, pembrolizumab can be re-introduced with the axitinib treatment, 
and patients can be treated with the axitinib/pembrolizumab treatment for up to an 
additional 17 cycles (approximately 1 year). 
8.5.1 Axitinib
During the first two years of axibitinib/pembrolizumab combination treatment, eligible 
patients will be dispensed the appropriate number of axitinib tablets required for at least 
21 days of dosing plus an additional 3-day supply to account for visit scheduling. 
Once participants have completed the first two years of axitinib/pembrolizumab 
combination treatment, eligible patients will be treated with axitinib monotherapy until 
progression. During this time, eligible patients will be dispensed the appropriate number 
of axitinib tablets required for at least 84 days of dosing plus an additional 3-day supply 
to account for visit scheduling. 
Pembrolizumab will be re-introduced for participants who progress while being treated 
with axitinib monotherapy. Eligible patients will be dispensed the appropriate number of 
axitinib tablets required for at least 21 days of dosing plus an additional 3-day supply to 
account for visit scheduling. 
Once participants complete the additional year of axitinib/pembrolizumab treatment, they 
will continue with axitinib monotherapy indefinitely until they experience toxicity, 
withdrawal or consent, or as per the treating physician’s discretion. During this time, 
eligible patients will be dispensed the appropriate number of axitinib tablets required for 
at least 84 days of dosing plus an additional 3-day supply to account for visit scheduling
Treatment compliance will be assessed based on return of unused axitinib tablets and a 
dosing diary. Eligible patients will be given a dosing diary for each treatment cycle.  Date, 
time, and dose should be recorded at each dosing time point to confirm that each BID 
dose of axitinib was taken for each day.
      
 
 
        
 
 


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The medication diary will be reviewed weekly during each week of axitinib 
administration (at a minimum during the first 3 weeks of each cycle, or otherwise noted) 
and returned to clinic staff at the end of each cycle.  See Appendix I for the dosing diary.  
During the first cycle of axitinib, or for the first three weeks after any dose escalation or 
reduction of axitinib, patients will also be asked to record their blood pressure at least 
once each day before their evening dose of axitinib.  See also Appendix I for the blood 
pressure diary.
If a dose of axitinib is missed due to patient error/oversight, then he/she should take the 
axitinib dose within 2 hours of the missed dose. If more than 2 hours have elapsed, that 
missed dose should be omitted, the patient should resume treatment at the next scheduled 
dosing time point, and the reason for missed dose reported on the dosing diary.  If the 
patient vomits, an additional dose should not be taken.  The next prescribed dose should 
be taken at the usual time. 
If a dose of axitinib is held due to AE, SAE, or at the investigator’s discretion, then he/she 
should resume treatment at the investigators discretion taking into account all of the dose 
modification/discontinuation guidelines provided in Section 10.0 Treatment/Dose 
Modifications.  
8.5.2 Pembrolizumab
Eligible subjects shall be treated with the investigational supply of pembrolizumab.  
Clinical supplies may not be used for any purpose other than that stated in the protocol.
Clinical supplies will be affixed with a clinical label in accordance with regulatory 
requirements.  Drug identity (name, strength) is included in the label text.  Clinical 
supplies must be stored in a secure, limited-access location under the storage conditions 
specified on the label.  
Receipt and dispensing of investigational product must be recorded by authorized 
person(s) at the trial site.  The Investigator is responsible for maintaining accurate records 
of the clinical supplies received from Merck, the amount dispensed to subjects and the 
amount remaining at the conclusion of the trial.  
Upon completion or termination of the study, all unused and/or partially used 
investigational product will be destroyed at the site per institutional policy.  It is the 
Investigator’s responsibility to arrange for the 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.
8.6 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 (AEs) with potential immunologic etiology are outlined below.  Where 
appropriate, these guidelines include the use of oral or intravenous treatment with 
      
 
 
        
 
 


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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.  
It may also become necessary to perform conditional procedures such as bronchoscopy, 
endoscopy, or skin photography as part of evaluation of the event.  Suggested conditional 
procedures for Events of Clinical Interest (ECI) associated with pembrolizumab, can be 
found in Appendix H. As appropriate, supportive care can be found in Section 8.0 for 
Axitinib.  
Diet: Subjects should maintain a normal diet unless modifications are required to manage 
an AE such as diarrhea, nausea or vomiting.
The treatment guidelines are intended to be applied when the Investigator(s) determine 
the events to be related (possible, probable or definite) to trial treatment.  Note: if after 
an evaluation the event is determined not to be related to the trial treatment, the 
Investigator is instructed to follow the reporting guidance in Appendix A (and Section 
15.0).  Refer to Section 10.0 for dose modification(s).  
8.4.1 Concurrent Medications 
Because there is a potential for interaction of axitinib 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 PI should be alerted if the patient is taking any agent know to affect or 
with the potential to affect selected CYP450 isoenzymes. Appendix E presents guidelines 
for identifying medications/substances that could potentially interact with the study 
agent, axitinib. CYP3A4/5 substrates are allowed as concomitant medication at physician 
discretion and will not be exclusionary for study participation.
Strong CYP3A4/5 Inhibitors: The concomitant use of strong CYP3A4/5 inhibitors 
should be avoided (e.g., ketoconazole, itraconazole, clarithromycin, atazanavir, 
indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole). 
Selection of an alternate concomitant medication with no or minimal CYP3A4/5 
inhibition potential is recommended. Although axitinib (INLYTA®) dose adjustment has 
not been studied in patients receiving strong CYP3A4/5 inhibitors, if a strong 
CYP3A4/5 inhibitor must be co-administered, a dose decrease of INLYTA by 
approximately half is recommended, as this dose reduction is predicted to adjust the 
axitinib area under the plasma concentration vs time curve (AUC) to the range observed 
without inhibitors. The subsequent doses can be increased or decreased based on 
individual safety and tolerability. If co-administration of the strong inhibitor is 
discontinued, the INLYTA dose should be returned (after 3 – 5 half-lives of the inhibitor) 
to that used prior to initiation of the strong CYP3A4/5 inhibitor.  
      
 
 
        
 
 


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Strong CYP3A4/5 Inducers: The concomitant use of strong CYP3A4/5 inducers should 
also be avoided (e.g. rifampin, dexamethasone, phenytoin, carbamazepine, rifabutin, 
rifapentin, phenobarbital and St. John’s wort).  Selection of concomitant medication with 
no or minimal CYP3A4/5 induction potential is recommended.  Moderate CYP3A4/5 
inducers (e.g. bosentan, efavirenz, etravirine, modafinil and nafcillin) should also be 
avoided if possible.
Appendix J provides a list of common CYP3A4 substrates, inhibitors and inducers. 
8.7 Concomitant Medications/ Vaccinations
Medications or vaccinations specifically prohibited in the exclusion criteria are not 
allowed during the ongoing trial.  If there is a clinical indication for one of these or other 
medications or vaccinations specifically prohibited during the trial, discontinuation from 
trial therapy or vaccination may be required.  The Investigator should discuss any 
questions regarding this with the Principal Investigator (PI).  The final decision on any 
supportive therapy or vaccination rests with these Investigator(s) and/or the subject’s 
primary physician.  
8.5.1 Acceptable Concomitant Medications 
All treatments that the Investigator considers necessary for a subject’s welfare may 
be administered at the discretion of the Investigator
8.5.2 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 and axitinib

Radiation therapy
o
Note: Radiation therapy to a symptomatic solitary lesion or to the brain 
may be allowed at the Investigator’s discretion

Live vaccines within 30 days prior to 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 sponsor and PI.  
Subjects who, in the assessment by the investigator, require the use of any of the 
aforementioned treatments for clinical management should be removed from the 
      
 
 
        
 
 


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trial.  Subjects may receive other medications that the investigator deems to be 
medically necessary.
The Exclusion Criteria describes other medications which are prohibited in this 
trial.
There are no prohibited therapies during the Post-Treatment Follow-up phase. 
8.8 Duration of Treatment
Trial therapy will last until withdrawal of consent, disease progression and/or 
unacceptable toxicity, whichever occurs first. 
8.9 Duration of Follow-Up 
All subjects will be followed at approximately 30-days (+5 days) after the last dose of 
trial treatment or before the initiation of a new anti-cancer treatment, whichever occurs 
first.  
Subjects who discontinue trial treatment for a reason other than disease progression will 
be assessed at least every 12 weeks (±7 days) to monitor disease status.  
Every effort should be made to collect information regarding disease status until the start 
of new anti-neoplastic therapy, disease progression, death, end of the study (EoS) or if 
new anti-neoplastic treatment is initiated. 
Following confirmed disease progression or initiation of new anti-cancer therapy, 
survival will be assessed (at a minimum) by telephone contact every 12 weeks (±7 days).  
See Section 12.5 for further details on Follow-Up assessments. 
8.10Telehealth
Patients unable to attend in-person study visits may conduct study visits via telehealth. 
Additionally, study assessments may be conducted locally and provided to treating 
physician for review. 
8.11Shipping of Investigational Product
Axitinib may be shipped to participants as per University of Miami or Pfizer policies. 
9.0 AGENTS (DRUG FORMULATION AND PROCUREMENT)
9.1 Axitinib
[Refer to the FDA-approved package insert for Axitinib (Inlyta®) for more 
information.]  
9.1.1 Other name(s)
Inlyta ®
9.1.2 Mechanism of Action
INLYTA (axitinib) is a kinase inhibitor. Axitinib has the chemical name N-methyl-
2-[3-((E)2-pyridin-2-yl-vinyl)-1H-indazol-6-ylsulfanyl]-benzamide. 
The 
molecular formula is C22H18N4OS and the molecular weight is 386.47 Daltons.
      
 
 
        
 
 


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Axitinib has been shown to inhibit receptor tyrosine kinases including vascular 
endothelial growth factor receptors (VEGFR)-1, VEGFR-2, and VEGFR-3 at 
therapeutic plasma concentrations. These receptors are implicated in pathologic 
angiogenesis, tumor growth, and cancer progression. VEGF-mediated endothelial 
cell proliferation and survival were inhibited by axitinib in vitro and in mouse 
models. Axitinib was shown to inhibit tumor growth and phosphorylation of 
VEGFR-2 in tumor xenograft mouse models.
9.1.3 Drug Metabolism, Pharmacokinetics and Toxicology
The population pharmacokinetic analysis pooled data from 17 trials in healthy 
subjects and patients with cancer. A two-compartment disposition model with first-
order absorption and lag-time adequately describes the axitinib concentration-time 
profile. 
Absorption and Distribution: Following single oral 5-mg dose administration, the 
median Tmax ranged from 2.5 to 4.1 hours. Based on the plasma half-life, steady 
state is expected within 2 to 3 days of dosing. Dosing of axitinib at 5 mg twice daily 
resulted in approximately 1.4-fold accumulation compared to administration of a 
single 
dose. 
At 
steady 
state, 
axitinib 
exhibits 
approximately 
linear 
pharmacokinetics within the 1-mg to 20-mg dose range. The mean absolute 
bioavailability of axitinib after an oral 5 mg dose is 58%. 
Compared to overnight fasting, administration of INLYTA with a moderate fat 
meal resulted in 10% lower AUC and a high fat, high-calorie meal resulted in 19% 
higher AUC. INLYTA can be administered with or without food [see Dosage and 
Administration (2.1)]. 
Axitinib is highly bound (>99%) to human plasma proteins with preferential 
binding to albumin and moderate binding to α1-acid glycoprotein. In patients with 
advanced RCC (n=20), at the 5 mg twice daily dose in the fed state, the geometric 
mean (CV%) Cmax and AUC0-24 were 27.8 (79%) ng/mL and 265 (77%) 
ng.h/mL, respectively. The geometric mean (CV%) clearance and apparent volume 
of distribution were 38 (80%) L/h and 160 (105%) L, respectively. 
Metabolism and Elimination: The plasma half life of INLYTA ranges from 2.5 to 
6.1 hours. Axitinib is metabolized primarily in the liver by CYP3A4/5 and to a 
lesser extent by CYP1A2, CYP2C19, and UGT1A1. Following oral administration 
of a 5-mg radioactive dose of axitinib, approximately 41% of the radioactivity was 
recovered in feces and approximately 23% was recovered in urine. Unchanged 
axitinib, accounting for 12% of the dose, was the major component identified in 
feces. Unchanged axitinib was not detected in urine; the carboxylic acid and 
sulfoxide metabolites accounted for the majority of radioactivity in urine. In 
plasma, the N-glucuronide metabolite represented the predominant radioactive 
component (50% of circulating radioactivity) and unchanged axitinib and the 
sulfoxide metabolite each accounted for approximately 20% of the circulating 
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The sulfoxide and N-glucuronide metabolites show approximately ≥400-fold less 
in vitro potency against VEGFR-2 compared to axitinib.
9.1.4 Management of Agent-Specific Adverse Events
Hypertension and Hypertensive Crisis 
In a controlled clinical study with INLYTA for the treatment of patients with RCC, 
hypertension was reported in 145/359 patients (40%) receiving INLYTA and 
103/355 patients (29%) receiving sorafenib. Grade 3/4 hypertension was observed 
in 56/359 patients (16%) receiving INLYTA and 39/355 patients (11%) receiving 
sorafenib. Hypertensive crisis was reported in 2/359 patients (<1%) receiving 
INLYTA and none of the patients receiving sorafenib. The median onset time for 
hypertension (systolic blood pressure >150 mmHg or diastolic blood pressure >100 
mmHg) was within the first month of the start of INLYTA treatment and blood 
pressure increases have been observed as early as 4 days after starting INLYTA. 
Hypertension 
was 
managed 
with 
standard 
antihypertensive 
therapy. 
Discontinuation of INLYTA treatment due to hypertension occurred in 1/359 
patients (<1%) receiving INLYTA and none of the patients receiving sorafenib.
Blood pressure should be well-controlled prior to initiating INLYTA. Patients 
should be monitored for hypertension and treated as needed with standard anti-
hypertensive therapy. In the case of persistent hypertension despite use of anti-
hypertensive medications, reduce the INLYTA dose. Discontinue INLYTA if 
hypertension is severe and persistent despite anti-hypertensive therapy and dose 
reduction of INLYTA, and discontinuation should be considered if there is 
evidence of hypertensive crisis. If INLYTA is interrupted, patients receiving 
antihypertensive medications should be monitored for hypotension.
Aneurysms and artery dissections
The use of Vascular Endothelial Growth Factor (VEGF) pathway inhibitors in 
patients with or without hypertension may promote the formation of aneurysms 
and/or artery dissections. Before initiating INLYTA, this risk should be carefully 
considered in patients with risk factors such as hypertension or history of 
aneurysm.
Thyroid Dysfunction 
In a controlled clinical study with INLYTA for the treatment of patients with RCC, 
hypothyroidism was reported in 69/359 patients (19%) receiving INLYTA and 
29/355 patients (8%) receiving sorafenib. Hyperthyroidism was reported in 4/359 
patients (1%) receiving INLYTA and 4/355 patients (1%) receiving sorafenib. In 
patients who had thyroid stimulating hormone (TSH) <5 μU/mL before treatment, 
elevations of TSH to ≥10 μU/mL occurred in 79/245 patients (32%) receiving 
INLYTA and 25/232 patients (11%) receiving sorafenib.
      
 
 
        
 
 


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Monitor thyroid function before initiation of, and periodically throughout, 
treatment with INLYTA. Treat hypothyroidism and hyperthyroidism according to 
standard medical practice to maintain euthyroid state.
Arterial Thromboembolic Events
In Phase 3 study A4061032 with INLYTA for the treatment of patients with RCC, 
Grade 3/4 arterial thromboembolic events were reported in 4/359 patients (1%) 
receiving INLYTA. The most frequent arterial thromboembolic event was 
transient ischemic attack (1%). Fatal cerebrovascular accident was reported in 
1/359 patients (<1%).
In pooled clinical studies with INLYTA for the treatment of patients with RCC, 
arterial thromboembolic events were reported in 19/672 patients (3%) receiving 
INLYTA. Grade 3 arterial thromboembolic events were reported in 8/672 patients 
(1%). Grade 4 arterial thromboembolic events were reported in 9/672 patients 
(1%). Fatal arterial thromboembolic events were reported in 2 patients (<1%) 
receiving INLYTA.
In monotherapy studies with INLYTA, arterial thromboembolic events (including 
transient ischemic attack, cerebrovascular accident, myocardial infarction, 
cerebral infarction, arterial embolism, lacunar infarction, and retinal artery 
occlusion) were reported in 16/699 subjects (2%).
INLYTA should be used with caution in patients who are at risk for, or who have 
a history of, these events. INLYTA has not been studied in patients who had an 
arterial thromboembolic event within the previous 12 months.
Venous Thromboembolic Events 
In Phase 3 study A4061032 with INLYTA for the treatment of patients with 
RCC, venous thromboembolic events were reported in 11/359 patients (3%) 
receiving INLYTA. Grade 3/4 venous thromboembolic events (including 
pulmonary embolism, deep vein thrombosis, and retinal-vein 
occlusion/thrombosis) were reported in 9/359 patients (3%). Fatal pulmonary 
embolism was reported in 1/359 patients (<1%).
In pooled clinical studies with INLYTA for the treatment of patients with RCC, 
venous thromboembolic events were reported in 19/672 patients (3%) receiving 
INLYTA. Grade 3 venous thromboembolic events were reported in 6/672 
patients (1%). Grade 4 venous thromboembolic events were reported in 8/672 
patients (1%). Fatal venous thromboembolic events were reported in 1/672 
patients (<1%) receiving INLYTA.
      
 
 
        
 
 


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INLYTA should be used with caution in patients who are at risk for, or who have 
a history of, these events. INLYTA has not been studied in patients who had a 
venous thromboembolic event within the previous 6 months.
Elevation of Hemoglobin or Hematocrit
Increases in hemoglobin or hematocrit, reflective of increases in red blood cell 
mass, may occur during treatment with INLYTA. An increase in red blood cell 
mass may increase the risk of thromboembolic events.
In Phase 3 study A4061032 with INLYTA for treatment of patients with RCC, 
elevated hemoglobin above the upper limit of normal (ULN) was observed in 
31/320 patients (10%) receiving INLYTA.
Monitor hemoglobin or hematocrit before initiation of, and periodically 
throughout, treatment with INLYTA. If hemoglobin or hematocrit becomes 
elevated above the normal level, patients should be treated according to standard 
medical practice to decrease hemoglobin or
hematocrit to an acceptable level.
Hemorrhage
In Phase 3 study A4061032 with INLYTA for the treatment of patients with 
RCC, hemorrhagic events were reported in 58/359 patients (16%) receiving 
INLYTA. The most common hemorrhagic events in patients treated with 
INLYTA were epistaxis (6%), hematuria (3%), hemoptysis (2%), and rectal 
hemorrhage (2%). Grade 3/4 hemorrhagic events (including cerebral hemorrhage, 
haematuria, hemoptysis, lower gastrointestinal hemorrhage, and melaena) were 
reported in 5/359 (1%) patients. Fatal hemorrhage (gastric hemorrhage) was 
reported in 1/359 patients (<1%) receiving INLYTA.
In pooled clinical studies with INLYTA for the treatment of patients with RCC, 
hemorrhagic events were reported in 173/672 patients (26%) receiving INLYTA. 
Grade 3 hemorrhagic events were reported in 20/672 patients (3%). Grade 4 
hemorrhagic events were reported in 7/672 patients (1%) and fatal hemorrhagic 
events were reported in 3/672 patients (<1%) receiving INLYTA.
INLYTA has not been studied in patients who have evidence of untreated brain 
metastasis or recent active gastrointestinal bleeding and should not be used in 
those patients. If any
bleeding requires medical intervention, temporarily interrupt the INLYTA dose.
Gastrointestinal Perforation and Fistula Formation
In Phase 3 study A4061032 with INLYTA for the treatment of patients with 
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INLYTA. In addition to cases of gastrointestinal perforation, fistulas were 
reported in 2/359 patients (1%). In pooled clinical studies with INLYTA for the 
treatment of patients with RCC, gastrointestinal perforation and fistula were 
reported in 13/672 patients (2%) receiving INLYTA. In monotherapy studies 
with INLYTA (N = 699), fatal gastrointestinal perforation was reported in 1/699 
patient (<1%).
Monitor for symptoms of gastrointestinal perforation periodically throughout 
treatment with INLYTA.
Wound Healing Complications
No formal studies of the effect of INLYTA on wound healing have been 
conducted. In Phase 3 study A4061032 with INLYTA for the treatment of patients 
with RCC, all-causality adverse events suggestive of wound healing complications 
were reported in 4/359 patients (1%).
Treatment with INLYTA should be stopped at least 24 hours prior to scheduled 
surgery. The decision to resume INLYTA therapy after surgery should be based 
on clinical judgment of
adequate wound healing.
Reversible Posterior Leukoencephalopathy Syndrome/Posterior Reversible 
Encephalopathy Syndrome
In Phase 3 study A4061032 with INLYTA for the treatment of patients with RCC, 
reversible posterior leukoencephalopathy syndrome (RPLS)/posterior reversible 
encephalopathy syndrome (PRES) was reported in 1/359 patients (<1%).
In pooled clinical studies with INLYTA for the treatment of patients with RCC, 
RPLS was reported in 2/672 patients (<1%) receiving INLYTA.
RPLS/PRES is a neurological disorder which can present with headache, seizure, 
lethargy, confusion, blindness and other visual and neurologic disturbances. Mild 
to severe hypertension may be present. Magnetic resonance imaging is necessary 
to confirm the diagnosis of RPLS/PRES. In patients with signs/symptoms of 
RPLS/PRES, temporarily interrupt or permanently discontinue INLYTA. The 
safety of reinitiating INLYTA therapy in patients previously experiencing 
RPLS/PRES is not known.
Proteinuria 
In a controlled clinical study with INLYTA for the treatment of patients with RCC, 
proteinuria was reported in 39/359 patients (11%) receiving INLYTA and 26/355 
patients (7%) receiving sorafenib. Grade 3 proteinuria was reported in 11/359 
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Monitoring for proteinuria before initiation of, and periodically throughout, 
treatment with INLYTA is recommended. For patients who develop moderate to 
severe proteinuria, reduce the dose or temporarily interrupt INLYTA treatment. 
Elevation of Liver Enzymes 
In a controlled clinical study with INLYTA for the treatment of patients with RCC, 
alanine aminotransferase (ALT) elevations of all grades occurred in 22% of patients 
on both arms, with Grade 3/4 events in <1% of patients on the INLYTA arm and 
2% of patients on the sorafenib arm. 
Monitor ALT, aspartate aminotransferase (AST) and bilirubin before initiation of 
and periodically throughout treatment with INLYTA. 
Hepatic Impairment
In clinical studies with INLYTA, the systemic exposure to INLYTA was 
approximately 2-fold higher in subjects with moderate hepatic impairment (Child-
Pugh class B) compared to subjects with normal hepatic function. A dose 
decrease is recommended when administering INLYTA to patients with moderate 
hepatic impairment (Child-Pugh class B). INLYTA has not been studied in 
patients with severe hepatic impairment (Child-Pugh class C).
9.1.5 Composition
Axitinib is a white to light-yellow powder with a pKa of 4.8. The solubility of 
axitinib in aqueous media over the range pH 1.1 to pH 7.8 is in excess of 0.2 μg/mL. 
The partition coefficient (noctanol/water) is 3.5. 
INLYTA is supplied as red, film-coated tablets containing either 1 mg or 5 mg of 
axitinib together with microcrystalline cellulose, lactose monohydrate, 
croscarmellose sodium, magnesium stearate, and Opadry® II red 32K15441 as 
inactive ingredients. The Opadry II red 32K15441 film coating contains lactose 
monohydrate, HPMC 2910/Hypromellose 15cP, titanium dioxide, triacetin 
(glycerol triacetate), and red iron oxide. 
9.1.6 Storage Recommendations and Dosage Forms
INLYTA tablets are supplied as follows: 
1 mg tablets are red film-coated, oval tablets debossed with “Pfizer” on one side 
and “1 XNB” on the other; available in bottles of 180: NDC 0069-0145-01. 
5 mg tablets are red film-coated, triangular tablets debossed with “Pfizer” on one 
side and “5 XNB” on the other; available in bottles of 60: NDC 0069-0151-11. 
Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F 
to 86°F) [see USP Controlled Room Temperature]. 
9.1.7 Dispensation and Accountability
      
 
 
        
 
 


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For this study, axitinib (Inlyta®) will be provided by Pfizer as 1 mg and/or 5 mg 
tablets.  (See also Section 8.5.1 Treatment Dispensation, Compliance and 
Accountability for Axitinib.) 
9.2 Pembrolizumab
[Refer to the FDA-approved package insert for pembrolizumab (Keytruda®) for more 
information.]  
9.2.1 Other name(s)
MK-3475, Keytruda ®
9.2.2 Mechanism of Action
MK-3475 is a potent and highly selective humanized mAb designed to block the 
interaction between PD-1 and its ligands, PD-L1 and PD-L2. MK-3475 potently 
blocks binding to both ligands with half maximal inhibitory concentration (IC50) 
values below 1 nM. MK-3475 enhances T cell responses in human donor blood cell 
cultures with an EC50 of ~0.1 to 0.3 nM. MK-3475 binds to cynomolgus PD-1 with 
similar affinity, blocking activity, and demonstrates equivalent enhancement of 
cynomolgus T cell responses. It does not cross-react with rodent PD-1.  MK-3475 
strongly enhances T lymphocyte immune responses in cultured blood cells from 
healthy human donors, cancer patients, and primates. The antibody potentiates 
existing immune responses only in the presence of antigen-receptor stimulation and 
does not nonspecifically activate all T cells.  Using an anti-mouse PD-1 analog 
antibody, PD-1 blockade is demonstrated to significantly inhibit tumor growth in a 
variety of syngeneic murine tumor models. In experiments in mice, anti-PD-1 
therapy is synergistic with chemotherapeutic agents such as gemcitabine and 5-FU 
and combination therapy results in increased efficacy and increased complete 
regression rates in vivo.
Pembrolizumab is generally well tolerated and demonstrates a favorable safety 
profile in comparison to chemotherapy. Pembrolizumab is an immunomodulatory 
agent, and based on this mechanism of action, immune mediated adverse events are 
of primary concern.
9.2.3 Drug Metabolism, Pharmacokinetics and Toxicology
No traditional metabolism studies were conducted with pembrolizumab per current 
ICH S6 (R1) guidance on preclinical safety evaluation of biotechnology-derived 
pharmaceuticals. However, in vivo studies were conducted in C.B17 SCID mice to 
demonstrate the lack of Fab-arm or half molecule exchange for pembrolizumab.  
IgG4 wild type molecules can undergo in vitro and in vivo molecular rearrangement 
called Fab-arm (or half molecule) exchange by swapping their half molecule with 
other IgG4 half molecules, thereby generating bispecific or hybrid antibodies.  A 
point mutation (S228P) in the core hinge region in IgG4 has been shown to be 
sufficient to prevent the Fab-arm exchange.  The results supported that 
      
 
 
        
 
 


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pembrolizumab, which has a hinge mutation from S to P at position 228, did not 
form detectable hybrid antibodies with co-administered wild type IgG4 molecules 
in vivo in SCID mice.  This observation is consistent with the results of extensive 
in vitro characterization of pembrolizumab and indicates that pembrolizumab is not 
likely to engage in Fab-arm exchange in humans.
The pharmacokinetics of pembrolizumab was studied in 479 patients who received 
doses of 1 to 10 mg/kg every 2 weeks or 2 to 10 mg/kg every 3 weeks. Based on a 
population pharmacokinetic analysis, the mean [% coefficient of variation (CV%)] 
clearance (CL) is 0.22 L/day (28%) and the mean (CV%) elimination half-life (t1/2) 
is 26 days (24%). Steady-state concentrations of pembrolizumab were reached by 
18 weeks of repeated dosing with an every 3-week regimen and the systemic 
accumulation was 2.1-fold. The peak concentration (Cmax), trough concentration 
(Cmin), and area under the plasma concentration versus time curve at steady state 
(AUCss) of pembrolizumab increased dose proportionally in the dose range of 2 to 
10 mg/kg every 3 weeks.  In animal models, inhibition of PD-1 signaling resulted 
in an increased incidence of infections and enhanced inflammatory responses. M. 
tuberculosis-infected PD-1 knockout mice exhibit markedly decreased survival 
compared with wild-type controls, which correlated with increased bacterial 
proliferation and inflammatory responses in these animals. PD-1 knockout mice 
have also shown decreased survival following infection with lymphocytic 
choriomeningitis 
virus 
(LCMV). 
Administration 
of 
pembrolizumab 
in 
chimpanzees with naturally occurring chronic hepatitis B infection resulted in two 
out of four animals with significantly increased levels of serum ALT, AST, and 
GGT, which persisted for at least 1 month after discontinuation of pembrolizumab.
The preclinical toxicology program for pembrolizumab is compliant with 
preclinical safety assessment guidelines for biotechnology products.  Preclinical 
toxicity studies consisted of a 1-month repeat-dose study with a 4-month recovery 
period in Cynomolgus monkeys and a 6-month repeat-dose study with a 4-month 
recovery period in Cynomolgus monkeys.  Additional studies consist of tissue 
cross-reactivity studies in both normal human and Cynomolgus monkey tissues.  In 
conclusion, pembrolizumab administered once every other week over 6-month 
duration to Cynomolgus monkeys was well tolerated, with systemic exposure 
(AUC) up to approximately 67,500 µg.day/mL, and the no observed adverse effect 
level (NOAEL) was ≥200mg/kg/dose (the highest dose tested).
9.2.4 Management of Agent-Specific Adverse Events
Important identified risks for pembrolizumab are of an immune mediate nature, 
including: 
pneumonitis, 
colitis, 
thyroid 
disorders 
(hypothryoidism/hyperthyroidism), hepatitis, hypophysitis, Type I diabetes 
mellitis, uveitis, and nephritis. After a recent review of data, events newly 
characterized as identified risks also include pancreatitis, myositis, and severe skin 
reaction; these are included in the reference safety information below. The majority 
of immune-mediated adverse events were mild to moderate in severity, were 
      
 
 
        
 
 


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manageable with appropriate care, and rarely required discontinuation of therapy. 
Further details around frequency, reporting, and management of immune-related 
adverse events (irAEs) are described below. In addition to the previously noted 
identified risks, infusion-related reactions are a risk but are not considered immune 
mediated; these are further described below.  (An irAE is defined as a clinically 
significant AE of any organ that is associated with study drug exposure, is of 
unknown etiology, and is consistent with an immune-related mechanism.)
Clinical Trials Experience
The safety of KEYTRUDA was investigated in two controlled, randomized 
studies (KEYNOTE-002 and KEYNOTE-006) for the treatment of unresectable 
or metastatic melanoma and in an uncontrolled, open-label study (KEYNOTE-
001) for the treatment of unresectable or metastatic melanoma and metastatic non-
small cell lung carcinoma (NSCLC). Overall, 1567 subjects with melanoma (699 
previously treated with ipilimumab and 868 naïve to ipilimumab) and 550 
subjects with NSCLC were treated. Safety is described for the pooled population 
of 2117 subjects (studied across three doses; 2 mg/kg every 3 weeks and 10 
mg/kg every 2 or 3 weeks). The median treatment duration was 4.6 months (range 
1 day to 28.3 months) including 906 subjects treated for greater than or equal to 6 
months and 203 subjects treated for greater than or equal to one year.
KEYTRUDA was discontinued for treatment-related adverse reactions in 4% of 
subjects. Treatment-related serious adverse events (SAEs) reported up to 90 days 
after the last dose occurred in 9% of subjects receiving KEYTRUDA. Of these 
treatment-related SAEs, those occurring in more than five subjects (out of 2117) 
were pneumonitis (n=24), colitis (n=19), diarrhea (n=16), pyrexia (n=8), adrenal 
insufficiency (n=6) and autoimmune hepatitis (n=6).
Immune-Related Adverse Events (irAEs)
An irAE is defined as a clinically significant AE of any organ that is associated 
with study drug exposure, is of unknown etiology, and is consistent with an 
immune-related mechanism. AEs of Special Interest (AEOSI) data for melanoma 
and lung subjects demonstrates that irAEs were reported in 16.1% of subjects 
(251 of 1562) overall; AEOSI were considered by the Investigators to be drug 
related in 14.3% of subjects (223 of 1562). The majority of AEOSI were Grade 1 
or 2 in severity. Overall, serious AEOSI occurred in 4.2% of subjects at 2 mg/kg 
Q3W, 3.7% of subjects at 10 mg/kg Q3W, and 3.9% of subjects at 10 mg/kg 
Q2W. There was one AEOSI (pneumonitis) related to death in 10 mg/kg Q3W 
arm, in a subject with NSCLC.
The rate of discontinuation due to AEOSI was low (2.6%). The most commonly 
reported immune-related adverse events across the dose schedules are 
hypothyroidism (7.2%), pneumonitis (2.9%), hyperthyroidism (2.2%), colitis 
(1.3%) and skin AEOSI (1.3% including all terms). Based on the mechanism of 
      
 
 
        
 
 


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action of MK-3475 and similar immunomodulatory agents, the Sponsor is 
interested in potential irAEs, and encourages appropriate investigation of signs 
and symptoms suggestive of these.
Consultation with the appropriate medical specialist should be considered when 
investigating a possible irAE. These events can occur after the first dose to several 
months after the last dose of treatment. Mild irAEs are usually treated 
symptomatically and do not require dosing delays or discontinuation. Higher 
grade and persistent lower grade irAEs typically necessitate withholding or 
discontinuing treatment and administration of systemic steroids or other 
immunosuppressive agents (such as tumor necrosis factor blockers), when 
systemic steroids are not effective. Early recognition of irAEs and initiation of 
treatment are critical to reduce the risk of complications, since the majority of 
irAEs are reversible with the use of steroids and other immune suppressants.
Identification and Treatment of irAEs
If an irAE is suspected, a thorough evaluation should be conducted in an effort to 
possibly rule out neoplastic, infectious, metabolic, toxin or other etiologic causes 
prior to diagnosing an irAE. Serological, immunological, and histological 
(biopsy) data should be considered to support the diagnosis of an immune-related 
toxicity.
A separate document entitled Pembrolizumab Program (MK-3475) Event of 
Clinical Interest Guidance Document is maintained and distributed to 
investigational sites along with this IB and study protocols. Please refer to this 
guidance document in conjunction with this IB when assessing irAEs. Updates 
and modifications to the irAE guidance document will be made and distributed to 
Investigators to provide the most current information, and therefore will be 
independent of the IB update cycle.
It is possible that irAEs other than those listed in the guidance document may be 
observed in subjects receiving pembrolizumab; therefore, all AEs of unknown 
etiology associated with drug exposure should be evaluated to determine if it is 
possibly immune related. This is meant to be a general guidance; therefore, 
recommendations in the current document might not be all inclusive. As such 
Investigators are encouraged to contact a Merck Clinical Monitor as needed to 
discuss cases that warrant separate discussion outside of the scope of current 
guidelines. Permanent discontinuation of pembrolizumab due to irAE may be 
subject of discussion between the SPONSOR and treating Investigator. The 
general approach to handling irAEs can be found in Appendix I.
All AEs are to be graded according to National Cancer Institute Common 
Terminology Criteria for Adverse Events (NCI CTCAE), version 4.0 
(http://ctep.cancer.gov).
      
 
 
        
 
 


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If an irAE does not resolve or improve to ≤ Grade 1 within 12 weeks after last 
administration of pembrolizumab, study therapy discontinuation should be 
considered after discussion with a Merck Clinical Director.
Immune-Mediated Pneumonitis
Pneumonitis occurred in 12 (2.9%) of 411 melanoma patients, including Grade 2 
or 3 cases in 8 (1.9%) and 1 (0.2%) patients, respectively, receiving KEYTRUDA 
in Trial 1. The median time to development of pneumonitis was 5 months (range 
0.3 weeks-9.9 months). The median duration was 4.9 months (range 1 week-14.4 
months). Five of eight patients with Grade 2 and the one patient with Grade 3 
pneumonitis required initial treatment with high-dose systemic corticosteroids 
(greater than or equal to 40 mg prednisone or equivalent per day) followed by a 
corticosteroid taper. The median initial dose of high-dose corticosteroid treatment 
was 63.4 mg/day of prednisone or equivalent with a median duration of treatment 
of 3 days (range 1-34) followed by a corticosteroid taper. Pneumonitis led to 
discontinuation of KEYTRUDA in 3 (0.7%) patients. Pneumonitis completely 
resolved in seven of the nine patients with Grade 2-3 pneumonitis. Pneumonitis 
(including fatal cases) has been reported in subjects receiving KEYTRUDA. 
Monitor patients for signs and symptoms of pneumonitis. Evaluate patients with 
suspected pneumonitis with radiographic imaging and administer corticosteroids 
for Grade 2 or greater pneumonitis (initial dose of 1-2 mg/kg/day prednisone or 
equivalent followed by a taper). Withhold KEYTRUDA for moderate (Grade 2) 
pneumonitis, and permanently discontinue KEYTRUDA for severe (Grade 3), life-
threatening (Grade 4) or recurrent moderate (Grade 2) pneumonitis. (See Immune-
mediated adverse reactions below.)
Immune-Mediated Colitis
Colitis (including microscopic colitis) occurred in 4 (1%) of 411 patients, including 
Grade 2 or 3 cases in 1 (0.2%) and 2 (0.5%) patients, respectively, receiving 
KEYTRUDA in Trial 1. The median time to onset of colitis was 6.5 months (range 
2.3-9.8). The median duration was 2.6 months (range 0.6 weeks-3.6 months). All 
three patients with Grade 2 or 3 colitis were treated with high-dose corticosteroids 
(greater than or equal to 40 mg prednisone or  quivalent per day) with a median 
initial dose of 70 mg/day of prednisone or equivalent; the median duration of initial 
treatment was 7 days (range 4-41), followed by a corticosteroid taper. One patient 
(0.2%) required permanent discontinuation of KEYTRUDA due to colitis. All four 
patients with colitis experienced complete resolution of the event. Monitor patients 
for signs and symptoms of colitis. Administer corticosteroids for Grade 2 or greater 
colitis. Withhold KEYTRUDA for moderate (Grade 2) or severe (Grade 3) colitis, 
and permanently discontinue KEYTRUDA for life-threatening (Grade 4) colitis.
Immune-Mediated Hepatitis
Hepatitis (including autoimmune hepatitis) occurred in 2 (0.5%) of 411 patients, 
including a Grade 4 case in 1 (0.2%) patient, receiving KEYTRUDA in Trial 1. The 
time to onset was 22 days for the case of Grade 4 hepatitis which lasted 1.1 months. 
The patient with Grade 4 hepatitis permanently discontinued KEYTRUDA and was 
      
 
 
        
 
 


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treated with high-dose (greater than or equal to 40 mg prednisone or equivalent per 
day) systemic corticosteroids followed by a corticosteroid taper. Both patients with 
hepatitis experienced complete resolution of the event. Monitor patients for 
changes in liver function. Administer corticosteroids for Grade 2 or greater hepatitis 
and, based on severity of liver enzyme elevations, withhold or discontinue 
KEYTRUDA.
Immune-Mediated Hypophysitis
Hypophysitis occurred in 2 (0.5%) of 411 patients, consisting of one Grade 2 and 
one Grade 4 case (0.2% each), in patients receiving KEYTRUDA in Trial 1. The 
time to onset was 1.7 months for the patient with Grade 4 hypophysitis and 1.3 
months for the patient with Grade 2 hypophysitis. Both patients were treated with 
high-dose (greater than or equal to 40 mg prednisone or equivalent per day) 
corticosteroids followed by a corticosteroid taper and remained on a physiologic 
replacement dose. Monitor for signs and symptoms of hypophysitis. Administer 
corticosteroids for Grade 2 or greater hypophysitis. Withhold KEYTRUDA for 
moderate (Grade 2) hypophysitis, withhold or discontinue KEYTRUDA for severe 
(Grade 3) hypophysitis, and permanently discontinue KEYTRUDA for 
lifethreatening (Grade 4) hypophysitis.
Renal Failure and Immune-Mediated Nephritis
Nephritis occurred in 3 (0.7%) patients, consisting of one case of Grade 2 
autoimmune nephritis (0.2%) and two cases of interstitial nephritis with renal 
failure (0.5%), one Grade 3 and one Grade 4. The time to onset of autoimmune 
nephritis was 11.6 months after the first dose of KEYTRUDA (5 months after the 
last dose) and lasted 3.2 months; this patient did not have a biopsy. Acute interstitial 
nephritis was confirmed by renal biopsy in two patients with Grades 3-4 renal 
failure. All three patients fully recovered renal function with treatment with high-
dose corticosteroids (greater than or equal to 40 mg prednisone or equivalent per 
day) followed by a corticosteroid taper.
Monitor patients for changes in renal function. Administer corticosteroids for 
Grade 2 or greater nephritis. Withhold KEYTRUDA for moderate (Grade 2) 
nephritis, and permanently discontinue KEYTRUDA for severe (Grade 3), or life-
threatening (Grade 4) nephritis.
Immune-Mediated Hyperthyroidism and Hypothyroidism
Hyperthyroidism occurred in 5 (1.2%) of 411 patients, including Grade 2 or 3 cases 
in 2 (0.5%) and 1 (0.2%) patients, respectively, receiving KEYTRUDA in Trial 1. 
The median time to onset was 1.5 months (range 0.5-2.1). The median duration was 
2.8 months (range 0.9 to 6.1). One of two patients with Grade 2 and the one patient 
with Grade 3 hyperthyroidism required initial treatment with high-dose 
corticosteroids (greater than or equal to 40 mg prednisone or equivalent per day) 
followed by a corticosteroid taper. One patient (0.2%) required permanent 
discontinuation of KEYTRUDA due to hyperthyroidism. All five patients with 
hyperthyroidism experienced complete resolution of the event. Hypothyroidism 
occurred in 34 (8.3%) of 411 patients, including a Grade 3 case in 1 (0.2%) patient, 
      
 
 
        
 
 


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receiving KEYTRUDA in Trial 1. The median time to onset of hypothyroidism was 
3.5 months (range 0.7 weeks-19 months). All but two of the patients with 
hypothyroidism were treated with long-term thyroid hormone replacement therapy. 
The other two patients only required short-term thyroid hormone replacement 
therapy. No patient received corticosteroids or discontinued KEYTRUDA for 
management of hypothyroidism. Thyroid disorders can occur at any time during 
treatment. Monitor patients for changes in thyroid function (at the start of treatment, 
periodically during treatment, and as indicated based on clinical evaluation) and for 
clinical signs and symptoms of thyroid disorders. Administer corticosteroids for 
Grade 3 or greater hyperthyroidism, withhold KEYTRUDA for severe (Grade 3) 
hyperthyroidism, and permanently discontinue KEYTRUDA for life-threatening 
(Grade 4) hyperthyroidism. Isolated hypothyroidism may be managed with 
replacement therapy without treatment interruption and without corticosteroids.
Other Immune-Mediated Adverse Reactions
Other clinically important immune-mediated adverse reactions can occur. The 
following clinically significant, immune-mediated adverse reactions occurred in 
less than 1% of patients treated with KEYTRUDA in Trial 1: exfoliative dermatitis, 
uveitis, arthritis, myositis, pancreatitis, hemolytic anemia, partial seizures arising 
in a patient with inflammatory foci in brain parenchyma, Guillain-Barré syndrome, 
vitiligo and adrenal insufficiency.  Across clinical studies with KEYTRUDA in 
approximately 2000 patients, the following additional clinically significant, 
immune-mediated adverse reactions were reported in less than 1% of patients: 
myasthenic syndrome, optic neuritis, and rhabdomyolysis. For suspected immune-
mediated adverse reactions, ensure adequate evaluation to confirm etiology or 
exclude other causes. Based on the severity of the adverse reaction, withhold 
KEYTRUDA and administer corticosteroids. Upon improvement to Grade 1 or 
less, initiate corticosteroid taper and continue to taper over at least 1 month. Based 
on limited data from clinical studies in subjects whose immune-related adverse 
reactions could not be controlled with corticosteroid use, administration of other 
systemic immunosuppressants can be considered. Restart KEYTRUDA if the 
adverse reaction remains at Grade 1 or less. Permanently discontinue KEYTRUDA 
for any severe or Grade 3 immune-mediated adverse reaction that recurs and for 
any life-threatening immune-mediated adverse reaction
Infusion Reactions 
Infusion reactions have been reported with pembrolizumab at a rate of 2.5%; these 
were generally Grade 1 and 2 and the majority were considered related by the 
Investigator. One event of Grade 4 anaphylaxis has been reported. Infusion 
reactions may present as allergic reaction, serum sickness, infusion reaction, 
cytokine release syndrome, or anaphylaxis. Mild infusion reactions can generally 
be treated with interruption of the infusion and medical intervention including IV 
fluids, antihistamines, nonsteroidal antiinflammatory drugs, acetaminophen, and 
narcotics as needed. More severe or life thereatening reactions may require 
pressors, corticosteroids, and epinephrine. Pembrolizumab therapy should not be 
redosed in these more severe cases.
      
 
 
        
 
 


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Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
One fatal case of SJS in a clinical trial and one fatal case of TEN in the post-
marketing setting have been reported in patients treated with Pembrolizumab.  In 
total 8 cases of SJS and 2 cases of TEN all of which were serious.  The risk of SJS 
and TEN is reported at approximately 0.4 – 7 cases per million patient years in the 
general adult population.  Independent risk factors include certain medications such 
as anticolvulsants, sulfonamines, aminopenicillins, allopurinol and NSAIDs.   Non-
medication triggers include infection, contrast media, and vaccinations.  
Malignancy is associated with an increased mortality rate in patients with SJS and 
TEN.
Monitor patients for signs and symptoms of SJS and/or TEN, withhold 
Pembrolizumab and refer patient for specialized care and treatment.  Administer 
corticosteroids for SJS grade 3 or 4 or TEN grade 4 (initial dose of 1-2 mg/kg/day 
prednisone or equivalent followed by a taper). Permanently discontinue 
Pembrolizumab for any grade of SJS or TEN.
Immune-Mediated Myocarditis 
A total of 6 cases of myocarditis have been reported in patients treated with 
Pembrolizumab in clinical trials or in expanded access program.  One fatal case 
was reported from a clinical trial.   Immune-mediated myocarditis should be 
suspected if other causes of myocarditis, such as infection or prior radiation 
therapy, have been excluded.  Risk factors include certain medications and 
treatment modalities such as radiation, anthracycline, alkylating agents and most 
recently checkpoint inhibitors.
Monitor patients for signs and symptoms of Immune-Mediated Myocarditis and 
ensure adequate evaluation to exclude the other ethiologies.  Administer 
corticosteroids for grade 2 immune-mediated myocarditis (initial dose of 1-2 
mg/kg/day prednisone or equivalent followed by a taper). Permanently discontinue 
Pembrolizumab for grade 3-4 myocarditis or if toxicity does not resolve within 12 
weeks of start of grade 2 toxicity or inability to reduce corticosteroid to 10 mg or 
less of prednisone or equivalent per day within 12 weeks.
9.2.5 Composition
For injection: 50 mg, lyophilized powder in single-use vial for reconstitution
9.2.6 Storage Recommendations and Dosage Forms
Two Drug Product (DP) dosage forms are available for MK-3475: a white to off-
white lyophilized powder, 50 mg/vial, and a liquid, DP 100 mg/vial, both in Type 
I glass vials intended for single use only.
o
MK-3475) Pembrolizumab Powder for Solution for Infusion, 50 mg/vial 
(manufactured using the partially formulated DS), is reconstituted with sterile 
water for injection prior to use. MK-3475 DP is formulated with L-histidine as 
      
 
 
        
 
 


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buffering agent, polysorbate 80 as surfactant, sucrose as stabilizer/tonicity 
modifier, and hydrochloric acid (HCl) and/or sodium hydroxide (NaOH) for 
pH adjustment (if necessary).
o
MK-3475) Pembrolizumab Solution for Infusion 100 mg/vial is a liquid DP 
(manufactured using the fully formulated DS with L-histidine as buffering 
agent, polysorbate 80 as surfactant, and sucrose as stabilizer/tonicity modifier), 
and has the identical formulation as that of the reconstituted lyophilized vial.  
Both drug product dosage forms are stored under refrigerated conditions (2°C 
- 8°C).  The product after reconstitution with sterile water for injection and the 
liquid drug product are a clear to opalescent solution which may contain 
proteinaceous and extraneous particulates. The reconstituted lyophilized 
product and the liquid product are intended for IV administration. The 
reconstituted DP solution or the liquid DP can be further diluted with normal 
saline or 5% dextrose in the concentration range of 1 to 10 mg/mL in IV 
containers made of polyvinyl chloride (PVC) or non-PVC material. 
Reconstituted vials should be immediately used to prepare the infusion 
solution in the IV bag and the infusion solution should be immediately 
administered. If not used immediately, vials and/or IV bags may be stored at 
2-8 °C for up to a cumulative time of 20 hours. If refrigerated, the vials and/or 
IV bags should be allowed to equilibrate to room temperature prior to 
subsequent use. MK-3475 solutions may be stored at room temperature for a 
cumulative time of up to 4 hours. This includes room temperature storage of 
reconstituted or liquid DP solution in vials, room temperature storage of 
infusion solution in the IV bag and the duration of infusion.  This 
recommendation is based on up to 24 hours of room temperature and up to 24 
hours of refrigerated stability data of diluted pembrolizumab solutions in the 
IV bags.
9.2.7 Dispensation and Accountability
For this study, pembrolizumab (Keytruda®) will be provided by Merck as 
Pembrolizumab 50 mg (lyophilized powder for injection) and/or pembrolizumab 
100 mg/ 4mL (solution for injection).  Please see Appendix K for Preparation and 
Administration/ Reconstitution of Pembrolizumab (Keytruda®) for Injection 
(lyophilized powder).
(See also Section 8.5.2 Treatment Dispensation, Compliance and Accountability 
for Pembrolizumab.) 
10.0TREATMENT/ DOSE MODIFICATIONS
10.1Unacceptable Toxicity
Causality for all adverse events should be assessed and if deemed attributable, attempts 
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In the case of toxicities refractory to routine medical management which are assessed as 
possibly attributable to both drugs (i.e. liver enzyme elevation, renal dysfunction, thyroid 
dysfunction, diarrhea/colitis) that may be autoimmune in origin, dose interruption of 
axitinib should be attempted first.  Generally prompt resolution of the toxicity is observed 
if attributable to axitinib.  If the toxicity is persistent, treatment should be administered 
as per the pembrolizumab treatment guidelines below, including corticosteroid therapy 
where advised.
Drug-related grade 4 toxicities will generally require subject to discontinue all study 
treatment.  Exceptions include the following: 1) clear evidence that the toxicity was 
attributable to axitinib alone, resolved upon cessation of axitinib, and there is rationale to 
continuing pembrolizumab monotherapy 2) Grade 4 lab abnormalities that are not 
immune-related, where the patient is asymptomatic, and the abnormalities can be 
reversed with medical treatment. Example: grade 4 hypertriglyceridemia that responds to 
antilipid drugs. Intolerable grade 2 and grade 3 toxicities should be managed as per dose 
modification guidelines listed in the tables below.  For grade 2 and grade 3 toxicities 
attributable to axitinib that do not resolve to ≤ grade 1 within 3 weeks of holding study 
drug, axitinib should be permanently discontinued.  Pembrolizumab therapy may be 
continued providing the residual adverse events are within permissible ranges for 
pembrolizumab dosing.  
10.2Dose Titration Guidelines for Axitinib
All patients will begin therapy at the starting dose level of 5 mg PO twice daily.  Patients 
will be evaluated closely during cycle 1 for adverse events, laboratory studies, and review 
of study diaries and blood pressure logs.  Additionally, patients will be instructed to call 
with any adverse events between study visits.  If there is no grade 2 or greater toxicity 
on cycle 2 day 1, the patient will be eligible for dose escalation of axitinib as per 
Table 8.  Dose escalation DURING a cycle is not permitted.  Consideration of 
escalation should only be done on day 1 of all subsequent cycles. If a patient is dose-
escalated on day 1, they should resume blood pressure monitoring daily during the 
first three weeks of that cycle until evaluated during week 4 (i.e. day 22) visit of that 
same cycle.
Dose reductions for grade 2 or greater toxicities may be done at any time during the 
cycles as per the following guidelines, and Tables 8 and 9.  

For grade 2 or greater fatigue, hand-foot syndrome, mucositis, or diarrhea, 
attempt medical supportive care first:  (topical creams, anti-diarrheal, magic 
mouthwash or similar).

If no improvement within 3 days, dose reduce axitinib as per Table 8.  

Axitinib may be held for 3-5 days prior to dose reduction in the judgment of the 
treating investigator, particularly for grade 3 toxicities 
Management of Axitinib-related Hypertension:
      
 
 
        
 
 


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
Patients will be provided with blood pressure cuffs and monitoring sheets.  They 
will be instructed to monitor their blood pressure once daily before the evening 
dose of axitinib.  They are to notify the study team for BP ≥ 150/100 mm Hg or 
for BP ≥ 120/80 mm Hg with any symptoms perceived to be related to BP 
(headache, chest pressure, shortness of breath, dizziness, blurry vision).

Medications are to be added and titrated aggressively.  Preferred sequence as 
follows:
o
Calcium channel blockers:  (amlodipine, nifedipine, diltiazem, etc.)
o
ACE inhibitors or ARB (lisinopril, valsartan, losartan, etc.)
o
Diuretics (hydrochlorothiazide, furosemide).  Patient should be prescribed 
concurrent potassium and magnesium supplementation and scheduled for 
potassium and magnesium laboratory tests within three days of starting.  
o
Avoid beta-blockers, clonidine, digoxin.
o
If BP still ≥ 150/100 mm Hg despite maximal doses of three anti-
hypertensive medications, axitinib should be reduced by one dose level.  
Dose Level
Dose
If grade 2 or greater toxicity 
If no grade 2 or 
greater toxicity after 
21 days a
Dose 
reduction 
level -3
2 mg 
BID
Discontinue axitinib
Stay on 2mg BIDc
Dose 
reduction 
level -2
3 mg 
BID
Dose reduce to 2mg BIDb 
(can hold axitinib prior to restarting per 
MD discretion)
Stay on 3mg BIDc
Dose 
reduction 
level -1
4 mg 
BID
Dose reduce to 3mg BIDb
(can hold axitinib prior to restarting per 
MD discretion)
Stay on 4mg BIDc
Starting 
dose level
5 mg 
BID
Dose reduce to 4mg BIDb
(can hold axitinib prior to restarting per 
MD discretion)
Dose escalate to
6 mg BID
Dose 
escalation 
level 1
6 mg 
BID
Dose reduce to 5mg BIDb
(can hold axitinib prior to restarting per 
MD discretion)
Dose escalate to
7 mg BID
Dose 
escalation 
level 2
7 mg 
BID
Dose reduce to 6mg BIDb
(can hold axitinib prior to restarting per 
MD discretion)
Dose escalate to
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Table 10. Dose Titration of Axitinib
a Dosing modifications based only on the following grade 2 toxicities: oral mucositis, diarrhea, hand-foot syndrome, 
fatigue. Dose modifications for other drug-related AEs as per table below and as per study principal investigator.
CTC v4 definitions of grade 2 toxicities:
Oral mucositis: Moderate pain; not interfering with oral intake; modified diet indicated
Diarrhea: Increase of 4 - 6 stools per day over baseline
HFS: Skin changes (e.g., peeling, blisters, bleeding, edema, or hyperkeratosis) with pain; limiting 
instrumental ADL
Fatigue: Fatigue not relieved by rest; limiting instrumental ADL
b After dose reduction, re-escalation as tolerated may be considered per provider discretion
Toxicity
Grade:
Treatment
Dose reduction
2
Add appropriate anti-
hypertensive medications 
No dose reduction required
3
Add appropriate anti-
hypertensive medications
If persistent despite 3 or more 
medications and associated with 
persistent symptoms, dose 
reduce one level
Hypertension/
Hypertensive crisis
(Defined as ≥ 
150/100 or symptoms 
such as headache, 
chest pressure, blurry 
vision)
4
Discontinue axitinib
Discontinue axitinib
Thrombotic events 
(arterial)
2-4
Discontinue axitinib
Discontinue axitinib
Thrombotic events 
(venous) – 
uncomplicated 
DVT/PE
3
Provide anticoagulation
No dose adjustment required
Other venous 
thromboembolic 
disease (ie retinal 
vein occlusion)
3
Consider discontinuation 
of axitinib
Consider discontinuation of 
axitinib
Hemorrhage
2
Hold axitinib until 
resolution to ≤ grade 1
Dose reduce one dose level
Dose 
escalation 
level 3
8 mg 
BID
Dose reduce to 7mg BIDb
(can hold axitinib prior to restarting per 
MD discretion)
Dose escalate to
10 mg BID
Dose 
escalation 
level 4
10 mg 
BID
Dose reduce to 8mg BIDb
(can hold axitinib prior to restarting per 
MD discretion)
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3
Hold axitinib until 
resolution to ≤ grade 1
Dose reduce one dose level.  
Discontinue if recurs with 
restarting medication.  
4
Discontinue axitinib.
Discontinue axitinib.
2
Treat with 
replacement/suppression
No dose change
3
Treat with 
replacement/suppression.
Hold axitinib until 
resolution to ≤ grade 1.  
*refer to pembrolizumab 
dose modifications for 
additional treatment
Dose reduce one dose level
Thyroid dysfunction
4
Discontinue axitinib
Discontinue axitinib
Reversible posterior 
Leukoencephalopathy 
Syndrome
2-4
Discontinue axitinib
Discontinue axitinib
2
Continue treatment if 
asymptomatic and not 
associated with 
creatinine rise.  If 
accompanied by renal 
insufficiency or evidence 
of nephritis, refer to 
pembrolizumab 
guidelines for treatment 
and hold axitinib until ≤ 
grade 1.
If isolated proteinuria, no dose 
reduction.  If associated with 
AKI/nephritis, dose reduce one 
dose level after resolution to ≤ 
grade 1.
Proteinuria
3
Hold axitinib until ≤ 
grade 1.  Refer to 
pembrolizumab 
guidelines as per grade 2.
Dose reduce one dose level
2/3
Hold axitinib until ≤ 
grade 1.  *
Dose reduce one dose level. 
Elevation of liver 
enzymes or bilirubin
4
Discontinue axitinib
Discontinue axitinib.
2
Intolerable grade 2 
toxicity, may hold 
axitinib or dose-reduce at 
physician discretion.  
May hold axitinib or dose-
reduce at physician discretion.  
3
Hold until resolution to ≤ 
grade 1
Dose reduce one dose level.
Other toxicity
4
Discontinue axitinib
Discontinue axitinib.
Table 11. Additional Dose Modification Guidelines for Axitinib.
*NOTE: if patient starts with grade 2 LFT elevation (liver metastases), any increase of >/= to 50% of baseline that 
does not resolve within 7 days is considered grade 3 toxicity and patients should be dose reduced as above.  
      
 
 
        
 
 


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10.3Dose Modification Guidelines for Pembrolizumab
Adverse events (AEs) both serious and non-serious associated with pembrolizumab 
exposure may represent an immunologic etiology.  These AEs may occur shortly after 
the first dose or several months after the last dose of treatment.  Pembrolizumab must be 
withheld for drug-related toxicities and severe or life-threatening AEs as per Table 10 
below.  See also Section 8.4 for supportive care guidelines and Appendix H.
Dosing interruptions are permitted in the case of medical/surgical events or logistical 
reasons not related to study therapy (e.g. elective surgery, unrelated medical events, 
patient vacation, and/or holidays).  Subjects should be placed back on study therapy 
within 3 weeks of the scheduled interruption, unless otherwise discussed with the PI.  The 
reason for the interruption should be documented in the patient’s study record. 
      
 
 
        
 
 


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Table 12. Dose Modification and Toxicity Management Guidelines for Immune-Related AEs Associated with Pembrolizumab. 
General instructions:
1.
Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 weeks.
2.
For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to Grade 1 or 0 and 
corticosteroid has been tapered. Pembrolizumab should be permanently discontinued if AE does not resolve within 12 weeks of last dose or 
corticosteroids cannot be reduced to ≤10 mg prednisone or equivalent per day within 12 weeks. 
3.
For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other immunosuppressive treatment 
should be initiated if irAEs cannot be controlled by corticosteroids.
Immune-related 
AEs
Toxicity grade or 
conditions 
(CTCAEv4.0)
Action taken to 
pembrolizumab
irAE management with 
corticosteroid and/or other 
therapies 
Monitor and follow-up 
Steven-Johnson 
Syndrome (SJS)
Any
Permanently discontinue
Refer patient for specialized 
care for assessment and 
treatment.
If SJS confirmed, permanently discontinue 
pembrolizumab
Toxic Epidermal 
Necrolysis 
(TEN)
Any
Permanently discontinue
Refer patient for specialized 
care for assessment and 
treatment.
If TEN confirmed, permanently discontinue 
pembrolizumab
Grade 2
Withhold 
Pneumonitis 
Grade 3 or 4, or 
recurrent Grade 2
Permanently discontinue
Administer corticosteroids 
(initial dose of 1-2 mg/kg 
prednisone or equivalent) 
followed by taper
Monitor participants for signs and symptoms of 
pneumonitis
Evaluate participants with suspected pneumonitis 
with radiographic imaging and initiate corticosteroid 
treatment
Add prophylactic antibiotics for opportunistic 
infections
Diarrhea / Colitis 
Grade 2 or 3
Withhold
Administer corticosteroids 
(initial dose of 1-2 mg/kg 
prednisone or equivalent) 
followed by taper
Monitor participants for signs and symptoms of 
enterocolitis (ie, diarrhea, abdominal pain, blood 
or mucus in stool with or without fever) and of 
bowel perforation (ie, peritoneal signs and ileus).
Participants with ≥ Grade 2 diarrhea suspecting 
colitis should consider GI consultation and 
performing endoscopy to rule out colitis. 
Participants with diarrhea/colitis should be 
advised to drink liberal quantities of clear fluids.  
If sufficient oral fluid intake is not feasible, fluid 
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Grade 4
Permanently discontinue
infusion.
3
Withhold
Administer corticosteroids 
(initial dose of 0.5- 1 mg/kg 
prednisone or equivalent) 
followed by taper
AST / ALT 
elevation
4
Permanently discontinue 
--see exception below2
Administer corticosteroids 
(initial dose of 1-2 mg/kg 
prednisone or equivalent) 
followed by taper
Monitor with liver function tests (consider weekly 
or more frequently until liver enzyme value returned 
to baseline or is stable
Grade 2
Withhold
Administer corticosteroids 
(initial dose of 0.5- 1 mg/kg 
prednisone or equivalent) 
followed by taper
Increased 
bilirubin
Grade 3 or 4 
Permanently discontinue
Administer corticosteroids 
(initial dose of 1-2 mg/kg 
prednisone or equivalent) 
followed by taper
Monitor with liver function tests (consider weekly 
or more frequently until liver enzyme value returned 
to baseline or is stable
Type 1 diabetes 
mellitus (T1DM) 
or 
Hyperglycemia
Newly onset 
T1DM or 
Grade 3 or 4 
hyperglycemia 
associated with 
evidence of -cell 
failure
Withhold
Initiate insulin replacement 
therapy for participants with 
T1DM 
Administer anti-
hyperglycemic in participants 
with hyperglycemia 
Monitor participants for hyperglycemia or other 
signs and symptoms of diabetes.
Grade 2
Withhold
Hypophysitis
Grade 3 or 4 
Withhold or 
permanently 
discontinue1 
Administer corticosteroids 
and initiate hormonal 
replacements as clinically 
indicated.  
Monitor for signs and symptoms of hypophysitis 
(including hypopituitarism and adrenal 
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Grade 2
Continue 
Hyperthyroidism 
Grade 3 or 4 
Withhold or 
permanently 
discontinue1
Treat with non-selective beta-
blockers (eg, propranolol) or 
thionamides as appropriate 
Monitor for signs and symptoms of thyroid 
disorders. 
Hypothyroidism
Grade 2-4
Continue 
Initiate thyroid replacement 
hormones (eg, levothyroxine 
or liothyroinine) per standard 
of care
Monitor for signs and symptoms of thyroid 
disorders. 
Grade 2
Withhold 
Nephritis and 
Renal 
dysfunction
Grade 3 or 4 
Permanently discontinue
Administer corticosteroids 
(prednisone 1-2 mg/kg or 
equivalent) followed by taper.
Monitor changes of renal function
Grade 1 or 2
Withhold
Myocarditis
Grade 3 or 4
Permanently discontinue
Based on severity of AE 
administer corticosteroids
Ensure adequate evaluation to confirm etiology 
and/or exclude other causes
Intolerable/ 
persistent Grade 2
Withhold
Grade 3
Withhold or discontinue 
based on the type of 
event.  Events that 
require discontinuation 
include and not limited 
to:  Gullain-Barre 
Syndrome, encephalitis
All other 
immune-related 
AEs3
Grade 4 or 
recurrent Grade 3 
Permanently discontinue
Based on type and severity of 
AE administer corticosteroids 
Ensure adequate evaluation to confirm etiology 
and/or exclude other causes
1. Withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating physician. 
2.  For grade 3 liver toxicity with elevated AST and/or ALT. Since HCC patients may have grade 1-2 elevation of AST/ALT at baseline, if these patients have Grade 3 
elevation of AST/ALT, hold therapy and resume treatment when AST/ALT return to baseline or Grade ≤1. The AST/ALT should return to baseline or < 5 x ULN within 
12 weeks from start of grade 3, otherwise patient should be discontinued from study.
3. 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.
NOTE: For participants with Grade 3 or 4 immune-related endocrinopathy where withhold of pembrolizumab is required, pembrolizumab may be resumed when AE 
resolves to ≤ Grade 2 and is controlled with hormonal replacement therapy or achieved metabolic control (in case of T1DM).  


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11.0TREATMENT DISCONTINUATION
Treatment may be discontinued for any of the following reasons:

The patient experiences a DLT 

The patient demonstrates radiologic progression by RECIST 1.1.  (See exception 
below).  

The patient withdraws consent from the study

The patient has not received study treatment for >21 days due to a medical/surgical 
events or logistical reasons not related to study therapy (e.g. elective surgery, unrelated 
medical events, patient vacation, and/or holidays).  

The patient has completed 24 months of uninterrupted treatment with pembrolizumab 
or 35 administrations of study medication, whichever is later. 

The patient experiences an adverse event that in the opinion of the Investigator makes 
continued study treatment an unacceptable risk

The patient becomes pregnant (also see Section 15.6 and Appendix A for Expedited 
Adverse Event Reporting Requirements)

The patient requires continuous treatment with a prohibited concomitant drug(s) for 
which no safe alternatives can be substituted

The patient is significantly noncompliant with the requirements of the protocol
Exception: Patients who exhibit radiologic progression by RECIST 1.1 may remain on 
the study if in the opinion of the Investigator, he/she is deriving clinical benefit from 
study treatment, particularly if response assessment by immune-related RECIST 
criteria, Choi criteria, or MRI volumetrics would not require discontinuation.  A follow 
up confirmatory scan should be scheduled in 6 weeks.  For later analysis of the primary 
endpoint, assuming that the confirmatory scan ALSO shows RECIST progression, the 
initial scan will be recorded as the first date of progression.
Should discontinuation of study therapy occur, all efforts should be made to execute/ report 
End-of-Treatment and Follow-up Evaluations as completely as possible and to determine/ 
document the reason for discontinuation (unless the patient withdraws consent for follow-
up). 
If a patient wishes to withdraw consent from the study, the PI must be notified.  The 
information regarding withdrawal (i.e. subject identifiers and date of withdrawal) should 
be documented in the subject’s record and updated within any other research database(s). 
      
 
 
        
 
 


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12.0SCHEDULE OF CLINICAL & LABORATORY EVALUATIONS
Prior to performing any study-specific procedures or evaluations, written informed consent 
and authorization for the use of protected health information (HIPAA) must be obtained in 
accordance with all applicable policies, regulations and laws.  
Correlative evaluations must also be performed at specified visits.  Please refer to Section 
13.0 Correlative Studies for specific details. 
12.1Pre-Treatment Evaluation (Screening)
The following must be collected/ performed within ≤28 days prior to Cycle 1, day 1 of 
treatment.  Clinical and laboratory evaluations performed as part of routine standard of 
care do not need to be repeated if performed within the appropriate window. 

Demographics: The age, race, ethnicity and gender of each patient 

Medical history: Relevant medical history including background and progress of 
the malignancy and description of all prior therapies

Physical examination (PE): A complete PE will include assessments of general 
appearance, skin, head (eyes, ear, nose, and throat), neck, lungs, heart, abdomen, 
back, lymph nodes, extremities, and neurological exam 

ECOG Performance Status (ECOG PS) will be assessed as specified in Appendix 
C

Height

Weight

Vital signs (V/S): Vital signs measurements include: diastolic blood pressure 
(BP) and systolic BP, heart rate (HR), respiratory rate (RR), oral temperature (oral 
temp) and oxygen saturation (O2)

Complete Blood Count (CBC): CBC evaluations with differential and platelets

Comprehensive Metabolic Panel (CMP): CMP evaluations to include 
magnesium, phosphate, and direct bilirubin

Coagulation studies: PT/ (INR), aPTT

Thyroid Function Tests (TFTs): Thyroid stimulating hormone (TSH), thyroxine 
(free T4), and triiodothyronine (T3)

Urine pregnancy test: A pregnancy test will be performed for women of 
childbearing potential (WOCBP) at screening and throughout the study.

Urinalysis: A urinalysis with microscopic analysis (UA micro) will be performed 
at Screening.  Any patient with 1+ or greater protein screen without evidence of 
infection or contaminated sample must have urine microalbumin and/or 24 hour 
urine creatinine clearance to document proteinuria.

12-lead Electrocardiogram (ECG)

2D Echocardiogram (ECHO) 

Imaging studies for tumor assessment (CT and/or MRI of all known sites of 
disease): the same method of assessment and technique should be used at baseline 
and during treatment and follow-up

Correlative studies: 
o
PET/CT
      
 
 
        
 
 


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o
Tumor biopsy: Patients will require pre-treatment biopsy for tumor-
infiltrating lymphocyte extraction and profiling as part of correlative 
studies.  In the event that the pre-treatment biopsy is not adequate for 
immunohistochemistry testing, archival tissue may be substituted if 
deemed adequate by pathology for baseline staining.  If the archival tissue 
dates prior to extensive chemotherapy/TKI therapy, or is not 
representative of the current tumor (i.e. primary lesion when the current 
disease is metastatic) then repeat biopsy should be attempted if feasible.

Concomitant medications and procedures: Concomitant medications and 
procedures will be recorded beginning at the time of Screening 

Pretreatment events: baseline events, findings and conditions prior to study 
treatment initiation should be documented and continually reassessed throughout 
the study
12.2Evaluations on Treatment
Collection of Concomitant Medications should occur throughout trial treatment until 
30-days (±5 days) post-treatment discontinuation. 
The collection of Adverse Events (AEs) should occur throughout trial treatment and 
continue during Follow-up.  Any SAE, or follow up to a SAE, including death due to 
any cause other than progression of the cancer under study that occurs to any subject 
from the time the consent is signed through 90 days following end of treatment, or the 
initiation of new anti-cancer therapy, whichever is earlier, whether or not related to the 
Merck product, must be reported within 24 hours to the Sponsor and within 2 working 
days to Merck Global Safety.  All subjects with SAEs must be followed up for 
outcome.  (See Section 15.0 and Appendix A for details).
Imaging studies should be done at the beginning of every odd cycle or 12 weeks 
(every 84 days ±7 days) from the date of Registration/Enrollment, timed to coincide 
with the end of the prior treatment cycle; assessing all known sites of disease using 
the same type(s) of scan(s) that was/were performed at baseline.
The appropriate axitinib dosing diary, blood pressure (BP) log monitoring forms and 
directions’ sheet should be given to the patient before each treatment cycle (Appendix I). 
Afterwards, the dosing diary completed for that (previous) treatment cycle should be 
collected from the patient. This should be repeated for each cycle.
12.2.1 Cycle 1, day 1 (±3 days) – CTU visit
The following assessments should be performed on Cycle 1, day 1:

PE

ECOG PS

V/S

Weight

CBC with differential
      
 
 
        
 
 


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
CMP, Mg, Phosphate, direct bilirubin

UA

Urine pregnancy test (repeat only if not done within 7-days prior)

Imaging studies (repeat only if screening imaging scans are deemed 
inadequate as per Radiology, i.e. missing fat suppression, contrast-
enhancement, otherwise inadequate views, or performed outside of the 28 
day window)

Correlative studies: peripheral blood collection – see Section 13.0
12.2.2 Cycle 1, day 8 (±3 days) – CTU visit (Pembrolizumab administration)
The following assessments should be performed on Cycle 1, day 8:

PE

ECOG PS

V/S

Weight

Patient dosing diary review and BP logs

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Urine pregnancy test

12 lead EKG

Correlative studies: peripheral blood collection – see Section 13.0 
(additional sample for expansion cohort)
12.2.3 Cycle 1, day 15 (±3 days) – Clinic visit
The following assessments should be performed on Cycle 1, day 15:

PE

ECOG PS

V/S

Weight

Patient dosing diary review and BP logs

CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.4 Cycle 1, day 22 (±3 days) – Labs only – may be done locally.  
The following assessments should be performed on Cycle 1, day 22:

Patient dosing diary and BP log review

PE

ECOG PS

V/S

Weight
      
 
 
        
 
 


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
CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.5 Cycle 1, day 29 (±3 days) – CTU visit – Pembrolizumab administration
The following assessments should be performed on Cycle 1, day 29: 

PE

ECOG PS

V/S

Weight

Patient dosing diary and BP log review

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Urine pregnancy test

12 lead EKG
12.2.6 Cycle 1, day 36 (±3 days) – Labs only, locally permitted.
The following assessments should be performed on Cycle 1, day 36: 

PE

ECOG PS

V/S

Weight 

Patient dosing diary and BP log review

CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.7 Cycle 1, day 43 (±3 days) – Labs only, locally permitted.
The following assessments should be performed on Cycle 1, day 43: 

Patient dosing diary and BP log review

PE 

ECOG PS

V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.8 Cycle 2, day 1: CTU visit, Pembrolizumab administration
The following assessments should be performed on Cycle 2, day 1: 

Collection of previous cycle’s patient dosing diary and BP log 

PE

ECOG PS
      
 
 
        
 
 


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
V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Coagulation factors

TFTs (T3, T4 and TSH)

UA (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance)

Urine pregnancy test

Consider axitinib dose escalation (see Section 10.2)
12.2.9 Cycle 2, day 8 (±3 days) – Labs locally
The following assessments should be performed on Cycle 2, day 8:

Patient dosing diary and BP log review (BP log only if escalation 
occurred this cycle)

PE

ECOG PS

V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.10 Cycle 2, day 15 (±3 days)
The following assessments should be performed on Cycle 2, day 15:

Patient dosing diary and BP log review (BP log only if escalation 
occurred this cycle)

PE 

ECOG PS

V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.11 Cycle 2, day 22 (±3 days) – CTU visit, Pembrolizumab administration
The following assessments should be performed on Cycle 2, day 22:

PE

ECOG PS

V/S

Weight
      
 
 
        
 
 


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
Patient dosing diary review

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Urine pregnancy test

12 lead EKG, ONLY if axitinib dose escalation performed at this cycle
12.2.12 Cycle 2, day 29 (±3 days) – Labs only – locally permitted
The following assessments should be performed on Cycle 2, day 29:

PE

ECOG PS

V/S

Weight

Patient dosing diary review

CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.13 Cycle 2, day 36 (±3 days) – Labs only – locally permitted
The following assessments should be performed on Cycle 2, day 36:

PE

ECOG PS

V/S

Weight

Patient dosing diary review

CBC with differential

CMP, Mg, Phosphate, direct bilirubin
12.2.14 Cycle 3, day 1 (±3 days)
The following assessments should be performed on Cycle 3, day 1:

Note: Imaging Studies (PET/CT, CT and/or MRI) should be repeated 
prior to treatment every 12 weeks (±7 days) (i.e. every 84 days or 
subsequent odd cycle).  If there are treatment delays leading to the patient 
being off schedule, scans should coincide with Day 1 of the next cycle as 
long as within 3 weeks. If delays greater than 3 weeks then scans should 
be continued every 12 weeks as per schedule.

Collection/review of previous cycle’s patient dosing diary 

PE

ECOG PS

V/S

Weight
      
 
 
        
 
 


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
CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Coagulation factors

TFTs

U/A – (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance)

Urine pregnancy test

Correlative studies:  Tumor biopsy – see Section 13.0

Correlative studies: PET/CT, Peripheral blood collection – see Section 
13.0

Consideration for axitinib dose escalation; see Section 10.2; for all 
subsequent cycles, if a patient is dose-escalated on day 1, they should 
keep BP log for the first three weeks of the cycle.
12.2.15 Cycle 3, day 22 (±3 days) – CTU visit, pembrolizumab administration
The following assessments should be performed on Cycle 3, day 22:

Dosing diary review, BP log reviewed if axitinib escalated on day 1

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Urine pregnancy test

If Axitinib dose escalated on (day 1) of this cycle:
o
12 lead EKG (ONLY if axitinib dose escalation performed)
12.2.16 Subsequent Cycles, day 1 (±3 days)
The following assessments should be performed on subsequent Cycles, day 1:

Collection/review of previous cycle’s patient dosing diary 

PE

ECOG PS

V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Coagulation factors (PT/INR and aPTT)

TFTs (T3, T4 and TSH)

U/A (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance)

Urine pregnancy test
      
 
 
        
 
 


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
(Imaging studies (CT and/or MRI) should be performed prior to 
treatment on every subsequent odd cycle or every 12 weeks (±7 days) 
timed to coincide with the end of the prior treatment cycle; assessing all 
known sites of disease using the same type(s) of scans as at baseline.) If 
there are treatment delays leading to the patient being off schedule, scans 
should coincide with Day 1 of the next cycle as long as within 3 weeks. If 
delays greater than 3 weeks then scans should be continued every 3 
months as per schedule.

Consider axitinib dose escalation (see Section 10.2); for all subsequent 
cycles, if a patient is dose-escalated on day 1, they should monitor 
blood pressure for the first three weeks of the cycle.
12.2.17 Subsequent Cycles, day 22 (±3 days)
The following assessments should be performed on subsequent Cycles, day 22:

Dosing diary review, BP log review if escalated on day 1 of that cycle

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Urine pregnancy test

IF axitinib dose escalation on day 1:
o
12-lead EKG (ONLY if axitinib dose escalation performed)
12.2.18 Axitinib Monotherapy and axitinib indefinite treatment, all cycles, day 1 (±3 
days)
The following assessments should be performed on day 1 (±3 days) of each cycle 
during axitinib monotherapy and during the indefinite axitinib treatment:

Collection/review of previous cycle’s patient dosing diary 

PE

ECOG PS

V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Coagulation factors (PT/INR and aPTT)

TFTs (T3, T4 and TSH)

U/A (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance)

Urine pregnancy test

(Imaging studies (CT and/or MRI) should be performed prior to 
treatment on every subsequent odd cycle or every 12 weeks (±7 days) 
timed to coincide with the end of the prior treatment cycle; assessing all 
known sites of disease using the same type(s) of scans as at baseline.) If 
      
 
 
        
 
 


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there are treatment delays leading to the patient being off schedule, scans 
should coincide with Day 1 of the next cycle as long as within 3 weeks. If 
delays greater than 3 weeks then scans should be continued every 3 
months as per schedule.
Patients unable to attend in-person study visits may conduct study visits via 
telehealth. Additionally, study assessments may be conducted locally and 
provided to treating physician for review. Axitinib may be shipped to participants 
as per University of Miami and Pfizer policies. 
12.2.19 Pembrolizumab Re-introduction, all cycles, day 1 (±3 days)
The following assessments should be performed on day 1 (±3 days) of each cycle 
during pembrolizumab-reintroduction:

Collection/review of previous cycle’s patient dosing diary 

PE

ECOG PS

V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Coagulation factors (PT/INR and aPTT)

TFTs (T3, T4 and TSH)

U/A (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance)

Urine pregnancy test

(Imaging studies (CT and/or MRI) should be performed prior to 
treatment on every subsequent odd cycle or every 12 weeks (±7 days) 
timed to coincide with the end of the prior treatment cycle; assessing all 
known sites of disease using the same type(s) of scans as at baseline.) If 
there are treatment delays leading to the patient being off schedule, scans 
should coincide with Day 1 of the next cycle as long as within 3 weeks. If 
delays greater than 3 weeks then scans should be continued every 3 
months as per schedule.
12.2.20
Pembrolizumab Re-introduction, all cycles, day 22 (±3 days)
The following assessments should be performed on day 22 (±3 days) of each 
cycle during pembrolizumab-reintroduction:

Dosing diary review, BP log review if escalated on day 1 of that cycle

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Urine pregnancy test
      
 
 
        
 
 


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12.3Off-Treatment Evaluations 
The following assessments must be performed at the off treatment visit (± 7 days):

Adverse events/concurrent medications

PE

ECOG PS

V/S

Weight

Patient dosing diary and blood pressure (bp) log

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Coagulation factors

TFTs

U/A (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance)

Urine pregnancy test

12-Lead ECG

2D ECHO

Imaging studies (CT, and/or MRI) (not required if reason off study was 
radiographic progression)

Correlative studies: Tumor biopsy

Correlative studies: PET/CT, Peripheral blood collection – see Section 
13.0
12.4End of Treatment (EOT) Safety Evaluations 
The following assessments must be performed at 30-days (± 5 days) after the last dose 
of study treatment. 

PE

ECOG PS

V/S

Weight

CBC with differential

CMP, Mg, Phosphate, direct bilirubin

Coagulation factors

TFTs

U/A (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance)

Urine pregnancy test
      
 
 
        
 
 


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
Adverse Events: (Any SAE, or follow up to a SAE, including death due to 
any cause other than progression of the cancer under study that occurs to 
any subject from the time the consent is signed through 90 days following 
end of treatment, or the initiation of new anti-cancer therapy, whichever 
is earlier, whether or not related to the Merck product, must be reported 
within 24 hours to the Sponsor and within 2 working days to Merck 
Global Safety.  All subjects with SAEs must be followed up for outcome.  
(See Section 15.0 and Appendix A for details).)
12.5Follow-up Evaluations 
After treatment completion the following assessments should be performed at least 
every 3 months (or every 12 weeks) (± 7 days) or as clinically indicated, as per 
standard of care.  
Patients without documented evidence of objective disease progression will continue to 
have the same imaging studies as used at Baseline and during Treatment, performed at 
a 12-week interval during Follow-up, until disease progression.
Follow-up Visit: The following assessment(s) must be performed during Follow-up. 
• Adverse events: (Any SAE, or follow up to a SAE, including death due to any 
cause other than progression of the cancer under study that occurs to any subject 
from the time the consent is signed through 90 days following end of treatment, or 
the initiation of new anti-cancer therapy, whichever is earlier, whether or not 
related to the Merck product, must be reported within 24 hours to the Sponsor 
and within 2 working days to Merck Global Safety.  All subjects with SAEs must 
be followed up for outcome.  (See Section 15.0 and Appendix A for details).)
• PE
• ECOG PS
• Weight
• V/S (BP, HR, RR, oral temp and O2 saturation)
• CBC (with differential and platelets)
• CMP, Mg, Phosphate, direct bilirubin

Coagulation factors (PT/INR, aPTT)

TFTs (T3, T4 and TSH)

Urine Pregnancy Test

U/A (if protein 2+ or greater (grade 2) with no evidence of infection or 
contaminated sample, obtain urine microalbumin and urine creatinine 
clearance) 
• 2D ECHO: only if clinically indicated  
• 12-Lead ECG, only if clinically indicated
12.6Survival Assessment Evaluations 
      
 
 
        
 
 


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After treatment completion or if the patient starts an alternative treatment regimen, each 
patient will be followed for survival every 12 weeks (±7 days) until death or withdrawal 
of consent. A telephone call to the patient and/or the patient’s family will be made to 
evaluate the patient’s status.
      
 
 
        
 
 


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12.7Calendar of Clinical and Laboratory Evaluations (continued on following page)
Cycle
Screen-
ing
1
2
3
Subsequent 
Cycles
Off 
Treatment 
(treatment 
discontin-
uation)
EoT 
Safety 
Evaluation
Follow-
upA
Survival
Week (per 
Cycle)
1
2
3
4
5
6
7
1
2
3
4
5
6
1
4F
Weeks 1 and 
4F,I,J
(EOT)
±7 days
30 days 
(±5 
days) 
after 
EOT
Q12
Weeks (± 
7 days)
Q12
Weeks (± 
7 days)
Day (±3d 
per Cycle)
-28 to 
0
1
8
15
22
29
36
4
3
1
8
1
5
22
2
9
3
6
1
22 F 
Days 1 and 
22 F
ICF
X
Eligibility
X
Demograph-
ics
X
Medical 
history
X
PE
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X (Day 1)
X
X
X
ECOG PS
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X (Day 1)
X
X
X
Height
X
Weight
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X (Day 1)
X
X
X
V/S (BP, 
HR, RR, 
oral temp, 
and O2 sat)
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X (Day 1)
X
X
X
CBC, diff
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X
X (Days 1, 22)
X
X
X
A For those patients without documented evidence of objective disease progression, the same imaging studies used at Baseline/Screening; not 
required at Off-Treatment, if reason for ‘off study’ is radiographic progression.


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Cycle
Screen-
ing
1
2
3
Subsequent 
Cycles
Off 
Treatment 
(treatment 
discontin-
uation)
EoT 
Safety 
Evaluation
Follow-
upA
Survival
Week (per 
Cycle)
1
2
3
4
5
6
7
1
2
3
4
5
6
1
4F
Weeks 1 and 
4F,I,J
(EOT)
±7 days
30 days 
(±5 
days) 
after 
EOT
Q12
Weeks (± 
7 days)
Q12
Weeks (± 
7 days)
Day (±3d 
per Cycle)
-28 to 
0
1
8
15
22
29
36
4
3
1
8
1
5
22
2
9
3
6
1
22 F 
Days 1 and 
22 F
CMP, Mg, 
PO4, direct 
bilirubin
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X
X (Days 1, 22)
X
X
X
PT/INR, 
aPTT 
X
X
X
X (Day 1)
X
X
X
TFTs (T3, 
T4, TSH)
X
X
X
  
X (Day 1
X
X
X
Urine 
pregnancy
X
X
B
X
X
X
X
X
X
X (Days 1 and 
22)
X
X
X
U/A (micro-
albumin and 
Cr 
Clearance, 
if > 2+ 
protein 
without 
other cause)
X
X
X
X
X (Day 1)
X
X
X
12-Lead 
ECG
X
X
X
XC
(X)C
XC (Day 22C)
X
2D ECHO
X
X
B Repeat only if not done within previous 7 days.
C Perform only if axitinib dose escalation performed on day 1 of current cycle.


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Cycle
Screen-
ing
1
2
3
Subsequent 
Cycles
Off 
Treatment 
(treatment 
discontin-
uation)
EoT 
Safety 
Evaluation
Follow-
upA
Survival
Week (per 
Cycle)
1
2
3
4
5
6
7
1
2
3
4
5
6
1
4F
Weeks 1 and 
4F,I,J
(EOT)
±7 days
30 days 
(±5 
days) 
after 
EOT
Q12
Weeks (± 
7 days)
Q12
Weeks (± 
7 days)
Day (±3d 
per Cycle)
-28 to 
0
1
8
15
22
29
36
4
3
1
8
1
5
22
2
9
3
6
1
22 F 
Days 1 and 
22 F
Imaging 
scans (CT, 
MRI)
X
X
D
X
E
XE (Cycles 
3,5,7,etc)
XA
Correlatives: 
PET/CT
X
X
X
Axitinib 
(oral)
X
Evaluate for 
Axitinib 
dose 
escalation
X
X
X (Day 1)
Pembrolizu-
mab (IV) 
X
X
X
X
X
X
X (Days 1, 22)
D Repeat Imaging scans (for C1D1) only if Screening/Baseline scans are deemed inadequate as per Radiology. 
E After cycle 3, repeat imaging every 12 weeks or at every subsequent odd cycle (ie Cycle 5, 7, 9, etc.).
F If a patient is dose-escalated during the (specified) cycle they should be evaluated at least once on the Week 4 visit (beginning on Day 22) as 
well, or as clinically indicated.
G After Follow-up during “Survival” period, a telephone call to the patient and/or the patient’s family will be made to evaluate the 
patient’s status.


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Cycle
Screen-
ing
1
2
3
Subsequent 
Cycles
Off 
Treatment 
(treatment 
discontin-
uation)
EoT 
Safety 
Evaluation
Follow-
upA
Survival
Week (per 
Cycle)
1
2
3
4
5
6
7
1
2
3
4
5
6
1
4F
Weeks 1 and 
4F,I,J
(EOT)
±7 days
30 days 
(±5 
days) 
after 
EOT
Q12
Weeks (± 
7 days)
Q12
Weeks (± 
7 days)
Day (±3d 
per Cycle)
-28 to 
0
1
8
15
22
29
36
4
3
1
8
1
5
22
2
9
3
6
1
22 F 
Days 1 and 
22 F
Patient 
Dosing 
Diary 
Review
X
X
X
X
X
X
X X
X
X
X
B
P 
lo
X
X
X (Days 1, 22)
X
BP log 
reviewH
X
X
X
X
X
X
X
X
H
X
H
X
H
X
H
XH
XH
Correlatives
: Tumor 
biopsy
X
X
X
Peripheral 
blood for 
correlative 
studies
X
X
X
X
Conmeds
X
Pretreat-
ment events
X
AEs
X (through 90-days following end of treatment)
Telephone 
call
X G
H - BP logs are required during first cycle. For second and further cycles, if dose-escalated on day 1, patients should keep BP logs 
until day 22. If no change in dosing and three weeks of stable BP, logs are not required.
I-Refer to section 12.2.18 for a list of the assessments that will be performed on day 1 (±3 days) of each cycle during axitinib 
monotherapy.
J-Refer to section 12.2.19 and 12.2.20 for a list of the assessments that will be performed on each cycle, day 1 (±3 days) and day 22 
(±3 days) of pembrolizumab re-introduction.


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13.0
SCHEDULE OF CORRELATIVE EVALUATIONS 
All tissue and blood samples will be labeled and referred to only by subject number.  The 
scientific investigators performing correlative analysis will be blinded to the patient 
identification data and clinical outcomes.  Additional information regarding protection of 
patient data and complete details of laboratory procedures can be found in Appendix F.
13.1Pre-Treatment Specimen Collection 
13.1.1 Screening 
All eligible patients will undergo mandatory core needle biopsy of the tumor 
prior to study therapy.  If the tumor lesions are deemed unamenable to biopsy 
attempt, due to safety or technical concerns by the interventional radiologist, the 
patients will be considered screen failures and not enrolled on the study.  
For patients that are deemed to have a tumor lesion amenable to biopsy in the 
judgement of the radiologist, inadequate tissue sampling despite reasonable 
attempts at the time of biopsy will not preclude enrollment on the clinical trial and 
the patient will continue with other correlative studies.  Future biopsies will be 
foregone.  In this event, archival tumor tissue will be used for baseline immunologic 
markers via immunohistochemistry.  
All samples will be deidentified at the time of collection and labeled with a unique 
study identifier. Only the PI and research staff will have access to the patient 
identifying information and the study key linking identity with the research 
samples.

5 core biopsies (minimum of 2), 18-22 gauge in diameter and at least 1 cm in 
length, will be obtained. The interventional approach used to obtain the sample 
(ultrasound or CT-guided biopsy) will be selected by the medical personnel 
performing the biopsy.  
o
One needle core biopsy will be transported in formalin to Pathology for 
immunohistochemistry evaluation of immunologic markers.  This analysis 
will be performed in collaboration with Wistuba Ignacio, MD at MD 
Anderson Cancer Center. Samples will be deidentified and sent to his 
laboratory for multiplex immunohistochemistry.
o
Unstained slides from the formalin fixed biopsies will be sent to Nanostring 
for RNA expression analysis using the Universal Immunooncology 
Expression Panel under a collaborative research agreement to identify 
potential biomarkers of response.
o
The remaining cores (if any) will be collected in cell culture media and 
transported to the Komanduri lab for preparation of a single cell suspension, 
isolation of lymphocytes, and immediate analysis by flow cytometry.  For 
expansion patients, additional cores will be collected for RNA analysis and 
      
 
 
        
 
 


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performance of T cell receptor sequencing and clonality assays using the 
Archer DX platform.
13.1.2 Cycle 1, Day 1 (PRE-DOSE)

Immediately prior to treatment initiation on Cycle 1 Day 1, patients will also 
undergo phlebotomy for analysis of circulating mononuclear cells with banking 
of serum fractions for later analysis. 
o
(6) 10 cc green top tubes and (1) 10 cc purple top tube will be collected 
for each time point.  Samples will be separated using a Ficoll gradient.  
Mononuclear cells will be removed, washed, treated with RBC lysis 
process, then either stained immediately for flow cytometric analysis or 
frozen for later use.  Aliquots of plasma will also be frozen.  One tube 
of PBMCs will be preserved in RNA later for T cell clonality assays 
using the ArcherDX platform. 
o
Banked PBMCs will be sent out to Simpatica Medicine for RNA 
expression analysis to identify potential biomarkers of response under a 
collaborative research agreement.
o
Banked plasma samples will be analyzed for plasma angiogenic activity 
in collaboration with Dr. Jaime Merchan at University of Miami. 
Samples will be exposed to human umbilical vein endothelial cells and 
angiogenic activity measured. 

Additional peripheral blood will be obtained for circulating tumor cell analysis. 
o
Two 10 cc Cell-Saver tubes will be drawn and transported immediately to 
the laboratory of Dr. Ram Datar for analysis.  Blood will be filtered and one 
slide stained for H&E to detect CTCs.  The other slide will be reserved for 
additional 
analysis, 
including 
genomic 
analysis, 
FISH, 
or 
immunocytochemistry depending on the specific histology.  The number of 
CTCs will be recorded for each patient.
13.1.3 Cycle 1, Day 8 (PRE-PEMBROLIZUMAB (expansion cohort only)
o
6) 10 cc green top tubes and (1) 10 cc purple top tube will be collected 
for each time point.  Samples will be separated using a Ficoll gradient.  
Mononuclear cells will be removed, washed, treated with RBC lysis 
process, then either stained immediately for flow cytometric analysis or 
frozen for later use.  Aliquots of plasma will also be frozen.  
o
Banked PBMCs will be sent out to Simpatica Medicine for RNA 
expression analysis to identify potential biomarkers of response under a 
collaborative research agreement.
o
Banked plasma samples will be analyzed for plasma angiogenic activity 
in collaboration with Dr. Jaime Merchan at University of Miami. 
      
 
 
        
 
 


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Samples will be exposed to human umbilical vein endothelial cells and 
angiogenic activity measured. 
13.2On Treatment Specimen Collection  
13.2.1 Cycle 3, Day 1 (PRE-DOSE)
For 
patients 
who 
have 
successfully 
completed 
two 
cycles 
of 
axitinib/pembrolizumab therapy, the following on-treatment correlative studies will 
also be performed:

5 core biopsies (minimum of 2), 18-22 gauge in diameter and at least 1 cm in 
length, will be obtained. The interventional approach used to obtain the sample  
(ultrasound or CT guided biopsy) will be selected by the medical personnel 
performing the biopsy  If possible, the biopsy site should be in the same tumor 
initially biopsied prior to therapy.
o
One needle core biopsy will be transported in formalin to pathology for 
immunohistochemistry evaluation of immunologic markers.  This analysis 
will be performed in collaboration with Wistuba Ignacio, MD at MD 
Anderson Cancer Center. Samples will be deidentified and sent to his 
laboratory for multiplex immunohistochemistry.
o
Unstained slides from the formalin fixed biopsies will be sent to Nanostring 
for RNA expression analysis using the Universal Immunooncology 
Expression Panel under a collaborative research agreement to identify 
potential biomarkers of response.
o
The remaining cores (if any) will be collected in cell culture media and 
transported to the Komanduri lab for preparation of a single cell suspension, 
isolation of lymphocytes, and immediate analysis by flow cytometry.  For 
expansion patients, additional cores will be collected for RNA analysis and 
performance of T cell receptor sequencing and clonality assays using the 
Archer DX platform.

Patients will also undergo phlebotomy for analysis of circulating mononuclear 
cells with banking of serum fractions for later analysis. 
o
(6) 10 cc green top tubes and (1) 10 cc purple top tube will be collected 
for each time point.  Samples will be separated using a Ficoll gradient.  
Mononuclear cells will be removed, washed, treated with RBC lysis 
process, then either stained immediately for flow cytometric analysis or 
frozen for later use.  Aliquots of plasma will also be frozen.  One tube 
of PBMCs will be preserved in RNA later for T cell clonality assays 
using the ArcherDX platform. 
o
Banked PBMCs will be sent out to Simpatica Medicine for RNA 
expression analysis to identify potential biomarkers of response under a 
collaborative research agreement.
      
 
 
        
 
 


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o
Banked plasma samples will be analyzed for plasma angiogenic activity 
in collaboration with Dr. Jaime Merchan at University of Miami. 
Samples will be exposed to human umbilical vein endothelial cells and 
angiogenic activity measured. 

Additional peripheral blood will be obtained for circulating tumor cell analysis.  
o
Two 10 cc Cell-Saver tubes will be drawn and transported immediately to 
the Datar lab for analysis.  Blood will be filtered and one slide stained for 
H&E to detect CTCs.  The other slide will be reserved for additional 
analysis, including genomic analysis, FISH, or immunocytochemistry 
depending on the specific histology.  The number of CTCs will be recorded 
for each patient.
13.3Off-Treatment Specimen Collection (End of Treatment or EOT visit)
The following must be performed at the EOT visit and should occur 30-days (± 7 days) 
after the last dose of study treatment. 

5 core biopsies (minimum of 2), 18-22 gauge in diameter and at least 1 cm in 
length, will be obtained. The interventional approach used to obtain the sample  
(ultrasound or CT guided biopsy) will be selected by the medical personnel 
performing the biopsy  If possible, the biopsy site should be in the same tumor 
initially biopsied prior to therapy.
o
One needle core biopsy will be transported in formalin to pathology for 
immunohistochemistry evaluation of immunologic markers.  This analysis 
will be performed in collaboration with Wistuba Ignacio, MD at MD 
Anderson Cancer Center. Samples will be deidentified and sent to his 
laboratory for multiplex immunohistochemistry.
o
Unstained slides from the formalin fixed biopsies will be sent to Nanostring 
for RNA expression analysis using the Universal Immunooncology 
Expression Panel under a collaborative research agreement to identify 
potential biomarkers of response.
o
The remaining cores (if any) will be collected in cell culture media and 
transported to the Komanduri lab for preparation of a single cell suspension, 
isolation of lymphocytes, and immediate analysis by flow cytometry.  For 
expansion patients, additional cores will be collected for RNA analysis and 
performance of T cell receptor sequencing and clonality assays using the 
Archer DX platform.

Patients will also undergo phlebotomy for analysis of circulating mononuclear 
cells with banking of serum fractions for later analysis. 
o
(6) 10 cc green top tubes and (1) 10 cc purple top tube will be collected 
for each time point.  Samples will be separated using a Ficoll gradient.  
Mononuclear cells will be removed, washed, treated with RBC lysis 
      
 
 
        
 
 


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process, then either stained immediately for flow cytometric analysis or 
frozen for later use.  Aliquots of plasma will also be frozen.  One tube 
of PBMCs will be preserved in RNA later for T cell clonality assays 
using the ArcherDX platform. 
o
Banked PBMCs will be sent out to Simpatica Medicine for RNA 
expression analysis to identify potential biomarkers of response under a 
collaborative research agreement.
o
Banked plasma samples will be analyzed for plasma angiogenic activity 
in collaboration with Dr. Jaime Merchan at University of Miami. 
Samples will be exposed to human umbilical vein endothelial cells and 
angiogenic activity measured. 

Additional peripheral blood will be obtained for circulating tumor cell (CTC) 
analysis.  
o
Two 10 cc Cell-Saver tubes will be drawn and transported immediately to the 
laboratory of Dr. Ram Datar lab for analysis.  Blood will be filtered and one slide 
stained for H&E to detect CTCs.  The other slide will be reserved for additional 
analysis, including genomic analysis, FISH, or immunocytochemistry depending 
on the specific histology.  The number of CTCs will be recorded for each patient.
13.4Radiology correlative studies
Patients who undergo CT imaging for tumor response assessment will have their images 
analyzed by a designated sarcoma radiologist who will be blinded to patient clinical 
outcome and phase of treatment according to Choi criteria. 
 
Patients who undergo MRI evaluation for tumor response assessment will have dynamic 
contrast enhancement (DCE) protocol added to the standard sequences obtained.  The 
patient may experience a slightly longer duration in the scanner for these purposes.  The 
outcomes based on DCE imaging will also be analyzed by the designated sarcoma 
radiologist who will be blinded to patient clinical outcome and phase of treatment.  
Tumor volume will be calculated using MRI volumetrics in a blinded fashion and 
analyzed for correlation with RECIST response.
PET/CT scans will be obtained at Screening, Cycle 3 (day 1) and End-of-Treatment 
visits, to assess metabolic response which may precede radiographic response.  If the 
patient does not have a positive PET/CT at baseline, subsequent scans will be cancelled.
      
 
 
        
 
 


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13.5Calendar of Specimen Collection for Correlative Studies 
Timepoints
Tumor 
biopsies
Tumor/TIL 
analysis 
(IHC/flow 
cytometry)
Circulating 
Tumor 
Cells 
(CTCs)
Circulating 
lymphocyte 
analysis 
(flow 
cytometry)
PET/CT
Screening
X
X
X
Cycle 1, 
day 1 
(predose)
X
X
Cycle 1, day 
8
X
Cycle 3, 
day 1 
(predose)
X
X
X
X
X
End of 
Treatment
X
X
X
X
X
Table 13. Correlative Studies' Timepoints
13.6Banking of Additional Specimens
In the event that study treatment results in a clinical response to the degree of permitting 
surgical resection, we will obtain any surgical specimens from patients who opt to 
withdraw from the study and undergo surgery.  
Tumor tissue will be collected and analyzed as follows:
1. Immunohistochemistry for immunomodulatory markers after formalin fixation, 
2. Fresh tissue will be transported to the Komanduri lab for tumor-infiltrating lymphocyte 
extraction and flow cytometry.  TILs will be banked in RNA later for RNA expression 
analysis using Archer DX platform to determine T cell clonality.
3. Excess tumor tissue will be placed in RNA and frozen for later use.  
14.0MEASUREMENT OF EFFECT
14.1Antitumor Effect in Solid Tumors
For the purposes of this study, patients should be re-evaluated for response every 12 
weeks (84 days, ±7 days) from date of Enrollment, (while on treatment and until there is 
documented evidence of disease progression for those patients who come off treatment). 
Imaging studies should be timed to coincide with the end of the prior treatment cycle, 
assessing all known sites of disease using the same type(s) of scan(s) that was/were 
performed at baseline.  Response assessments during follow-up after disease progression 
should follow the same frequency (every 12 weeks, ±7 days).
Response and progression will be evaluated in this study using the international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) version 
1.1 guideline(s). Changes in the largest diameter (unidimensional measurement) of the 
      
 
 
        
 
 


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tumor lesions and the shortest diameter in the case of malignant lymph nodes are used in 
the RECIST criteria.
 
The following general principles must be followed: 
1. To assess objective response, it is necessary to estimate the overall tumor burden at 
baseline to which subsequent measurements will be compared. All baseline evaluations 
should be performed as closely as possible to the beginning of treatment and never more 
than four weeks before registration. 
2. Measurable disease is defined by the presence of at least one measurable lesion. 
3. All measurements should be recorded in metric notation by use of a ruler or calipers. 
4. The same method of assessment and the same technique must be used to characterize 
each identified lesion at baseline and during follow-up. 
14.1.1 Definitions
Evaluable for Objective Response
Only those eligible patients 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 response. These patients will have their response 
classified according to the definitions stated below. (Note: Patients who exhibit 
objective disease progression prior to the end of cycle 1 will also be considered 
evaluable.)
Evaluable for Toxicity
All eligible patients who receive at least 80% of scheduled doses of axitinib during 
weeks 1-4, and receive pembrolizumab during week 2. Patients who withdraw from 
the study prior to week 2 for any reason other than DLT or other significant toxicity 
will not be considered evaluable for toxicity
14.1.2 Disease Parameters
 Measurable Disease
Measurable lesions are defined as those that can be accurately measured in at least 
one dimension (longest diameter to be recorded) as ≥ 20 mm by chest x-ray, as ≥ 
10 mm with CT scan, or ≥ 10 mm with 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 may be 
considered measurable if they have grown subsequent to previous radiation.
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 
      
 
 
        
 
 


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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, and abdominal masses (not followed by CT or MRI), are considered as 
non-measurable. Non-measurable also includes lesions that are < 20 mm by chest 
x-ray. 
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 patient, 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 of the diameters will be used as reference to further 
characterize any objective tumor regression in the measurable dimension of the 
disease.
Non-target Lesions
All other lesions (or sites of disease) including any measurable lesions over and 
above the 5 target lesions should be identified as non-target lesions and should 
also be recorded at baseline. Measurements of these lesions are not required, but 
the presence or absence of unequivocal progression of each should be noted 
throughout follow-up.
      
 
 
        
 
 


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14.1.3 Methods for Evaluation of Disease
All measurements should be taken and recorded in metric notation using a ruler or 
calipers. All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 4 weeks (28 days) before enrollment. 
The same method of assessment and the same technique must 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 since it is 
considered more sensitive.
Conventional CT and MRI 
This guideline has defined measurability of lesions on CT scan based on the 
assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness 
greater than 5 mm, the minimum size for 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 must be the same as was used at baseline and 
the lesions should be measured/assessed on the same pulse sequence. It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence 
parameters for all scanners, body parts, and diseases. Ideally, the same type of 
scanner should be used and the image acquisition protocol should be followed as 
closely as possible to prior scans. Body scans should be performed with breath-hold 
scanning techniques, if possible. 
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 (slice thickness of 5 
      
 
 
        
 
 


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mm or less and generally with IV and sometimes with 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 date and, because they are operator 
dependent, it cannot be guaranteed that the same technique and measurements will 
be taken from one assessment to the next. If new lesions are identified by ultrasound 
in the course of the study, confirmation by CT or MRI is advised. If there is concern 
about radiation exposure at CT, MRI may be used instead of CT in selected 
instances.
14.1.4 Response Criteria
Evaluation of Target Lesions 
Complete Response (CR) 
Disappearance of all target lesions. Any pathological lymph nodes (whether target 
or non-target) must have reduction in short axis to < 10 mm. 
Partial Response (PR)
At least a 30% decrease in the sum of the diameters of target lesions, taking as 
reference the baseline sum diameters 
Progressive Disease (PD) 
At least a 20% increase in the sum of the diameters of target lesions, taking as 
reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study). In addition to the relative increase of 20%, the sum must also 
demonstrate an absolute increase of at least 5 mm.  (NOTE: the appearance of one 
or more new lesions is also considered progression).
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. (Note: a change 
of 20% or more that does not increase the sum of the diameters by 5 mm or more 
is coded as stable disease). 
To be assigned a status of stable disease, measurements must have met the stable 
disease criteria at least once after study entry at a minimum interval of 12 weeks 
(±7 days) after the date of Enrollment.
Evaluation of Non-Target Lesions
      
 
 
        
 
 


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Complete Response (CR) 
Disappearance of all non-target lesions. All lymph nodes must be non-pathological 
in size (<10 mm short axis) 
Non-CR/Non-PD 
Persistence of one or more non-target lesion(s). 
Progressive Disease (PD) 
Appearance of one or more new lesions and/or unequivocal progression of existing 
non-target lesions. Unequivocal progression should not normally trump target 
lesion status. It must be representative of overall disease status change, not a single 
lesion increase. 
When the patient also has measurable disease, there must be an overall level of 
substantial worsening in non-target disease such that, even in the presence of SD or 
PR in target disease, the overall tumor burden has increased sufficiently to merit 
discontinuation of therapy. A modest “increase” in the size of one or more non-
target lesions is usually not sufficient to qualify for unequivocal progression status. 
The designation of overall progression solely on the basis of change in non-target 
disease in the face of SD or PR of target disease will therefore be extremely rare. 
When the patient only has non-measurable disease, the increase in overall disease 
burden should be comparable in magnitude to the increase that would be required 
to declare PD for measurable disease: i.e., an increase in tumor burden from “trace” 
to “large”, an increase in nodal disease from “localized” to “widespread”, or an 
increase sufficient to require a change in therapy. 
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).
Evaluation of New Lesions 
The appearance of new lesions constitutes Progressive Disease (PD). 
A growing lymph node that did not meet the criteria for reporting as a measurable 
or non-measurable lymph node at baseline should only be reported as a new lesion 
(and therefore progressive disease) if it: 
a) increases in size to ≥15 mm in the short axis or; 
b) there is new pathological confirmation that it is disease (regardless of size). 
Evaluation of Best Overall Response 
      
 
 
        
 
 


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The best overall response is the best response recorded from the start of the 
treatment until disease progression/recurrence or non-protocol therapy (taking as 
reference for progressive disease the smallest measurements recorded since the 
treatment started). The patient’s best response assignment will depend on the 
achievement of measurement criteria.
Target
Lesions
Non-Target Lesions
New
Lesions*
Best Overall
Response
Remarks
CR
CR
No
CR
CR
Non-CR/Non-PD***
No
PR
CR
Not evaluated
No
PR
PR
Non-PD***/not 
No
PR
SD
Non-PD***/not 
evaluated
No
SD
Documented at 
least once ≥ 12 
wks. from 
study entry
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.
** In exceptional circumstances, unequivocal progression in non-target lesions may be accepted 
as disease progression.
*** PD in non-target lesions should not normally trump target lesion status. It must be representative of 
overall disease status change, not a single lesion increase. Please refer to the Evaluation of Non-
Target Lesions – Progressive Disease section for further explanation.
NOTE: Patients 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.
Table 14. RECIST 1.1 For Patients with Measurable Disease (i.e. Target 
Disease)
Duration of Response 
Duration of Overall Response 
The duration of overall response is measured from the time measurement criteria 
are met for CR or PR (whichever is first recorded) until the first date that recurrent 
or progressive disease is objectively documented (taking as reference for 
progressive disease the smallest measurements recorded since the treatment 
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The duration of overall CR is measured from the time measurement criteria are first 
met for CR until the first date that progressive disease is objectively documented. 
Duration of Stable Disease 
Stable disease is measured from the start of the treatment until the criteria for 
progression are met, taking as reference the smallest measurements recorded since 
the treatment started, including the baseline measurements. 
To be assigned a status of stable disease, measurements must have met the stable 
disease criteria at least once after study entry at a minimum interval of 12 weeks 
(84 days, ±7 days) after the date of Enrollment.
14.2Progression-Free Survival (PFS)
Patients will be evaluated during treatment and by follow-up assessments post-treatment 
at: 30-days (+5 days).  PFS is defined as the time from treatment initiation until 
documented disease progression or death (by any cause, in the absence of progression).  
In progression-free patients, PFS will be censored at the last evaluable tumor assessment 
(RECIST v1.1).
14.3Overall Survival (OS)
OS is defined as the elapsed time from start of treatment to death or date of censoring.  
Patients alive or those lost to follow-up will be censored at the last date of contact (or last 
date known to be alive).  
15.0 ADVERSE EVENTS
The descriptions and grading scales found in the revised NCI Common Terminology Criteria 
for   Adverse Events (CTCAE) version 4.03 will be utilized for adverse event reporting.
15.1Purpose
Adverse event data collection and reporting, which are required as part of every clinical 
trial, are done to ensure the safety of patients enrolled in the studies, as well as those who 
will enroll in future studies using similar agents.  Adverse events are reported in a routine 
manner at scheduled times during a trial.  Additionally, certain adverse events must be 
reported in an expedited manner for timelier monitoring of patient safety and care. 
15.2 Adverse Event
Adverse Event (AE): Can be any unfavorable and unintended sign (e.g., an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of a drug, 
medical treatment, or procedure without judgment about causality.  An adverse event 
can arise from any use and from any route of administration, formulation, or dose 
including an overdose. This includes any newly occurring event or a previous condition 
that has increased in severity or frequency since initiation of a drug, medical treatment, 
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Abnormal Findings
In any clinical assessment, a value outside the normal or reference range (such as a 
clinical laboratory, vital sign, or ECG) will not be reported or assessed as an AE unless 
that value is considered to be of clinical significance by the investigator.  A value of 
clinical significance is one that leads to discontinuation or delay in protocol treatment, 
dose modification, therapeutic intervention*, or is considered to be a clinically 
significant new finding or change from baseline by the investigator. 
*Transfusion support administered to offset clinical symptoms of anemia or 
thrombocytopenia will not be considered therapeutic intervention.
Signs and Symptoms
Signs/symptoms resulting from an underlying clinical diagnosis should be documented 
as one comprehensive AE.  If no underlying clinical diagnosis can be identified, each 
sign/symptom should be reported as a separate independent event.  (A new or worsening 
event resulting from an underlying clinical diagnosis or a reaction to concurrent 
medications should be documented as a separate independent AE unless it is within the 
normal range of fluctuation for that patient.)  
Grade Changes/Fluctuations
AEs will be reported at the maximum grade/severity experienced for the duration of the 
event.  Should one particular event warrant further investigation, additional details may 
be collected at the discretion of the Principal Investigator.  
Progression of Disease
Progression of disease, if documented in accordance to standard of care, should not be 
reported as an AE.
Tests and Procedures
Tests and procedures should not be reported as AEs.  The underlying clinical diagnosis 
(or sign/symptom in the event an underlying clinical diagnosis is not known) requiring 
testing or a procedure, should be reported as an adverse event if it meets criteria for 
reporting.
15.3Serious Adverse Events (see also Appendix A)
Serious AE (SAE) means any untoward medical occurrence that occurs at any dose:
1. Results in death. 
2. Is life-threatening. 
The term "life-threatening" in the definition of "serious" refers to an event in which 
the patient was at risk of death at the time of the event; it does not refer to an event 
which hypothetically might have caused death if it were more severe).
3. Requires inpatient hospitalization or prolongation of present hospitalization. 
Elective hospitalization to simplify protocol treatment/evaluations or to treat a 
baseline condition that did not worsen from baseline will not be considered an SAE.   
      
 
 
        
 
 


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4. Results in persistent or significant disability/incapacity. 
Disability is defined as a substantial disruption of a person’s ability to conduct normal 
life functions.
5. Is a congenital anomaly/birth defect. 
6. Is a medically important event.
A medically important event may not be immediately life threatening or result in 
death or hospitalization but may jeopardize the patient or may require intervention to 
prevent one of the other outcomes listed in the definition above, or involves suspected 
transmission via a medicinal product of an infectious agent.   Examples of such 
medical events include allergic bronchospasm requiring intensive treatment in an 
emergency room or at home, blood dyscrasias or convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse; any 
organism, virus, or infectious particle (e.g., prion protein transmitting Transmissible 
Spongiform Encephalopathy), pathogenic or nonpathogenic, is considered an 
infectious agent. 
Additional SAE classification(s) for AEs occurring at any dose or during any use 
of Merck product(s): 
6. Is a new cancer (that is not a condition of the study);
7. Is associated with an overdose (whether accidental or intentional): Any adverse 
event associated with an overdose is considered a serious adverse event. An 
overdose that is not associated with an adverse event is considered a non-serious 
event of clinical interest and must be reported within 24 hours.
8. Is another important medical event
Clarification should be made between the terms serious and severe because they ARE 
NOT synonymous.  The term severe is often used to describe the intensity (severity) of a 
specific event (as in mild, moderate, or severe myocardial infarction); the event itself, 
however, may be of relatively minor medical significance (such as a severe headache).  
This is NOT the same as serious, which is based on patient/event outcome or action 
criteria described above and is usually associated with events that pose a threat to a 
patient’s life or functioning.  A severe AE does not necessarily need to be considered 
serious.  For example, persistent nausea of several hours duration may be considered 
severe nausea but not an SAE.  On the other hand, a stroke resulting in only a minor 
degree of disability may be considered mild but would be defined as an SAE based on 
the above noted criteria.  Seriousness (not severity) serves as a guide for defining 
regulatory reporting obligations.  
      
 
 
        
 
 


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15.4Adverse Event Collection Period
In this protocol, adverse events include only treatment-emergent adverse events.  A 
treatment-emergent adverse event (TEAE) is defined as any event that begins or worsens 
after the start of protocol treatment.  All baseline-emergent adverse events, any event that 
begins or worsens after completion of the informed consent protocol but prior to the start 
of protocol treatment, should be reported as a Baseline/Comorbid Condition. 
All adverse events that occur within ≤ 30 days of the last dose of study therapy will be 
reported and followed until resolution.  Resolution is defined as a return to baseline status 
or the stabilization of an event with the expectation that it will remain chronic.  
(Exception: If a patient begins an alternative therapy that confounds accurate assessment 
of AEs within ≤ 30 days of the last dose of study therapy, all adverse event collection 
will stop and any ongoing events will be left open.)
15.5Adverse Event Reporting Requirements
The information to be reported in AEs will be assessed by and assigned severity using 
the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI 
CTCAE), Version 4.03.   The NCI CTCAE provides descriptive terminology and a 
grading scale for each adverse event listed.  A copy of the NCI CTCAE v4.03 can be 
downloaded from the CTEP home page 
(http://evs.nci.nih.gov/ftp1/CTCAE/About.html).   
Information to be reported in the description of each adverse event may be included, but 
is not limited to:
1. Clinical Diagnosis of the event as determined by NCI CTCAE, Version 4.03 
descriptive terminology.  If no clinical diagnosis can be identified, each 
sign/symptom should be reported as a separate independent event.
2. Date of onset of the AE (start date).
3. Date of resolution of the AE (end date). 
4. Severity of the event determined by NCI CTCAE, Version 4.03 grading scale.    
5. Relationship of the AE to study therapy.  Categorized as follows:
Definite
The adverse event is clearly related to the investigational agent(s)
Probable
The adverse event is likely related to the investigational agent(s)
Possible
The adverse event may be related to the investigational agent(s)
Unlikely
The adverse event is doubtfully related to the investigational agent(s)
Unrelated
The adverse event is clearly not related to the investigational agent(s)
6. Whether or not the AE is Serious or Not Serious as defined in Section 15.3 Serious 
Adverse Events.
      
 
 
        
 
 


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7. Whether the AE is Suspected and/or Unexpected.
Suspected
Any AE for which there is a reasonable possibility that the drug caused 
the AE. For the purposes of expedited safety reporting, ‘reasonable 
possibility’ means there is evidence to suggest a causal relationship 
between the drug and the AE.
Unexpected
Any AE for which the nature or severity of the event is not consistent 
with the applicable product information, e.g., the Investigator’s 
Brochure or Package Insert.
8. Action taken as a result of the AE. 
9. Outcome.
15.6Expedited Adverse Event Reporting Requirements
All AEs, regardless if serious or not, will be described in the source documents, 
reported on the applicable AE page of the CRFs, and entered into Velos.  However, 
certain adverse events must also be reported in an expedited manner for more timely 
monitoring of patient safety and care.  Appendix A provides information about these 
expedited reporting requirements.
16.0STATISTICAL CONSIDERATIONS
16.1Overview
This single-arm phase II study will assess the progression-free rate at 3 months after 
concurrent axitinib and pembrolizumab therapy in advanced soft tissue sarcomas not 
amenable to traditional chemotherapy or that have failed standard of care treatment.    (See 
Section 7.0, Study Design).  Sample size justification of 30 patients is provided in Section 
16.4 based on single-arm survival design. 
16.2Definitions and Endpoints
Analysis set
Analysis set: The analysis set for evaluation of treatment response consists of all study-
eligible patients who receive at least 80% of scheduled axitinib doses and two infusions of 
pembrolizumab, have measurable disease at baseline and at least one post-baseline disease 
assessment.  The analysis set for the second endpoint of toxicity will include all study-
eligible patients who receive at least one dose of both drugs.  
Exclusions
Patients who are enrolled on study but do not complete the first cycle and drop out due to 
any reason except dose limiting toxicity (DLT) or clinical progression will be excluded 
from analysis of efficacy endpoints. Reasons for such exclusions will be characterized such 
as consent withdrawn or eligibility subsequently not confirmed. 
Endpoints
      
 
 
        
 
 


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The primary endpoint will be the progression-free survival by RECIST 1.1 in evaluable 
patients treated with combination axitinib/pembrolizumab.
The secondary endpoints include:

The objective response rate (ORR) is defined as the proportion of patients 
whose response by RECIST 1.1 is complete response (CR) or partial response 
(PR).  The clinical benefit rate (CBR) is the proportion of patients whose 
response by RECIST 1.1 is complete response (CR), partial response (PR), or 
stable disease (SD).  The time to progression (TTP) is defined as time from 
treatment initiation to first occurrence of progression by RECIST v1.1 or death 
of sarcoma patients treated with concurrent axitinib/pembrolizumab therapy.  
Overall survival (OS) is defined as the elapsed time from treatment initiation to 
death from any cause, whichever is earlier. Patients alive or those lost to follow-
up will be censored at the last date of contact (or last date known to be alive).

Adverse events, including dose-limiting toxicity and grade 3 or grade 4 serious 
adverse events 
o
DLT includes treatment-related (possible, probably, or definite) grade 3 or 
higher toxicities as detailed in section 7.2.  Toxicity will be reported by 
short name, type, grade, and attribution as per CTCAE v4.0.3.
The exploratory endpoints include:

The quantity of CD3+ T-cells in peripheral blood and in tumor biopsies at 
each timepoint (baseline, cycle 3, and off-study).

The expression category in tumor tissue (none (0%), low (<5%), intermediate 
(5-50%), or high (>50%) of various markers including PD-1, PD-L1, PD-L2, 
CTLA-4, TIM-3, LAG-3 at each timepoint (baseline, cycle 3, and off-study). 

The following T cell subsets will be studied in peripheral blood and tumor 
tissue:  (CD4, CD8, T-reg, CTLA4, TIM3, LAG3, memory, naïve, PD-1, 
Ki67).  For each marker, the absolute change in the marker(s) value will be 
calculated: 
o
Cycle 3 marker value minus Baseline marker value
o
Progression marker value minus Cycle 3 marker value
o
Progression marker value minus Baseline marker value

For each of the alternative (non-RECIST) radiological measurements we will 
categorize tumor response as CR/PR/SD vs PD.  CT and/or MRI with dynamic 
contrast enhanced sequences will be collected throughout the study at every 
disease evaluation and analyzed using Choi criteria, MRI volumetrics, and 
      
 
 
        
 
 


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immune-related response criteria.  PET/CT will be obtained at baseline, Cycle 
3, and off-study and tumor response analyzed by PERCIST 1.0.  

The quantity of circulating tumor cells (CTCs) in peripheral blood will be 
measured at three timepoints:  baseline, cycle 3, and off-study.  

RNA expression of a panel of angiogenesis and immune related genes 
performed using Nanostring Universal Immunooncology platform on tumor 
biopsies. RNA expression of immune related genes will be performed on 
banked peripheral blood samples by Simpatica Medicine. Expression profiles 
will be obtained at baseline and at Cycle 3 Day 1 on treatment. 
T cell clonality indices of tumor biopsies and peripheral blood at baseline and on treatment at 
Cycle 3 Day 1.  
Plasma angiogenic activity at baseline, Cycle 1 Day 8, and Cycle 3 Day 1.  
16.3Statistical Analysis
Baseline clinical and demographic characteristics of patients will be summarized. Categorical 
data will be summarized by the number and percent of patients in each category. Continuous 
variables will be summarized by descriptive statistics using mean, standard deviation, median, 
minimum and maximum.
Analysis for Primary Endpoint
The primary endpoint is progression-free survival (PFS) by RECIST 1.1 in evaluable patients 
treated with combination axitinib/pembrolizumab. PFS will be analyzed by Kaplan-Meier (KM) 
methods, and point estimates and 2-sided 95% confidence intervals for PFS will be reported for 
selected times such as 3, 6 and 12 months from treatment start using Greenwood’s variance and 
the log-log transform method. Median PFS time, if attained, will also be reported.
Analysis for Secondary Endpoints 
Objective response (CR or PR) and best response (CR, PR, or SD) by RECIST 1.1 to 
axitinib/pembrolizumab combination therapy will be tabulated, summarized and reported with 
95% confidence intervals.  Overall survival will be analyzed by Kaplan-Meier (KM) curves with 
standard error according to Greenwood’s variance and the log-log transform method.  Median OS 
will be reported if attained.  
Toxicity will be summarized by reporting the number of patients treated, the number who 
experience DLT, SAEs and grade 3 or higher AE, the proportion of patients treated at various 
axitinib dose titration levels, the number of patients who discontinue therapy, and the reasons for 
discontinuation.  Comprehensive safety data on all grade 3 and 4 toxicities will be tabulated by 
type, grade, duration, attribution to treatment, and dose level received. 
      
 
 
        
 
 


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Analysis for Exploratory Endpoints 
Although a large number of factors are being tested, we will not be making adjustments for 
multiple testing because these analyses are exploratory and hypothesis-generating.  Findings will 
be validated in future larger studies.
Tumor infiltrating T-cells will be quantified by immunohistochemistry using a semiquantitative 
scoring system as detailed in Appendix F, Section C.  We will test for association of clinical 
benefit status (CR/PR/SD vs PD) vs. T-cell quantity using a Wilcoxon rank sum test.  We will 
test for association with progression-free status at 3 months (progression vs. no progression) vs. 
T-cell quantity using Wilcoxon rank sum test.  
The expression of immune markers such as PD-1, PD-L1, PD-L2, CTLA4, TIM3, and LAG3 by 
immunohistochemistry will be categorized as negative (0%), low (<5%), intermediate (5-50%), 
or high (>50%) as detailed in Appendix F, Section C.  We will test for association of clinical 
benefit status (CR/PR/SD vs PD) and expression category using a Chi-square test.  We will test 
for association of expression category vs. PFS using a log-rank test.  
To test for the association of the absolute change of each subset (CD4+, CD8+, T-reg, CTLA4+, 
TIM3+, LAG3+, memory, naïve, PD-1, Ki67) by flow cytometry in blood and tumor tissue 
between three timepoints (Cycle 3 marker value minus Baseline marker value, Progression 
marker value minus Cycle 3 marker value, Progression marker value minus Baseline marker 
value)) with clinical benefit status (CR/PR/SD vs. PD), we will use a Wilcoxon rank sum test.  
Absolute changes across timepoints will be graphically presented for each marker using boxplots.
To test for the association of the absolute change between three timepoints (Cycle 3 marker value 
minus Baseline marker value, Progression marker value minus Cycle 3 marker value, Progression 
marker value minus Baseline marker value)) of each subset (CD4+, CD8+, T-reg, CTLA4+, 
TIM3+, LAG3+, memory, naïve, PD-1, Ki67) with progression-free status at 3 months 
(progression vs. no progression), we will use a Wilcoxon rank sum test.  
We will describe the relationship between the assessment of tumor response according to RECIST 
1.1 and tumor response according to alternative radiologic methods (CT-based Choi criteria, 
immune related response criteria, MRI volumetrics, and PERCIST 1.0) using a 2 x 2 table to 
estimate the concordance between the two approaches.  Results will be reported with 95% 
confidence interval on the proportion concordant.  We are not attempting to demonstrate 
superiority of the alternative approaches, thus we will not use McNemar’s test.  We simply will 
describe the relationships between the approaches.  
To test for the association of absolute change in CTC counts at two time points (cycle 3 and off-
study) compared to baseline with clinical benefit status (CR/PR/SD vs. PD), we will use a Student 
t-test and Wilcoxon rank sum test for a specific time point and analysis of variance (ANOVA) 
and Kruskal-Wallis test for comparing all two time points. Repeated measure data analysis 
method will be used to analyze CTC count profiles by clinical benefit status.
      
 
 
        
 
 


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To test for the association of absolute change in CTC counts at two time points (cycle 3 and off-
study) compared to baseline with progression-free status at 3 months (progression vs. no 
progression), we will use a Student t-test and Wilcoxon rank sum test for a specific time point 
and analysis of variance (ANOVA) and Kruskal-Wallis test for comparing all two time points. 
Repeated measure data analysis method will be used to analyze CTC count profiles by 
progression-free status at 3 months.
Developing candidate biomarkers: We will be obtaining a large number of variables and looking 
for associations with response. In parallel to the above analysis, we will also utilize penalized 
logistic regression with bootstrapping to identify variables associated with response. We will 
adjust for multiple testing using Bonferroni adjustment and false discovery rate (FDR) due to 
multiplicity.
Genetic expression analysis: All statistical analysis will be performed by Nanostring, initially 
blinded to patient outcomes. Gene expression data will be log base 2-transformed and normalized 
using housekeeping genes selected using the nSolver 2.6 package. To identify signatures, an 
unsupervised cluster analysis will be performed requiring >15 genes and a correlation coefficient 
(r) among the genes >0.8. Genetic signature expression will be associated with the binary outcome 
of progression-free status at 3 months. These signatures will be analyzed using a penalized logistic 
regression analysis since these signatures are high-dimensional and highly correlated with each 
other.  Although LASSO method is used in this analysis, elastic next approach may be considered 
as well.
16.4Patient Enrollment and Sample Size
The study will be conducted at Sylvester Comprehensive Cancer Center.  Our expectation is that 
proposed treatment will improve PFS at 3 months from 19% to 40%. Assuming 15 months for 
enrollment and 12 months minimum follow-up, 40 evaluable patients (including expansion) will 
provide 97.5% power to reject 3 month PFS rate of 19% in favor of 3 month PFS rate of 40% using 
a one-sample survival test with one-sided 5% significance level using STPLAN (MD Anderson 
Biostatistics software) [6]. With estimated accrual of 1 patient every 2 months in the expansion 
cohort, we anticipate 18-24 months for patient enrollment followed by an additional year of follow 
up time.  Expected time to study completion is 3 years from date open to enrollment.
For the secondary objectives utilizing patient samples, we anticipate that we will be able to obtain 
complete sets or measurements for all patients (pre-treatment, on-treatment, and post-treatment) 
to permit analysis of intrapatient pharmacodynamic effect of therapy.  However, a critical 
component of this study is the analysis for exploratory endpoints, which are hypothesis-
generating in regards to potential biomarkers for response in sarcoma patients treated with 
concurrent axitinib/pembrolizumab.  Thus, if our primary endpoint is met by the conclusion of 
enrollment and the combination appears active with potential benefit to patients, yet collection of 
tumor biopsies and peripheral blood sample collection was incomplete, we would consider 
extending enrollment to an additional 10 patients in an effort to obtain complete paired samples 
at the baseline, cycle 3, and off-study timepoints in responders and non-responders.
      
 
 
        
 
 


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Power considerations for correlative studies: If we estimate 75% collection of complete, 
interpretable biopsies and blood samples from 40 patients, our analysis set of responders vs. non-
responders will include approximately 10 responding patients and 20 non-responding patients. A 
sample size of 10 in the responder group and 20 in the non-responder group will provide 89.4% 
statistical power to detect a difference in mean change of 2.5 with a standard deviation of 1 at 
both time points, and a correlation between two measurement pairs of 0.2. The significance level 
is 0.00083 using Bonferroni adjustment (=0.05/60).
17.0DATA AND SAFETY MONITORING (Interim monitoring)
The Research Team will continuously monitor study accruals, toxicities, and response to 
treatment.  The UM/Sylvester Comprehensive Cancer Center’s Data and Safety Monitoring 
Committee (DSMC) will monitor this protocol according to the Cancer Center’s DSM Plan.  In 
its oversight capacity, the DSMC bears responsibility for suspending or terminating this study. 
DSMC oversight of the conduct of this trial includes ongoing review of accrual and adverse event 
data, and periodic review of response. The DSMC also reviews reports from internal audits of 
protocol compliance and data integrity conducted by the University of Miami, Office of Research 
Compliance Assessment. The guidelines appearing in this section are offered for DSMC 
consideration in assessing adverse events and response to study treatment.  
Early stopping guidelines
We propose the following guidelines for the DSMC in its review of accumulating data on toxicity 
and response. The proposed guidelines were developed using Bayesian methods, which can be 
applied at any stage of enrollment without advance specification of the number of interim analyses 
to be performed, or the number of patients evaluable for toxicity, or response, at the time such 
assessments are made (45, 46).
Under the Bayesian method, we assign a prior probability (level of belief at the start of the trial) 
to a range of possible values for the true toxicity rate, and likewise for the true response rate.  As 
data on treated patients become available, each of these probability distributions is revised and 
the resulting posterior probability becomes the basis for recommending either early termination 
or continuation of the study. 
Early stopping rule is applied to 30 patients who receive concurrent axitinib with pembrolizumab.  
Details are given in the remainder of this section.
Early stopping due to safety
If a treatment-related (possible, probable, or definite) death occurs, enrollment will be suspended 
and continuation of the study will be reassessed by the DSMC.
If four out of first five treated patients experiences DLT then the study will be suspended and 
reviewed with the Data Safety Monitoring Committee for consideration of modification or 
      
 
 
        
 
 


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termination. It is based on Bayesian stopping rule that DLT rate should not exceed 40% with a 
posterior probability of 90% or higher.
For purposes of safety monitoring, we define an unacceptable toxicity to be any treatment-related 
DLT, where acute refers to the period of time from start of study treatment to one month following 
completion or discontinuation of treatment. Unacceptable toxicity is expected to occur in no more 
than 30% of study patients. Early stopping (suspension and possibly termination) will be 
considered if there is evidence that the proportion of patients experiencing unacceptable toxicity 
exceeds 40%.  Specifically, we suggest as a guideline for early termination a posterior probability 
of 90% or higher that the rate of unacceptable toxicity exceeds 40%. 
The table below shows specific instances where this guideline is met, thus suggesting early 
termination due to evidence of excessive toxicity. 
Number of patients 
with DLT among 30 
patients 
Total 
patients 
evaluated
Observed 
toxicity rate
4
4 to 5
≥ 80%
5
6 to 7
≥ 71%
6
8 to 9
≥ 67%
7
10 to 11
≥ 64%
8
12 to 13
≥ 62%
9
14 to 15
≥ 60%
10
16 to 17
≥ 58%
11
18 to 19
≥ 57%
12
20 to 21
≥ 54%
13
22 to 24
≥ 54%
14
25 to 26
≥ 54%
15
27 to 28
≥ 53%
16
29
≥ 55%
Table 13. Stopping Rule for Safety
For example, if 7 patients have been assessed for toxicity, the second row of the above table 
indicates that early stopping should be considered if 5 (71%) of these patients have 
experienced DLT.  
Posterior probabilities used to derive the preceding table are calculated under a prior beta 
distribution with parameters 1 = 0.6 and 2 = 1.4, which corresponds to an expected rate of 
30% based on very limited information, roughly equivalent to having studied two patients.  
This prior distribution implies also an a priori chance of only 32% that the rate of unacceptable 
toxicity is 40% or greater. 
Early stopping due to lack of efficacy
      
 
 
        
 
 


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We do not propose early stopping of this trial based on interim assessment of efficacy. We 
need to gather preliminary evidence of efficacy of the treatment for this study population.
18.0DATA REPORTING
Data must be submitted according to the protocol requirements for all patients registered.  
Patients for whom documentation is inadequate to determine eligibility will generally be 
deemed ineligible. 
19.0 STUDY MONITORING
This study will be monitored and/or audited (as applicable) according to the University of 
Miami requirements.  See also http://uresearch.miami.edu/regulatory-compliance-
services/rcqa and http://research.med.miami.edu/clinical-research/crors. 
20.0INVESTIGATOR RESPONSIBILITIES
20.1Investigator Responsibility/Performance
The investigator will ensure that this study is conducted in accordance with all 
regulations governing the protection of human subjects. The investigator will ensure 
that all work and services described in or associated with this protocol will be 
conducted in accordance with the investigational plan, applicable regulations, and the 
highest standards of medical and clinical research practice.
20.2Confidentiality
The investigator must ensure that each subject’s anonymity will be maintained and each 
subject’s identity will be protected from unauthorized parties.  A number will be 
assigned to each subject upon study entry and the number and the subject’s initials will 
be used to identify the subject for the duration of the study.  The investigator will 
maintain all documents related to this study in strict confidence.
20.3Informed Consent and Permission to Use Protected Health Information 
It is the responsibility of the investigator to obtain written informed consent from each 
subject participating in this study after adequate explanation, in lay language, of the 
methods, objectives, anticipated benefits, and potential hazards of the study.  The 
investigator must also explain that the subject is completely free to refuse to enter the 
study or to discontinue participation at any time (for any reason) and receive alternative 
conventional therapy as indicated.  Prior to study participation, each subject will sign an 
IRB approved informed consent form and receive a copy of same (and information 
leaflet, if appropriate).  For subjects not qualified or able to give legal consent, consent 
must be obtained from a parent, legal guardian, or custodian. The investigator or 
designee must explain to the subject before enrollment into the study that for 
evaluation of study results, the subject’s protected health information obtained during 
      
 
 
        
 
 


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the study may be shared with the study sponsor, regulatory agencies, and the IRB.  It is 
the investigator’s (or designee’s) responsibility to obtain permission to use protected 
health information per HIPAA from each subject, or if appropriate, the subjects’ parent 
or legal guardian.
20.4Source Documentation and Investigator Files
The investigator must maintain adequate and accurate records to fully document the 
conduct of the study and to ensure that study data can be subsequently verified.  These 
documents should be classified into two separate categories:  (1) investigator study file 
and (2) subject clinical source documents that corroborate data collected on the CRF’s.  
Subject clinical source documents may include hospital/clinic patient records; 
physician's and nurse's notes; appointment book; original laboratory, ECG, EEG, 
radiology, pathology, and special assessment reports; pharmacy dispensing records; 
subject diaries; signed informed consent forms; and consultant letters.  When the CRF 
or any form is used as the source document, this must be clearly stated in the 
investigator study file. Minimally, the following be documented in source documents:

Medical history/physical condition and diagnosis of the subject before involvement 
in the study sufficient to verify protocol entry criteria

Study number, assigned subject number, and verification that written informed 
consent was obtained (each recorded in dated and signed notes on the day of entry 
into the study)

Progress notes for each subject visit

Documentation of treatment

Laboratory test results

Adverse events (action taken and resolution)

Condition and response of subject upon completion of or early termination from 
the study
20.5Recording and Processing of Data
If using hard copies of CRF’s, study center personnel will complete individual CRF’s 
in black ink.  All corrections to entered data will be made by drawing a single line 
through the information to be corrected without obscuring it.  All corrections will be 
initialed, dated and explained, if necessary.  The use of “white-out” or obscuring 
correction tape will be prohibited.  A CRF is required for every patient who received 
any amount of study treatment.  The investigator will ensure that the CRF’s are 
accurate, complete, legible and timely. Separate source records are required to support 
all CRF entries except those for which use of the CRF as source document is clearly 
allowed per note in the investigator study file.
Data must be submitted according to the protocol requirements for ALL patients 
registered.  Patients for whom documentation is inadequate to determine eligibility will 
generally be deemed ineligible. 
      
 
 
        
 
 


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A list of forms to be submitted, as well as expectation dates may be found in Appendix 
B.
20.6Non-Protocol Research
No investigative procedures other than those described in this protocol will be 
undertaken on the enrolled subjects without the agreement of the IRB.
20.7Ethics
The investigator agrees to conduct the study in compliance with the protocol, current 
good clinical practices, and all applicable (local, FDA) regulatory guidelines and 
standard of ethics.
UM Ethics Programs’ Research Ethics Consultation Service (RECS) is a free resource 
for UM Researchers.  See the website for further information: 
http://www.miami.edu/index.php/ethics/projects/recs/   
20.8Essential documents for the conduct of a clinical trial
Essential documents are those documents with individually and collectively permit 
evaluation of the conduct of a trial and the quality of the data produced. The following 
documents should be on file: 1) 1572 or investigator’s agreement (for studies involving 
IND drugs or devices, respectively); 2) CV’s and license of all Investigators; 3) IRB 
documentation/correspondance and 4) Documentation of IRB certification
      
 
 
        
 
 


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APPENDIX A: EXPEDITED ADVERSE EVENT (AE) REPORTING REQUIREMENTS
For all AEs that meet criteria for expedited reporting, the Principal Investigator (PI) is obligated 
to pursue and provide follow-up reporting information until the event has resolved or until an 
acceptable medical endpoint has been reached (i.e. for the duration specified in the protocol), or 
the patient is lost to follow-up.
The PI and all applicable research study team members should become familiar with the safety 
profile of the investigational agent(s) and/or intervention at the start of the study and for the 
duration of the research, e.g. by reviewing the Investigator’s Brochure (IB) and any Safety 
Reports released, by the Sponsor as applicable.  
I.
FDA Expedited Reporting
a.
Sponsor-Investigators i.e. IND Holders, have additional reporting requirements to the 
FDA and other committees, and should consult the applicable regulations and agency 
guidelines for these requirements.  
b. Since this protocol involves the use of FDA IND agent(s), completion of the FDA 
MedWatch 3500A Reporting Form is required for Sponsor-Investigators.  The Form 
can be obtained electronically at: 
http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM0483
34.pdf
i. All serious, unexpected (unanticipated) and suspected adverse events must be 
directly reported to the FDA within 15 calendar days of being made known to the 
Principal Investigator (PI).  
ii. All fatal or life-threatening AEs must be directly reported to the FDA within 7 
calendar days of being made known to the PI.
c.
For more information regarding reporting to the FDA, please refer to the FDA 
website for REPORTING GUIDELINES:  
http://www.fda.gov/Safety/MedWatch/HowToReport/default.htm
II.
IRB Expedited Reporting
a.
All Investigators should also be aware of local Institutional requirements for AE 
reporting.  For more information regarding the IRB policy, please refer to the UM 
HSRO’s Investigator Manual: http://hsro.med.miami.edu/documents/HRP-103_-
_INVESTIGATOR_MANUAL_4.11.2014.docx and the UM HSRO SOP on New 
Information (HRP-024) 
https://eprost.med.miami.edu/eProst/Doc/0/HLJ5OTJVQEH419E0I6QPT3B199/HRP
-024%20-%20SOP%20-%20New%20Information.docx
b. All AEs that are serious, unanticipated and (at least) possibly related will be reported 
to the IRB within ten (10) working days of being made known to the PI.  
      
 
 
        
 
 


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c.
Events that are more frequent than anticipated or more severe than expected must be 
reported to the IRB within ten (10) working days of being made known to the PI.
d. All unanticipated deaths must be reported to the IRB within 24 hours of being made 
known to the PI.
III.
Merck Expedited Reporting (Events of Clinical Interest or ECIs)
a.
In addition to the mandatory MedWatch 3500A Form, the PI is also required to 
comply with all reporting requirements as supplied by the Investigational Drug 
Sponsor: Merck.  
b. Selected non-serious and serious adverse experiences must be reported to Merck 
within 24 hours (and within 2 working days to Merck Global Safety) regardless of 
attribution to study treatment. The AEs listed and any event that meets the criteria for 
reporting (as noted) in the protocol Appendix H (event term and Grade) must be 
reported regardless of physician-determined causality with study medication and 
whether or not considered immune-related by the physician (unless otherwise 
specified). Physicians/study coordinators/designated site personnel are required to 
record these experiences as events of clinical interest (ECIs) on the Adverse 
Events/Experience Forms and to provide supplemental information (such as medical 
history, concomitant medications, investigations, etc.) about the event.
c.
Additional Sponsor Requirements: 
i. Any other Grade 3 or higher event that the investigator/physician considers to be 
immune-related should be reported as an ECI regardless of whether the specific 
event term is in Appendix H (Table 13) and reported to Merck within 24 hours 
from the time the Investigator/physician is aware of such an occurrence. Adverse 
events that are both an SAE and an ECI should be reported one time as an SAE 
only, however the event must be appropriately identified as an ECI as well in the 
database (i.e. Velos). 
ii. Any serious adverse event, or follow up to a serious adverse event, including death 
due to any cause other than progression of the cancer under study that occurs to 
any subject from the time the consent is signed through 90 days following 
cessation of treatment, or the initiation of new anti-cancer therapy, whichever is 
earlier, whether or not related to Merck product, must be reported within 24 hours 
to the Sponsor and within 2 working days to Merck Global Safety. 
iii. Any other serious adverse event, considered by an investigator who is a qualified 
physician to be related to a Merck product that is brought to the attention of the 
investigator at any time outside of the time period specified in the previous 
paragraph also must be reported immediately to Merck.  All subjects with serious 
adverse events must be followed up for outcome.
iv. A copy of all 15 Day Reports and Annual Progress Reports is submitted as 
required by FDA, European Union (EU), Pharmaceutical and Medical Devices 
      
 
 
        
 
 


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agency (PMDA) or other local regulators. Investigators will cross reference this 
submission according to local regulations to the Merck Investigational Compound 
Number (IND, CSA, etc.) at the time of submission.  Additionally investigators 
will submit a copy of these reports to Merck & Co., Inc. (Attn: Worldwide Product 
Safety; FAX 215 993-1220) at the time of submission to FDA.
v. SAE reports and any other relevant safety information are to be forwarded to 
the Merck Global (ATTN: Worldwide Product) Safety Fax Number: +1-215-993-
1220
IV.
Pfizer Expedited Reporting Requirements
a.
For complete details always refer to the Safety Reporting Reference Manual 
Investigator-Initiated Research (IIR) Studies With Pfizer Products 
b. Complete the Pfizer-provided Investigator-Initiated Research Serious Adverse
Event (IIR SAE) Form (or other agreed reporting method as specified by and 
discussed with the Principal Investigator), and submit it to Pfizer immediately 
for a death or life-threatening event, and within 24 hours for all other reportable 
SAEs.
c.
Submit the Pfizer-provided Reportable Events Fax Cover Sheet with each
submission of an SAE to Pfizer.
d. Pfizer-specified “Points to Note: SAE Reporting” 
i. IIR SAE forms (or other agreed reporting method as specified by an 
discussed with the Principal Investigator) must be submitted for all 
SAEs in subjects receiving a Pfizer product or blinded therapy occurring 
in the specified reporting period as defined in your agreement with Pfizer.
ii. Even those that are not study-drug-related (e.g., those associated with 
concomitant medications) must be reported.
iii. Non-serious AEs observed in the clinical trial are NOT submitted.
iv. Specifically excluded from the reporting requirements for SAEs under this 
provision is any SAE identified in the protocol as anticipated to occur in 
the study population at some frequency independent of drug exposure, 
unless the Principal Investigator assesses such an event as related to the 
Pfizer Product.
      
 
 
        
 
 


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v.
APPENDIX B: DATA SUBMISSION SCHEDULE
CASE REPORT FORM(S)
TIMEPOINT TO BE COMPLETED
Pre-Treatment
ICF, including HIPAA signed/dated
Eligibility Checklist 
SCCC Protocol Enrollment Form
Prior to registration
On-study Form
e.g. Within 30 days of registration
On Treatment
Treatment Form Cycle X, Day Y
e.g. Due every cycle for phase II studies
End of Treatment
Off Treatment Form
Within 14 days of discontinuation/completion of 
protocol therapy
Follow-Up (for studies with long term follow-up)
Follow-up Form
Every 3 months if < 2 years from study entry;
Every 6 months is 2-5 years from study entry;
Every 12 months if more than 5 years from study 
entry
Progression/Relapse
Within 4 weeks of knowledge of progression/relapse
Notice of Death Form
Within 4 weeks of knowledge of death
Subsequent Malignancy
Within 4 weeks of knowledge of another malignancy
      
 
 
        
 
 


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APPENDIX C: PERFORMANCE STATUS SCALES
As published in Am J Clin Oncol: Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, 
McFadden ET, Carbone PP. Toxicity and Response Criteria of the Eastern Cooperative 
Oncology Group. Am J Clin Oncol 1982;5:649-655. The Eastern Cooperative Oncology Group, 
Robert Comis, MD, Group Chair. 
      
 
 
        
 
 


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APPENDIX D: NYHA CLASSIFICATION OF HEART DISEASE
New York Heart Association (NYHA) classification of heart disease
NYHA Class
Symptoms
I
No symptoms and no limitation in ordinary physical activity, e.g. shortness of 
breath when walking, climbing stairs etc.
II
Mild symptoms (mild shortness of breath and/or angina) and slight limitation 
during ordinary activity.
III
Marked limitation in activity due to symptoms, even during less-than-ordinary 
activity, e.g. walking short distances (20–100 m).
Comfortable only at rest.
IV
Severe limitations. Experiences symptoms even while at rest. Mostly 
bedbound patients.
      
 
 
        
 
 


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APPENDIX E: INFORMATION ON POSSIBLE DRUG INTERACTIONS [AXITINIB]
Information on Possible Interactions with Other Agents for Patients and Their Caregivers 
and Non-Study Healthcare Team*
[Note to Investigators:  This suggested appendix consists of an “information sheet” to be handed 
to the patient at the time of enrollment.  Use or modify the text as appropriate for the study 
agent, so that the patient is aware of the risks and can communicate with their regular 
prescriber(s) and pharmacist.  A convenient wallet-sized information card is also included for 
the patient to clip out and retain at all times.  This document must be IRB-reviewed and 
approved prior to patient distribution.]
The patient ____________________________ is enrolled on a clinical trial using the 
experimental agent axitinib.  This form is addressed to the patient, but includes important 
information for others who care for this patient. 
Axitinib interacts 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: 
Axitinib interacts with (a) certain specific enzyme(s) in your liver. 
The enzyme(s) in question is/are cytochrome P450 (CYP) 3A4/5 and, to a lesser extent 
(<10 % each), by CYP1A2, CYP2C19, and uridine diphosphate glucuronosyltransferase 
(UGT) 1A1 
Axitinib 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.
o
Substances that increase the enzyme’s activity (“inducers”) could result in high 
levels of the active drug, increasing the chance of harmful side effects, while 
substances that decrease the enzyme’s activity (“inhibitors”) could reduce the 
effectiveness of the drug.
o
Axitinib is considered a(n) “[inducer/inhibitor]”of the enzyme, meaning that it 
can affect the levels of other drugs that are processed by that enzyme.  This can 
lead to harmful side effects and/or reduce the effectiveness of those medications.   
      
 
 
        
 
 


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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 medicines that are considered “strong inducers/inhibitors or substrates of 
cytochrome P450 (CYP) 3A4/5, CYP1A2, CYP2C19, and UGT 1A1 .”
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 4 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 drink grapefruit juice or eat grapefruit:  Avoid these until the study is over. 
o
If you take herbal medicine regularly:  You should not take St. John’s wort while 
you are taking axitinib.
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 Jonathan C. Trent, MD, PhD and he can be contacted 
at 305-243-1287.. 
      
 
 
        
 
 


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INFORMATION ON POSSIBLE DRUG 
INTERACTIONS 
You are enrolled on a clinical trial using the experimental 
agent __________________.  __________________ 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, 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.
*Reference: National Cancer Institute (NCI) CTEP Generic Protocol Template for Cancer 
Treatment Trial, Version Date: May 15, 2013.  
__________________ 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 F: BIOMARKER, CORRELATIVE AND SPECIAL STUDIES
A. Exploratory Objective 1: Characterization of immunomodulatory factors in patients 
treated with concurrent axitinib/pembrolizumab
Rationale and Preliminary Studies:  
Although the immune system is suspected to play a role in sarcoma development and 
recurrence, the specific mediators of immune surveillance and suppression of tumor growth 
are largely unknown.  Additionally, we have learned from analysis of patients treated thus far 
with PD-1-directed therapy that biomarkers of response to immunotherapy are extremely 
complex.  Although PD-L1 expression in tumor cells and the presence of lymphocyte 
infiltration with PD-1/PD-L1 expression seem to be the best predictors of response, 10-15% 
of patients without tumor PD-L1 expression have responded to therapy, suggesting that other 
immunomodulatory factors must be playing a role.  In addition to CTLA4 expression, other 
negative regulatory receptors have also been implicated, including LAG-3 and TIM-3, with 
pre-clinical blockade of some of these pathways resulting in improved anti-tumor response.  
Finally, the presence of myeloid-derived suppressor cells (MDSCs) and regulatory T-cells 
have been shown to negatively impact response to therapy in many cancers, though these are 
also understudied in sarcomas.  
Thus, a key correlative component of our study will be to profile sarcoma tumors and 
infiltrating tumor lymphocytes using pre- and post-treatment tumor biopsies, and analysis of 
circulating peripheral blood mononuclear cells to better understand the immune environment 
in sarcoma patients.  We aim to define changes in intra-tumoral and peripheral blood 
lymphocyte phenotypes, activation and differentiation markers, and checkpoint ligand 
expression after treatment with axitinib/pembrolizumab, and correlate with 
radiographic response to therapy.
As discussed in Section 2.6, our preliminary studies demonstrated PD-L1 expression in 9 of 
10 sarcoma patients, TIL infiltration in all patients, and evidence of increased TIL infiltration 
and PD-L1 expression in tumors refractory to prior therapy.  Using dispase/collagenase 
digestion as detailed below, a single cell suspension was prepared from freshly harvested 
sarcoma tissue from a patient undergoing surgery.  One million dissociated tumor cells were 
stained with live/dead dye, CD3, CD4, CD8, CD45, and CD27 and analyzed using FACS.  
From 1x106 dissociated tumor cells, 15,000 CD3+ lymphocytes were detected, including 
10,600 CD4+ and 4200 CD8+ (Figure F1).  Most of the cells in the tumor were central memory 
(Tcm) or functional effector memory (Tem) phenotypes, with largely depleted naïve fractions.  
This demonstrated feasibility of isolating a sufficient number of lymphocytes from fresh 
sarcoma tissue for analysis using this technique.  
      
 
 
        
 
 


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Approach:  
1. Analysis of tumor biopsies by immunohistochemistry (Andrew Rosenberg, Department of 
Pathology
a.
A single core biopsy specimen will be collected in formalin and transported to Andrew 
Rosenberg in the Department of Pathology (detailed in Section 14).  Due to the 
inefficiencies in traditional immunohistochemistry which require a large number of 
slides, we have opted to partner with Ignacio Wistuba at MD Anderson Cancer Center 
who have been performing multiplex IHC on multiple sarcoma trials utilizing 
immunotherapy. IHC will be performed on FFPE samples using validated antibodies 
and standard immunohistochemistry procedures for the following markers:
Figure F1.  TIL phenotype determined by flow cytometry.  After excluding 
doublets by height/width gating, the live cells were gated by live/dead dye exclusion.  From 
1 x 106 dissociated tumor cells, we were able to detect 15,000 CD3+ cells.  Of those 10,600 
were CD4+ and 4,200 were CD8+ cells.  We were able to determine the memory 
phenotype and found most of the cells in the tumor were Tcm (CD45RA-/CD27+) or Tem 
(CD45RA-/CD27-) cells.   In particular, the CD4 compartment were largely depleted of 
their naïve fraction (CD45RA+CD27+).  (Courtesy of Eric Wieder/Krishna Komanduri, 
University of Miami, unpublished data.)
      
 
 
        
 
 


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Figure F2 – 
Multiplex immunohistochemistry panels to be performed on tumor biopsies in 
collaboration with Dr. Wistuba at MD Anderson.  
b. The immune cell infiltrate in the tumor will be assessed according to the intensity and 
geographic distribution within the tumor. The percentage of the immune infiltrate 
subset (leukocytes - CD45+, T-lymphocytes - CD3+, macrophages - CD68+) is 
calculated by dividing the total number of each cell type by the total number of cells 
present in each 20X microscopic power field. A semiquantitative scoring system for 
the distribution of the cells is 0-3; 0 = no infiltrate; 1 = focal infiltrate, <5%, mostly 
perivascular in the tumor with some intratumoral extension; 2 = moderate infiltrate, 5-
50%, prominent intratumoral and intermingling with neoplastic cells; 3 = extensive 
infiltrate, >50%, obscuring tumor cells. 
c.
PD-L1 expression (cytoplasmic and cell membrane) by tumor cells and tumor 
infiltrating immune cells are independently scored by devising a percentage which is 
calculated by dividing the number of PD-L1 positive specific cells by the total number 
of each respective cell type. The positivity is scored as negative (0%), low (<5%), 
intermediate (5-50%) and high (>50%).
      
 
 
        
 
 


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d. PD-1 expression (cytoplasmic and cell membrane) is evaluated in CD3+ T cells using 
percentage calculated by dividing PD1 positive cells by total number of CD3+ T cells. 
The positivity is scored as negative (0%), low (<5%), intermediate (5-50%) and high 
(>50%).
e.
Statistical analysis and outcomes are detailed in section 16.3.
2. Analysis of tumor biopsies for immunomodulatory markers (Flow cytometry)
a.
2-4 needle core biopsy specimens will be collected in RPMI media and immediately 
transferred to Komanduri laboratory.  
b. A single cell suspension will be made from the biopsies by digesting tissue with 
dispase/collagenase (Roche Liberase DH) in media with addition of DNAse at 37 
degrees, and single cells isolated using a Ficoll gradient.  
c.
Cells will be stained with antibodies as per Table F1, followed by FACS analysis to 
profile tumor infiltrating lymphocytes. This panel allows for the determination of 
memory/naïve T cell markers, Treg, and markers associated with negative regulation 
of T cells. 
d. Statistical analysis and outcomes as per Section 16.3.  
Target
Clone
Fluorochrome
Purpose
CD3
UCHT1
BV570
T cells
CD4
RPA-T4
BV650
T helper subset
CD8
RPA-T8
PerCP-Cy5.5
T cytotoxic subset
CD25
M-A251
PE-Cy7
Treg/Activation
CD27
M-T271
APC-H7
Naïve/Memory
CD45RA
HL100
BV711
Naïve/Memory
CD127
HIL-7R-M21
BB-515
Treg gating
CD152 (CTLA4)
BNI3
BV421
Checkpoint
CD223 (Lag-3)
3DS223H
PE
Checkpoint
CD279 (PD-1)
EH12.1
BV786
Checkpoint
Tim-3
F38-2E2
APC
Checkpoint
      
 
 
        
 
 


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Live/Dead
Invitrogen kit
Aqua
Gate on live cells
Dump
CD14/16/19/56
Various
PE-CF594
Exclude non-T cells
Table F1.  Antibody panel for flow cytometry evaluation of tumor-infiltrating lymphocytes.
3. Analysis of circulating peripheral blood mononuclear cells for immunomodulatory 
markers and activation (Flow cytometry)
i.
Peripheral blood samples will be collected by phlebotomy
a.
60 cc blood heparinized (green top tubes) and 10 cc EDTA-anticoagulated 
(purple top tubes) for plasma and immediately transferred to Dr. Komanduri’s 
laboratory.
ii.
Blood samples will be processed by Ficoll gradient to isolate serum, peripheral blood 
mononuclear cells, and plasma.
iii.
PBMC will be stained with antibodies as per Table F2.  Due to the higher numbers of 
cells, we will repeat the same antibodies used in the TIL panel, but with additional 
markers to identify T-regulatory cells and more thoroughly assess activation status.  
iv.
Residual PBMC pellets and serum will be cryopreserved for future potential studies.
v.
Statistical analysis and outcomes as per section 16.3.  
Target
Clone
Fluorochrome
Purpose
CD3
UCHT1
BV570
T cells
CD4
RPA-T4
BV650
T helper subset
CD8
RPA-T8
PerCP-Cy5.5
T cytotoxic subset
CD25
M-A251
PE-Cy7
Treg/activation
CD27
M-T271
APC-H7
Naïve/Memory
CD45RA
HL100
BV711
Naïve/Memory
CD152 (CTLA4)
BNI3
BV421
Checkpoint
CD223 (Lag-3)
3DS223H
PE
Checkpoint
CD279 (PD-1)
EH12.1
BV786
Checkpoint
      
 
 
        
 
 


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Fox-P3
259D/C7
Alexa 647
Treg
Ki-67
B56
Alexa 488
Proliferation
Live/Dead
Invitrogen kit
Aqua
Gate on live cells
Dump
CD14/16/19/56
Various
PE-CF594
Exclude non-T cells
Table F2.  Antibody panel for flow cytometry evaluation of circulating lymphocytes.  
4. Analysis of tumor biopsies and circulating lymphocytes for RNA expression analysis of 
key angiogenic and immune-related genes
In collaboration with Nanostring, we will utilize a novel, 770-gene Universal Immunooncology 
panel to analyze pre-treatment tumor biopsies to identify immune signatures that correlate with 
PFR at 3 months. Additionally, we will compare immune signatures of the on-treatment 
biopsies to baseline which may reveal additional biomarkers of response, but also clarify 
mechanism of activity by including analysis of angiogenesis genes. In parallel, we will partner 
with Simpatica Medicine to perform similar analysis on RNA expression data from sequenced 
PBMC samples pre- and post-treatment.
5. Analysis of functional VEGF activity from peripheral blood
In collaboration with Jaime Merchan, we will quantify circulating endothelial cells (CEC) and 
endothelial progenitor cells (CPC), and determine plasma angiogenic activity as previously 
described. In the ASPS expansion patients, we will also collect PBMC/plasma at Cycle 1 Day 
8 prior to pembrolizumab to assess effects from axitinib alone. We will use flow cytometry to 
measure the concentrations of CEC and CPC in mononuclear cells. Angiogenic activity of 
patient plasma samples at baseline and after treatment with axitinib or axitinib/pembrolizumab 
will be measured by exposing plasma samples to human umbilical vein endothelial cells in 
vitro (HUVEC cell line, Lonza). The resulting proliferation of endothelial cells will be 
measured using a colorimetric assay. Changes in angiogenic activity will be correlated with 
patient responses and the maximum dose of axitinib achieved for each patient.
6. Identify clonal populations and the associated tumor-specific antigens of tumor-
infiltrating and circulating T cells in alveolar soft part sarcoma patients with clinical 
responses to axitinib/pembrolizumab therapy
After collecting TIL and PBMC from the expansion ASPS cohort as previously described, we 
will extract RNA using a microRNAeasy kit (Qiagen). In collaboration with our Oncogenomics 
core facility, quality and quantity of RNA will be assayed followed by library prep to identify T 
cell receptors corresponding to unique clones (PCR using the ArcherDX Immunoverse kit). The 
      
 
 
        
 
 


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libraries will be quantified and sequenced on the Illumina NextSeq sequencer, and analyzed 
using the ArcherDX immune repertoire analysis software platform. Once we have quantified T 
cell clones, we will compare baseline to on-treatment frequencies, as well as clonality of TIL vs. 
peripheral T cells for each patient. We will also compare frequencies of T cell clones across 
ASPS patients. We will perform confirmatory FISH for the ASPS1-TFE3 fusion as well as 
whole exome sequencing on baseline tumor samples and utilize existing databases to generate a 
list of candidate epitopes. In all steps, we will collaborate with Bioinformatics and 
Oncogenomics core facilities at SCCC.
B. Exploratory Objective 2:  Assessment of tumor response using alternative radiologic 
criteria
Rationale:  
Sarcomas often display atypical radiographic changes in response to treatment.  Traditional 
size-based criteria, such as RECIST and WHO criteria, in musculoskeletal tumors have been 
shown to be relatively insensitive to biological response as measured by other markers, such 
as histologic necrosis.  This is probably due the tendency of sarcomas to undergo internal 
hemorrhage and necrosis, and as a result enlarge in size (pseudoprogression) despite the fact 
that the tumor is actually exhibiting positive treatment response.  Comparable findings have 
been reported in other large STS treated with pazopanib.  With current advances in 
radiographic imaging, tumor responses or progression can be detected much earlier, and 
eliminate some of the clinical problems with RECIST.  Additionally, tumor response to 
immunotherapy often shows initial increase in size, followed by stabilization and shrinkage.  
While the official endpoint for this study is still RECIST 1.1, we are including alternative 
radiologic criteria and techniques to aid in developing the best imaging modality for 
subsequent trials utilizing immunotherapy for sarcomas.  
Approach:
A. Analysis of CT imaging using Choi Criteria and Immune-Related Response Criteria
Subjects enrolled on this study will undergo CT imaging for tumor imaging as per the 
guidelines of RECIST 1.1 and as detailed in the protocol.  In addition to standard tumor 
measurements performed by the investigators, a blinded radiologist will analyze tumor 
response by published Choi criteria and immune-related response criteria.  
Modified CT Response Evaluation Criteria (Choi criteria)
Tumor size is measured in the longest cross-sectional dimension for each lesion at each 
time point.  As in RECIST criteria, the sum of the longest dimensions of selected target 
lesions are measured, and the absolute and percent changes of the sum from the 
pretreatment evaluation to subsequent evaluations are calculated.
      
 
 
        
 
 


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Response
Definition
CR

Disappearance of all lesions

No new lesions
PR

A decrease in size of ≥ 10% or a decrease in tumor density 
(Hounsfield units) ≥ 15% on CT

No new lesions

No obvious progression of nonmeasurable disease
SD

Does not meet the criteria for CR, PR, or PD

No symptomatic deterioration attributed to tumor progression
PD

An increase in tumor size of ≥ 10% and does not meet criteria of 
PR by tumor density (Hounsfield units) on CT

New lesions

New intratumoral nodules or increase in the size of the existing 
intratumoral nodules
Table F3:  Modified CT Response Criteria (Choi criteria).  Taken from Choi et al.  J Clin 
Oncol, 2007.  25(13): 1753-1759
Immune-related Response Criteria
At the baseline tumor assessment, the sum of the products of the two largest perpendicular 
diameters (SPD) of all index lesions (up to 5 lesions per organ, up to 10 visceral lesions) is 
calculated.  At each subsequent assessment, the SPD of the index lesions and of new, 
measurable lesions (≥ 5x5 mm, up to 5 new lesions per organ, up to 10 visceral lesions) are 
added together to provide the total tumor burden:  
Tumor burden = SPDindex lesions + SPDnew, measurable lesions
Response
Definition
irCR

Complete disappearance of all lesions (whether measurable or not)

No new lesions

Confirmation by a repeat, consecutive assessment no less than 4 
weeks from the date first documented
irPR

Decrease in tumor burden by ≥50% relative to baseline confirmed 
by a consecutive assessment at least 4 weeks after first 
documentation
irSD

Not meeting criteria for irCR or irPR in absence of irPD
irPD

Increase in tumor burden ≥25% relative to nadir (minimum 
recorded tumor burden)

Confirmation by a repeat, consecutive assessment no less than 4 
weeks from the date first documented
Table F4:  Immune related response criteria.  Adapted from Wolchok et al, Clin Cancer Res 
2009, 15(23): 7412-20
      
 
 
        
 
 


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B. Dynamic Contrast Enhanced Magnetic Resonance Imaging (DCE-MRI)
Subjects enrolled in this study will undergo an MRI scan as per the research protocol. All 
imaging will be performed on a 3T Skyra magnet (Siemens, Erlangen, Germany). A 
multiparametric MRI protocol containing conventional MR sequences will be obtained 
(including non-fat-suppressed T1 weighted, T2 weighted with fat saturation, and fat- saturated 
pre- and post-contrast T1 weighted images).  Additional functional MRI techniques will be 
acquired, including diffusion-weighted imaging (DWI), magnetic resonance elastography 
(MRE), and dynamic contrast-enhanced MRI (DCE).  The DWI sequences require 
approximately 5 minutes for acquisition; the MRE requires approximately 10 minutes for 
acquisition; the DCE sequences require approximately 5 minutes for acquisition.  Formal 
reports for these exams will be generated by the co-investigators, and images will be stored in 
PACs. The MRI lasts approximately 45-60 minutes.
Images will be analyzed using third party software (iNtuition, TeraRecon, Foster City, 
California).  Changes in index tumor size will be assessed using conventional size-based 
RECIST 1.1 criteria; in addition, semi-automated tumor segmentation will be performed for 
volumetric analysis of changes in tumor size.  Apparent diffusion coefficient (ADC) maps will 
be constructed using the scanner’s in-line software (Syngo MapIt, Siemens, Erlangen, 
Germany) to quantify restricted diffusion.  Regions of interest will be constructed on ADC 
maps for comparison of ADC values; tumor volumetric segmentation on ADC map will also 
be performed for analysis of whole-tumor composition.  
Enhancement characteristics will be analyzed according to modified Choi criteria applied to 
subtracted post-contrast sequences, with partial response (PR) defined as a decrease >10% in 
tumor size or a decrease >15% in tumor contrast enhancement; progression (PD) as new 
lesions, an increase >10% in tumor size without meeting any criteria for a PR according to 
tumor contrast enhancement, or an increase >15% in tumor contrast enhancement.  Complete 
response (CR) will be defined as complete disappearance of all lesions and no new lesions; 
stable disease will be defined as tumor not meeting criteria for CR, PR, or PD.  
DCE-MRI perfusion kinetics will be calculated for the index tumor.  Tumor firmness will be 
assessed based on the shear modulus derived from MRE.  Comparisons of pre- and post-
treatment changes in tumor size, enhancement characteristics, ADC values, and tumor 
elasticity will be performed using paired t-tests and McNemar’s test as appropriate.
C. Determination of tumor response by FDG-PET/CT using PERCIST 1.0 
Subjects in this research study will undergo 18F-FDG-PET/CT at baseline, cycle 3, and off-
study as per the research protocol.  Images will be analyzed by nuclear medicine radiologist 
and metabolic response determined by PERCIST 1.0 (Wahl et al, J Nucl Med 2009).  
Selection of target and non-target lesions:
      
 
 
        
 
 


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Measurable target lesion is the hottest single tumor lesion with maximal ROI of 1.2 cm in 
diameter (SUL peak).  SUL peak should be at least 1.5 times higher than liver SUL mean + 2 
SD.  Up to five target lesions may be selected with no more than 2 per organ.  These lesions 
will be compared in subsequent scans.  
Response criteria:
Response category
Description
CMR
Complete resolution of FDG uptake within target 
lesion to indistinguishable levels compared to 
background blood-pool and liver.  Disappearance of 
all metabolic lesions.  No new lesions in the pattern of 
cancer.
PMR
Reduction of target lesion SUL peak by ≥30%
SMD
Not CMR, PMR, or PMD
PMD
>30% increase in target lesion SUL peak.  OR 
increase in TLG volume with no change in SUL.  OR 
appearance of new lesions.
Table F5.  PERCIST 1.0 for determination of metabolic response.  (Adapted from Wahl 
et al, J Nucl Med 2009).  
  
C. Exploratory Objective 3: Measurement of circulating tumor cells pre- and post-
treatment, and correlation with tumor response and time to progression
Rationale:  
Circulating tumor cells (CTC) have been shown to be prognostic of metastatic disease and 
correlate with response to therapy in solid tumors such as breast, colorectal and prostate 
cancers.  However, assessment of CTCs is challenging in sarcoma due to the lack of universal 
markers.  In collaboration with Dr. Ram Datar, we have demonstrated in a pilot study (Eprost 
20140062) that sarcoma circulating tumor cells are large and can be isolated using a unique, 
microfabricated parylene membrane-based device (Figure F2).  The hypothesis for this pilot 
study is that CTC could serve as a marker of early micrometastatic disease in sarcomas, and 
may portend worse prognosis as seen in other tumor types.  
      
 
 
        
 
 




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a.
Any additional samples, such as an extra core biopsy, or any patients that have surgery 
at any time along the protocol will have tissue samples banked.  If possible, tissue will 
be frozen viably, for RNA in RNA later, and flash frozen for protein analysis.  
Additionally blood samples will be banked in the Komanduri lab as part of the PBMC 
protocol as detailed above.  
b. Upon collection of all samples from the patients, a bar code system will be used to code 
the samples, assigning a subject number and bar code to each specimen. The actual 
physical samples will be tied to patient identifying information only at the time of 
sample collection. The patient's name will be written on the specimen collection tubes. 
Once the samples are coded, immediately following sample collection, the patient's 
name will be blacked out on the original sample tubes and the original tubes will be 
disposed of in the biohazardous waste, which gets sent for incineration.
c.
The database linking subject identification and specimen barcodes will be kept on a 
password protected database housed on the University of Miami server.  
d. The only investigators who will have access to samples and linking data to subjects are 
the principal investigator and his research staff named on the protocol. The tissue bank 
database will be the only location where patient's names and medical record numbers 
will be tied to their barcode numbers.  The only information that will be stored with the 
actual samples in the freezers is the barcode identifier used to identify each sample. 
Data and specimens will be maintained indefinitely. If at some point in time, a subject 
decides they wish to remove their specimens and data from the tissue bank, any 
remaining samples belonging to that patient will be destroyed and their data removed 
from the database.
      
 
 
        
 
 


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APPENDIX G: PROTOCOL APPROVED METHODS OF CONTRACEPTION
Pembrolizumab 
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.  Non-pregnant, non-
breast-feeding women may be enrolled if they are willing to use 2 methods of birth control or are 
considered highly unlikely to conceive.  Highly unlikely to conceive is defined as 1) surgically 
sterilized, or 2) postmenopausal (a woman who is ≥45 years of age and has not had menses for 
greater than 1 year will be considered postmenopausal), or 3) not heterosexually active for the 
duration of the study.  The two birth control methods can be either two barrier methods or a 
barrier method plus a hormonal method to prevent pregnancy. Subjects should start using birth 
control from study Visit 1 throughout the study period up to 120 days after the last dose of study 
therapy. 
The following are considered adequate barrier methods of contraception: diaphragm, condom (by 
the partner), copper intrauterine device, sponge, or spermicide.  Appropriate hormonal 
contraceptives will include any registered and marketed contraceptive agent that contains an 
estrogen and/or a progestational agent (including oral, subcutaneous, intrauterine, or 
intramuscular agents).
Subjects should be informed that taking the study medication may involve unknown risks to the 
fetus (unborn baby) if pregnancy were to occur during the study.  In order to participate in the 
study they must adhere to the contraception requirement (described above) for the duration of the 
study and within 120 days of completing the trial, or 30 days following cessation of treatment if 
the subject initiates new anticancer therapy, whichever is earlier.  If there is any question that a 
subject will not reliably comply with the requirements for contraception, that subject should not 
be entered into the study.
Use in Pregnancy
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab, the subject 
will immediately be removed from the study.  The site will contact the subject at least monthly 
and document the subject’s status until the pregnancy has been completed or terminated.  The 
outcome of the pregnancy will be reported to the Sponsor and to Merck without delay and within 
24 hours to the Sponsor and within 2 working days to Merck if the outcome is a serious adverse 
experience (e.g., death, abortion, congenital anomaly, or other disabling or life-threatening 
complication to the mother or newborn).  The study investigator will make every effort to obtain 
permission to follow the outcome of the pregnancy and report the condition of the fetus or 
newborn to the Sponsor.   If a male subject impregnates his female partner the study personnel at 
the site must be informed immediately and the pregnancy reported to the Sponsor and to Merck 
and followed as described above.
      
 
 
        
 
 


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Use in Nursing Women
It is unknown whether pembrolizumab is excreted in human milk.  Since many drugs are 
excreted in human milk, and because of the potential for serious adverse reactions in the nursing 
infant, subjects who are breast-feeding are not eligible for enrollment.
      
 
 
        
 
 


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APPENDIX H: EVENTS OF CLINICAL INTEREST & SUPPORTIVE CARE 
GUIDELINES FOR PEMBROLIZUMAB
Suggested supportive care measures for the management of AEs with potential immunologic 
etiology.  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.  These guidelines are intended to be applied when the 
Investigator determines the events to be related to pembrolizumab.  

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.

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).  
o
All subjects who experience diarrhea/colitis should be advised to drink liberal 
quantities of clear fluids.  If sufficient oral fluid intake is not feasible, fluid and 
electrolytes should be substituted via IV infusion.  For Grade 2 or higher diarrhea, 
consider GI consultation and endoscopy to confirm or rule out colitis.
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, steroid taper should be started and 
continued over no less than 4 weeks.

Type 1 diabetes mellitus (if new onset, including diabetic ketoacidosis [DKA]) or ≥ 
Grade 3 Hyperglycemia, if associated with ketosis (ketonuria) or metabolic acidosis 
(DKA)
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. 
      
 
 
        
 
 


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
Evaluate patients with serum glucose and a metabolic panel, urine ketones, 
glycosylated hemoglobin, and C-peptide. 

Hypophysitis:
o
For Grade 2 events, treat with corticosteroids. When symptoms improve to Grade 
1 or less, steroid taper should be started and continued over no less than 4 weeks. 
Replacement of appropriate hormones may be required as the steroid dose is 
tapered.
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, steroid taper 
should be started and continued over no less than 4 weeks. Replacement of 
appropriate hormones may be required as the steroid dose is tapered.

Hyperthyroidism or Hypothyroidism: 
Thyroid disorders can occur at any time during treatment. Monitor patients for changes in 
thyroid function (at the start of treatment, periodically during treatment, and as indicated 
based on clinical evaluation) and for clinical signs and symptoms of thyroid disorders.
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.

Hepatic:
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.
o
An elevated AST or ALT lab value that is ≥ 3X the upper limit of normal (ULN) 
and an elevated total bilirubin lab value that is ≥ 2X the ULN and, at the same time, 
an alkaline phosphatase lab value that is < 2X the ULN, as determined by way of 
protocol-specified laboratory testing or unscheduled laboratory testing.*
      
 
 
        
 
 


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*Note:  These criteria are based upon available regulatory guidance documents. 
The purpose of the criteria is to specify a threshold of abnormal hepatic tests that 
may require an additional evaluation for an underlying etiology.  The trial site 
guidance for assessment and follow up of these criteria can be found in the 
Investigator Trial File Binder (or equivalent).

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. 

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 H1 below shows treatment guidelines for subjects who experience an infusion reaction 
associated with administration of pembrolizumab (MK-3475).
NCI CTCAE Grade
Treatment
Premedication at 
subsequent dosing
Grade 1
Mild reaction; infusion 
interruption not 
indicated; intervention 
not indicated
Increase monitoring of vital 
signs as medically indicated until 
the subject is deemed medically 
stable in the opinion of the 
investigator.
None
Grade 2
Requires infusion 
interruption but responds 
promptly to symptomatic 
treatment (e.g., 
antihistamines, NSAIDS, 
narcotics, IV fluids); 
prophylactic medications 
indicated for < =24 hrs
Stop Infusion and monitor 
symptoms.
Additional appropriate medical 
therapy may include but is not 
limited to:
IV fluids
Antihistamines
NSAIDS
Acetaminophen
Narcotics
Increase monitoring of vital 
signs as medically indicated until 
the subject is deemed medically 
stable in the opinion of the 
investigator.
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).
      
 
 
        
 
 


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NCI CTCAE Grade
Treatment
Premedication at 
subsequent dosing
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.
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
      
 
 
        
 
 


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NCI CTCAE Grade
Treatment
Premedication at 
subsequent dosing
Appropriate resuscitation equipment should be available in the room and a physician 
readily available during the period of drug administration.
Table H1. Infusion Reaction Treatment Guidelines for Pembrolizumab

Overdose: An overdose that is not associated with clinical symptoms or abnormal 
laboratory results.
For purposes of this trial, an overdose of pembrolizumab will be defined as any dose of 
1,000 mg or greater (≥5 times the indicated dose).  No specific information is available on 
the treatment of overdose of pembrolizumab. Appropriate supportive treatment should be 
provided if clinically indicated. In the event of overdose, the subject should be observed 
closely for signs of toxicity.  Appropriate supportive treatment should be provided if 
clinically indicated.
If an adverse event(s) is associated with (“results from”) the overdose of a Merck product, 
the adverse event(s) is reported as a serious adverse event, even if no other seriousness 
criteria are met.
If a dose of Merck’s product meeting the protocol definition of overdose is taken without 
any associated clinical symptoms or abnormal laboratory results, the overdose is reported 
as a non-serious Event of Clinical Interest (ECI), using the terminology “accidental or 
intentional overdose without adverse effect.”
REFERENCE: Merck. Pembrolizumab Program (MK-3475) Event of Clinical Interest 
Guidance Document. Version 5.0. 18-Dec-2014. 
      
 
 
        
 
 


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APPENDIX I: PATIENT DOSING DIARY AND BLOOD PRESSURE LOG FOR 
AXITINIB
[Note to Investigators: This appendix consists of a “directions sheet and diary” to be handed 
to the patient prior to each cycle.  These sheets MUST be approved by the Institutional Review 
Board (IRB) before it may be given to patients.]
Diary Directions 
Begin taking axitinib twice a day, (as your doctor has told you to during the study): 
1. On the days that you are supposed to take axitinib – axitinib should be taken by mouth, twice 
a day on an empty stomach, approximately 12 hours apart with a glass of water.
2. You may take each dose with or without food. Do not chew or break tablets. 
3. If a dose is missed you may take the missed dose if it has been less than 2 hours from your 
scheduled dose. Do not make up missed doses if it has been more than 2 hours from your 
scheduled dose. 
4. If you vomit after a dose, do not take another dose.  Take your next dose of the day at the 
same time you would normally take it.
5. Avoid taking grapefruit juice and St. John’s Wort. 
6. Avoid smoking if you are taking axitinib because it may decrease the amount of the drug in 
your body. 
7. Taking over-the-counter drugs to block stomach acid may interfere with the absorption of the 
study drug. Please avoid taking medications like omeprazole (Prilosec OTC) or cimetidine 
(Tagamet) unless you first discuss with your doctor. 
8. Please bring the empty bottle or any leftover tablets and this diary to your next clinic visit. 
      
 
 
        
 
 


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Patient Dosing Diary
                         Axitinib Dose Level: _____ mg twice a day
Patient Initials (L, F, M): Patient ID: ______________________  
Cycle: _______
This is a diary on which you are to record the date, time and number of tablets you take each 
day on the days that you are supposed to take Axitinib. You should take your scheduled dose of 
each tablet. If you forget to take a dose, please write “0”, but remember to take your prescribed 
dose at the next regularly scheduled time.  
Day
Date(s)
# of 
Tablets
Time Taken 
(Circle AM or PM)
# of 
Tablets
Time Taken 
(Circle AM or PM)
1
AM
PM
AM
PM
2
AM
PM
AM
PM
3
AM
PM
AM
PM
4
AM
PM
AM
PM
5
AM
PM
AM
PM
6
AM
PM
AM
PM
7
AM
PM
AM
PM
8
AM
PM
AM
PM
9
AM
PM
AM
PM
10
AM
PM
AM
PM
11
AM
PM
AM
PM
12
AM
PM
AM
PM
13
AM
PM
AM
PM
14
AM
PM
AM
PM
15
AM
PM
AM
PM
16
AM
PM
AM
PM
17
AM
PM
AM
PM
18
AM
PM
AM
PM
19
AM
AM
      
 
 
        
 
 


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PM
PM
20
AM
PM
AM
PM
21
AM
PM
AM
PM
22
AM
PM
AM
PM
23
AM
PM
AM
PM
24
AM
PM
AM
PM
25
AM
PM
AM
PM
26
AM
PM
AM
PM
27
AM
PM
AM
PM
28
AM
PM
AM
PM
29
AM
PM
AM
PM
30
AM
PM
AM
PM
31
AM
PM
AM
PM
32
AM
PM
AM
PM
33
AM
PM
AM
PM
34
AM
PM
AM
PM
35
AM
PM
AM
PM
36
AM
PM
AM
PM
37
AM
PM
AM
PM
38
AM
PM
AM
PM
39
AM
PM
AM
PM
40
AM
PM
AM
PM
41
AM
PM
AM
PM
      
 
 
        
 
 


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Days 42 to 49 below are ONLY to be completed for Cycle 1 of axitinib; 
After Cycle 1: Do NOT take axitinib nor complete Days 42 to 49.
42
AM
PM
AM
PM
43
AM
PM
AM
PM
44
AM
PM
AM
PM
45
AM
PM
AM
PM
46
AM
PM
AM
PM
47
AM
PM
AM
PM
48
AM
PM
AM
PM
49
AM
PM
AM
PM
Patient Signature: _______________________________
Date: _________________
      
 
 
        
 
 


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Patient Blood Pressure Log           
 
Axitinib Dose Level: _____ mg twice a day 
Patient Initials (L, F, M): Patient ID: ______________________  
Cycle: _______
1. While on axitinib, measure and record your blood pressure at least once a day, before 
the evening dose of axitinib.  Measure as needed for any unusual symptoms as listed 
below or as otherwise directed by your doctor. If axitinib is increased, please continue 
to measure and record your blood pressure at least once a day until you are seen in 
clinic (three weeks).  
2. Please bring this completed diary with you to each clinic visit.
*If your blood pressure is 150/100 or greater OR if your blood pressure is 120/80 or greater with 
headache, chest pressure, shortness of breath, dizziness and/or blurry vision, notify your study 
doctor(s) at (305)-243-1000 immediately.
Blood Pressure Measurements
Repeat Blood Pressure 
Measurements
(if applicable)
Date
Time
Systolic 
(top 
number) 
Diastolic 
(bottom 
number)
Was your blood 
pressure 
≥150/100 or 
≥120/80 with 
symptoms?  *If 
yes, see above.
Time 
Systolic 
(top 
number)
Diastolic 
(bottom 
number)
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
      
 
 
        
 
 


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am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
am
□ Yes
□ No
am 
pm 
□ Yes
□ No
pm
Patient Signature: _______________________________
Date: _________________
      
 
 
        
 
 


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APPENDIX J: CYP1A2, CYP2C8, CYP2C19, CYP3A4 SUBSTRATES, INHIBITORS & 
INDUCERS *
SUBSTRATE(S)
1A2
2C8
2C19
3A4
amitriptyline
caffeine
clomipramine
clozapine
cyclobenzaprine
duloxetine
estradiol
fluvoxamine
haloperidol
imipramine N-DeMe
mexiletine
naproxen
olanzapine
ondansetron
phenacetin
acetaminophenNAP
QI
propranolol
riluzole
ropivacaine
tacrine
theophylline
tizanidine
triamterene
verapamil
(R)warfarin
zileuton
zolmitriptan
[paclitaxel]
torsemide
amodiaquine
cerivastatin
repaglinide
sorafinib
Proton Pump
Inhibitors (PPIs):
esomeprazole
lansoprazole
omeprazole
pantoprazole
rabeprazole
Anti-epileptics:
diazepamNor
phenytoin(O)
S-mephenytoin
phenobarbitone
amitriptyline
carisoprodol
citalopram
chloramphenicol
clomipramine
chlopidogrel
cyclophosphamide
hexobarbital
imipramine N-
DeME
indomethacin
labetalol
R-mephobarbital
moclobemide
nelfinavir
nilutamide
primidone
progesterone
proguanil
propranolol
teniposide
R-warfarin8-OH
voriconazole
Macrolide antibiotics:
clarithromycin
erythromycin (not 3A5) 
NOT azithromycin
telithromycin
Anti-arrhythmics:
quinidine3OH (not 3A5)
Benzodiazepines:
alprazolam
diazepam3OH
midazolam
triazolam
Immune Modulators:
cyclosporine
tacrolimus (FK506)
HIV Antivirals:
indinavir
nelfinavir
ritonavir
saquinavir
Prokinetic:
cisapride
Antihistamines:
astemizole
chlorpheniramine
terfenadine
Calcium Channel Blockers:
amlodipine
diltiazem
felodipine
lercanidipine
nifedipine
nisoldipine
nitrendipine
verapamil
HMG CoA Reductase
Inhibitors:
atorvastatin
cerivastatin
Steroid 6beta-OH:
estradiol
hydrocortisone
progesterone
testosterone
Miscellaneous:
alfentanyl
aprepitant
aripiprazole
boceprevir
buspirone
carbamazepine
cafergot
caffeineTMU
cilostazol
cocaine
codeine-N-
demethylation
dapsone
dexamethasone
dextromethorphan
docetaxel
domperidone
eplerenone
fentanyl
finasteride
gleevec
haloperidol
irinotecan
LAAM
lidocaine
methadone
nateglinide
nevirapine
ondansetron
pimozide
propranolol
quetiapine
quinine
risperidone
romidepsin
NOT rosuvastatin
salmeterol
sildenafil
sirolimus
sorafenib
      
 
 
        
 
 


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SUBSTRATE(S)
1A2
2C8
2C19
3A4
lovastatin
NOT pravastatin
NOT rosuvastatin
simvastatin
tamoxifen
taxol
telaprevir
terfenadine
torisel
trazodone
vemurafenib
vincristine
zaleplon
ziprasidone
zolpidem
INHIBITORS
1A2
2C8
2C19
3A4
fluvoxamine
ciprofloxacin
cimetidine
amiodarone
efavirenz
fluoroquinolones
fluvoxamine
furafylline
interferon
methoxsalen
mibefradil
ticlopidine
gemfibrozil
trimethoprim
glitazones
montelukast
quercetin
PPIs:
Esomeprazole
lansoprazole
omeprazole
pantoprazole
Other:
rabeprazole
chloramphenicol
cimetidine
felbamate
fluoxetine
fluvoxamine
indomethacin
ketoconazole
modafinil
oral 
contraceptives
oxcarbazepine
probenicid
ticlopidine
topiramate
voriconazole
HIV Antivirals:
indinavir
nelfinavir
ritonavir
clarithromycin
itraconazole
ketoconazole
nefazodone
saquinavir
telithromycin
aprepitant
erythromycin
fluconazole
grapefruit juice
verapamil
diltiazem
cimetidine
amiodarone
NOT azithromycin
Chloramphenicol
boceprevir
ciprofloxacin
delaviridine
diethyldithiocarbamate
fluvoxamine
gestodene
imatinib
mibefradil
mifepristone
norfloxacin
norfluoxetine
star fruit
telaprevir
voriconazole
      
 
 
        
 
 


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INDUCERS
1A2
2C8
2C19
3A4
broccoli
brussel sprouts
carbanazepine
char-grilled meat
insulin
methylcholanthrene
modafinil
nafcillin
beta-naphthoflavone
omeprazole
rifampin
tobacco
rifampin
carbamazepine
nevirapine
phenobarbital
rifampin
secobarbital
St. John’s Wort
HIV Antivirals:
efavirenz
nevirapine
barbiturates
carbamazepine
glucocorticoids
modafinil
oxcarbazepine
phenobarbital
phenytoin
pioglitazone
rifabutin
rifampin
St. John's wort
troglitazone
*Reference: http://medicine.iupui.edu/clinpharm/ddis/main-table/ 
      
 
 
        
 
 


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APPENDIX K: GUIDELINES FOR PREPARATION AND ADMINISTRATION/ 
KEYTRUDA FOR INJECTION (LYOPHILIZED POWDER)
Reconstitution of Keytruda for Injection (Lyophilized Powder)
 Add 2.3 mL of Sterile Water for Injection, USP by injecting the water along the walls of the 
vial and not directly on the lyophilized powder (resulting concentration 25 mg/mL). 
 Slowly swirl the vial. Allow up to 5 minutes for the bubbles to clear. Do not shake the vial. 
Preparation for Intravenous Infusion 
 Visually inspect the solution for particulate matter and discoloration prior to administration. 
The solution is clear to slightly opalescent, colorless to slightly yellow. Discard the vial if visible 
particles are observed. 
 Dilute KEYTRUDA injection (solution) or reconstituted lyophilized powder prior to 
intravenous administration. 
 Withdraw the required volume from the vial(s) of KEYTRUDA and transfer into an 
intravenous (IV) bag containing 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, 
USP. Mix diluted solution by gentle inversion. The final concentration of the diluted solution 
should be between 1 mg/mL to 10 mg/mL. 
 Discard any unused portion left in the vial. 
Storage of Reconstituted and Diluted Solutions 
The product does not contain a preservative. 
Store the reconstituted and diluted solution from the KEYTRUDA 50 mg vial either: 
 At room temperature for no more than 6 hours from the time of reconstitution. This includes 
room temperature storage of reconstituted vials, storage of the infusion solution in the IV bag, 
and the duration of infusion. 
 Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the time of 
reconstitution. If refrigerated, allow the diluted solution to come to room temperature prior to 
administration. 
Store the diluted solution from the KEYTRUDA 100 mg/4 mL vial either: 
 At room temperature for no more than 6 hours from the time of dilution. This includes room 
temperature storage of the infusion solution in the IV bag, and the duration of infusion. 
 Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the time of 
dilution. If refrigerated, allow the diluted solution to come to room temperature prior to 
administration. Do not freeze. 
      
 
 
        
 
 


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