Clinical trial NCT02996474
Conditions: Relapsed Acute Myeloid Leukemia
Keywords: Pembrolizumab Decitabine AML (Acute Myelogenous Leukemia)
Sponsor: National Heart, Lung, and Blood Institute (NHLBI)
Start date: 2016-12-16; Completion date: 2019-04-02
Enrollment: 10 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Background:

Acute myeloid leukemia (AML) is a cancer of the white blood cells. It is fatal if not treated. Treatment for AML that has not responded to treatment (refractory) or has returned after treatment (relapsed) often do not work. Researchers want to see if an immunotherapy drug, combined with a less intense chemotherapy, may be able to help.

Objective:

To test if pembrolizumab, in combination with decitabine, is a possible treatment for people with relapsed or refractory AML.

Eligibility:

Adults 18 years of age and older with refractory AML or relapsed AML.

Design:

Participants will be first screened for eligibility.

The study is counted in 21-day cycles. The initial phase of the study consists of 8 cycles. Participants may be in the study for up to 2 years if they are responding to the treatment.

The first 3 weeks of treatment is usually done in the hospital. The rest may be done as an outpatient.

Participants will get pembrolizumab at the beginning of each cycle through an IV.

Participants will usually get decitabine by IV on days 8 12 and days 15 19 of every other cycle.

Participants will give blood samples.

Participants will have bone marrow exams. A needle will be inserted into the hip to extract cells from the bone marrow.

Some participants may give a sample of saliva from the inside of their cheek.

Some participants may give a small skin sample. The top layer of the skin is removed.

Some patients may require leukapheresis before starting treatment. This is a procedure to remove leukemia cells in the blood stream.

Detailed description:
This is a pilot study to determine the feasibility of a novel combination of Pembrolizumab and Decitabine in relapsed/refractory adult AML patients. While both Pembrolizumab and Decitabine are FDA approved agents, this study will explore giving these drugs in combination for this population of patients.

Arms: arm 1: Pembrolizumab 200 mg will be administered as a 30 minute IV infusion every 3 weeks. Up to eight cycles of pembrolizumab will be given during the initial induction phase. Each cycle is 21 days. Decitabine will be administered at a dose of 20 mg/m\^2 by intravenous infusion over approximately 1 hour repeated daily ordinarily on days 8 through 12 and 15 through 19 of alternative cycles (ie: cycles 1, 3, 5, 7) for treatment relapsed/refractory AML.
Interventions: intervention 1: Pembrolizumab intervention 2: Decitabine
Intervention descriptions: intervention 1: 200 mg will be administered as a 30 minute IV infusion every 3 weeks. Every effort should be made to target infusion timing to be as close to 30 minutes as possible. However, given the variability of infusion pumps, a window of -5 minutes and +10 minutes is permitted (i.e., infusion time is 30 minutes: -5 min/+10 min). intervention 2: Will be administered at a dose of 20 mg/m\^2 by continuous intravenous infusion over 1 hour repeated daily ordinarily on days 8 through 12 and 15 through 19 of alternative cycles (ie: cycles 1, 3, 5, 7). Decitabine should be repeated every 6 weeks.

Protocol documents:
Prot_SAP_000.pdf: 
17-H-0026 (PD-AML)
Christopher S. Hourigan, BM BCh DPhil
September 27, 2019
1
CLINICAL RESEARCH PROJECT
Protocol # 17-H-0026 
Drug Names: Pembrolizumab, Decitabine
IND: 131826
Closed to accrual: November 30, 2017
Title: Pembrolizumab and Decitabine for Refractory or Relapsed Acute Myeloid Leukemia 
Short Title: PD-AML
Keywords: Pembrolizumab, Decitabine, AML.
 
Principal Investigator:
*Christopher S. Hourigan, BM BCh DPhil., HB, NHLBI (E)
451-0257
Bldg 10, Rm 5-5130
Collaborators:
Collaborative Health Initiative Research Program, Uniformed Services University School of Medicine 
Harvey B. Pollard, M.D., Ph.D.
Clifton Lee Dalgard, PhD, CLS
Matthew D. Wilkerson, PhD
New York Genome Center
Rahul Satija, D. Phil.
101 Avenue of the Americas, 4th Floor
New York City, NY 10013
IND Sponsor: Christopher S. Hourigan, BM BCh DPhil
Company Providing Investigational Drug: Merck
Subjects of Study:
Number 
Sex 
Age-range 
10
M/F
 18-99
(Maximal accrual including replacement subjects: 15)
Ionizing Radiation for Research:
No
Off-Site Project: 
No
Multi-center trial:
No
DSMB Involvement:
Yes
Tech Transfer:
Yes
IND:
Yes (IND number 131826)
Version:
11.0


17-H-0026 (PD-AML)
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September 27, 2019
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PRECIS
This is a pilot study to determine the feasibility of a novel combination of Pembrolizumab and Decitabine in 
relapsed/refractory adult AML patients.  While both Pembrolizumab and Decitabine are FDA approved 
agents, this study will explore giving these drugs in combination for this population of patients. 
Abbreviated Title
PD-AML
Trial Phase
Pilot
Clinical Indication
Relapsed or Refractory Acute Myeloid Leukemia
Trial Type
Single arm pilot study
Type of control
Historical
Route of administration
Intravenous
Trial Blinding
None
Treatment Groups 
Single-arm
Number of trial subjects
Ten
Estimated enrollment period
December 2016-December 2017
Estimated duration of trial
December 2016 – December 2019
Duration of Participation
Up to two years
Estimated average length of 
treatment per patient
Six months


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TABLE OF CONTENTS
1.0
OBJECTIVES..........................................................................................................................7
1.1.
Primary Objective........................................................................................................................7
1.2.
Secondary Objectives ..................................................................................................................7
1.3.
Exploratory Laboratory Objectives...............................................................................................7
2.0
BACKGROUND & RATIONALE...............................................................................................7
2.1.
Pharmaceutical and Therapeutic Background ..............................................................................8
2.2.
Rationale for the Trial and Selected Subject Population...............................................................9
2.3.
Pembrolizumab .........................................................................................................................11
2.3.1.
Mechanism of Action ................................................................................................................11
2.3.2.
Pharmacokinetics......................................................................................................................11
2.3.3.
Metabolism and Clearance .......................................................................................................13
2.3.4.
Clinical experiences...................................................................................................................14
2.4.
Decitabine .................................................................................................................................14
2.4.1.
Mechanism of Action ................................................................................................................14
2.4.2.
Pharmacokinetics......................................................................................................................15
2.4.3.
Metabolism and Clearance .......................................................................................................15
2.5.
Summary of Clinical Safety ........................................................................................................16
2.5.1.
Pembrolizumab.........................................................................................................................16
2.5.2.
Decitabine .................................................................................................................................17
2.6.
Rationale for Dose Selection/Regimen/Combination/Modifications..........................................19
2.7.
Rationale for Endpoints .............................................................................................................20
2.8.
Biomarker Research...................................................................................................................21
3.0
STUDY DESIGN...................................................................................................................21
4.0
ELIGIBILITY ASSESSMENT AND ENROLLMENT.....................................................................22
4.1.
Inclusion Criteria........................................................................................................................22
4.2.
Exclusion Criteria.......................................................................................................................23
5.0
TREATMENT PLAN..............................................................................................................25
5.1.
Treatment Schedule...................................................................................................................25
5.2.
Dose Modification Guidelines For Drug-Related Adverse Events................................................26
5.2.1.
Hematologic toxicities...............................................................................................................26
5.2.2.
Non-hematologic toxicities .......................................................................................................26
5.2.3.
Other acceptable dose delays...................................................................................................26
5.3.
Timing of Dose Administration ..................................................................................................28
5.4.
Randomization or Treatment Allocation ....................................................................................28
5.5.
Concomitant Medications/Vaccinations (allowed & prohibited) ................................................28
5.6.
Rescue Medications & Supportive Care......................................................................................29
5.7.
Diet/Activity/Other Considerations ...........................................................................................33
5.7.1.
Diet............................................................................................................................................33
5.7.2.
Contraception ...........................................................................................................................33
5.7.3.
Use in Pregnancy.......................................................................................................................34


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5.7.4.
Use in Nursing Women .............................................................................................................35
5.8.
Subject Withdrawal/Discontinuation Criteria ............................................................................35
5.8.1.
Off-Treatment Criteria ..............................................................................................................35
5.8.2.
Off-Study Criteria ......................................................................................................................35
5.9.
Optional Continuation Phase after Eight Cycles of Pembrolizumab ............................................36
5.10.
Subject Replacement Strategy ...............................................................................................37
5.11.
Criteria for Early Trial Termination.........................................................................................37
6.0
CLINICAL MONITORING......................................................................................................37
6.1.
Study Evaluations: Screening/Baseline ......................................................................................37
6.2.
On therapy evaluations during induction phase.........................................................................38
6.3.
Clinical Assessments ..................................................................................................................38
6.4.
On therapy evaluations during optional continuation phase......................................................39
6.5.
Post-Induction Treatment Follow-Up.........................................................................................39
6.5.1.
Safety Follow-Up Visit (SFV)......................................................................................................39
6.5.1.
Post-Treatment Active Surveillance Phase................................................................................39
6.5.2.
Off Study Visit (all patients) ......................................................................................................39
6.5.3.
Post-study follow-up stage (all patients)...................................................................................40
7.0
LABORATORY RESEARCH SAMPLES ....................................................................................40
7.1.
Collection of Research Samples..................................................................................................40
7.2.
Research Testing........................................................................................................................40
8.0
BIOSTATISTICAL CONSIDERATIONS ....................................................................................41
8.1.
Primary statistical hypothesis ....................................................................................................41
8.2.
Sample size................................................................................................................................41
8.3.
Statistical safety monitoring ......................................................................................................41
8.4.
Exploratory analyses..................................................................................................................42
9.0
DATA AND SAFETY MONITORING.......................................................................................42
9.1.
Assessment of safety .................................................................................................................43
9.1.1.
Timing........................................................................................................................................45
9.1.2.
Severity .....................................................................................................................................45
9.1.3.
Pregnancy..................................................................................................................................45
9.1.4.
Causality assessments...............................................................................................................46
9.2.
Documentation..........................................................................................................................46
9.3.
NHLBI-IRB and Clinical Director Reporting..................................................................................46
9.4.
Company Reporting...................................................................................................................47
9.5.
FDA Reporting Criteria...............................................................................................................48
9.5.1.
IND Safety Reports to the FDA (Refer to 21 CFR 312.32)..........................................................48
9.5.2.
FDA Annual Reports (Refer to 21 CFR 312.33)..........................................................................48
9.6.
Events of Clinical Interest...........................................................................................................48
9.7.
Protocol Amendments...............................................................................................................49
9.8.
Publication Policy ......................................................................................................................49
9.9.
Protocol Monitoring ..................................................................................................................50


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10.0 BIOSPECIMEN AND DATA MANAGEMENT PLAN.................................................................50
10.1.
Storage ..................................................................................................................................50
10.2.
Tracking.................................................................................................................................50
10.3.
End of study procedures ........................................................................................................50
10.4.
Loss or destruction of samples or data...................................................................................51
10.5.
Biospecimen Management.....................................................................................................51
10.6.
Data Management.................................................................................................................51
10.7.
Data sharing and future use of data .......................................................................................51
10.8.
Future use of biospecimens ...................................................................................................51
11.0 HUMAN SUBJECT PROTECTION ..........................................................................................52
11.1.
Rationale for subject selection...............................................................................................52
11.1.1.
Predicted distribution by gender, age and race........................................................................52
11.1.2.
Special Populations: ..................................................................................................................52
11.2.
Risks and discomforts ............................................................................................................53
11.2.1.
Risks related to pembrolizumab ...............................................................................................53
11.2.2.
Risks related to decitabine........................................................................................................56
11.2.3.
Risks related to blood draws.....................................................................................................57
11.2.4.
Risks related to CT scans ...........................................................................................................57
11.2.5.
Risks related to pregnancy and nursing mothers......................................................................57
11.2.6.
Risks related to central line placement.....................................................................................58
11.2.7.
Risks related to bone marrow and skin punch biopsy ..............................................................58
11.2.8.
Risks related to transfusions .....................................................................................................58
11.2.9.
Risks related to leukapheresis procedure.................................................................................58
11.3.
Risks in Relation to Benefit ....................................................................................................58
11.4.
Informed consent processes and procedures .........................................................................59
11.5.
Conflict of interest .................................................................................................................59
11.6.
Technical Transfer Agreements..............................................................................................59
12.0 PHARMACEUTICALS...........................................................................................................59
12.1.
Pembrolizumab......................................................................................................................59
12.2.
Decitabine .............................................................................................................................60
12.3.
Accountability procedures .....................................................................................................61
13.0 REFERENCES.......................................................................................................................62
APPENDIX A:  AML Diagnostic and Treatment Response Criteria.................................................64
APPENDIX B:  ECOG Performance Status Scale ............................................................................66
APPENDIX C:  Events of Clinical Interest ......................................................................................67
APPENDIX D:  NHLBI Hematology Branch Laboratory Research Studies .......................................68
APPENDIX E:  Anticipated Research Sample Collection................................................................74
APPENDIX F:  Current NCCN Guidelines for Relapsed/Refractory AML Treatment .......................75


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APPENDIX G:  Scheduled Clinical Assessments ............................................................................76
1.0
OBJECTIVES 
1.1. Primary Objective
To determine the feasibility of a novel combination of Pembrolizumab and Decitabine in relapsed/refractory 
AML patients.
1.2. Secondary Objectives 
To explore the efficacy of a novel combination of Pembrolizumab and Decitabine in relapsed/refractory AML 
patients.
To determine time to first response for the novel combination of Pembrolizumab and Decitabine in 
relapsed/refractory AML patients.
To determine time to best response for the novel combination of Pembrolizumab and Decitabine in 
relapsed/refractory AML patients.
To determine duration of response for the novel combination of Pembrolizumab and Decitabine in 
relapsed/refractory AML patients.
To determine duration of best response for the novel combination of Pembrolizumab and Decitabine in 
relapsed/refractory AML patients.
1.3. Exploratory Laboratory Objectives
Investigate changes in AML clonal composition in relapsed or refractory patients treated with Pembrolizumab 
and Decitabine.
Investigate measurable changes in immune parameters associated with clinical efficacy and/or toxicity (eg: 
autoimmunity) using repeated disease site sampling. 
 Investigate changes in AML disease burden during treatment of relapsed/refractory AML patients with 
Pembrolizumab and Decitabine.
 Investigate association of clinical response with marrow infiltrating lymphocytes (MILs), mutational burden 
in AML and PDL-1 expression.
2.0
BACKGROUND & RATIONALE


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2.1. Pharmaceutical and Therapeutic Background
The importance of intact immune surveillance in controlling outgrowth of neoplastic transformation has been 
known for decades.  Accumulating evidence shows a correlation between tumor-infiltrating lymphocytes (TILs) 
in cancer tissue and favorable prognosis in various malignancies.  In particular, the presence of CD8+ T-cells 
and the ratio of CD8+ effector T-cells / FoxP3+ regulatory T-cells seems to correlate with improved prognosis 
and long-term survival in many solid tumors.
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune control.  The 
normal function of PD-1, expressed on the cell surface of activated T-cells under healthy conditions, is to down-
modulate unwanted or excessive immune responses, including autoimmune reactions.  PD-1 (encoded by the 
gene Pdcd1) is an Ig superfamily member related to CD28 and CTLA-4 which has been shown to negatively 
regulate antigen receptor signaling upon engagement of its ligands (PD-L1 and/or PD L2).  The structure of 
murine PD-1 has been resolved.  PD-1 and family members are type I transmembrane glycoproteins containing 
an Ig Variable-type (V-type) domain responsible for ligand binding and a cytoplasmic tail which is responsible 
for the binding of signaling molecules.  The cytoplasmic tail of PD-1 contains 2 tyrosine-based signaling motifs, 
an immunoreceptor tyrosine-based inhibition motif (ITIM) and an immunoreceptor tyrosine-based switch motif 
(ITSM).  Following T-cell stimulation, PD 1 recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM 
motif within its cytoplasmic tail, leading to the dephosphorylation of effector molecules such as CD3ζ, PKCθ 
and ZAP70 which are involved in the CD3 T-cell signaling cascade.  The mechanism by which PD-1 down 
modulates T-cell responses is similar to, but distinct from that of CTLA-4 as both molecules regulate an 
overlapping set of signaling proteins.  PD-1 was shown to be expressed on activated lymphocytes including 
peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer cells.  Expression has also been shown 
during thymic development on CD4-CD8- (double negative) T-cells as well as subsets of macrophages and 
dendritic cells.  The ligands for PD-1 (PD-L1 and PD-L2) are constitutively expressed or can be induced in a 
variety of cell types, including non-hematopoietic tissues as well as in various tumors.  Both ligands are type I 
transmembrane receptors containing both IgV- and IgC-like domains in the extracellular region and contain 
short cytoplasmic regions with no known signaling motifs.  Binding of either PD-1 ligand to PD-1 inhibits T-
cell activation triggered through the T-cell receptor.  PD-L1 is expressed at low levels on various non-
hematopoietic tissues, most notably on vascular endothelium, whereas PD-L2 protein is only detectably 
expressed on antigen-presenting cells found in lymphoid tissue or chronic inflammatory environments.  PD-L2 
is thought to control immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen 
unwarranted T-cell function in peripheral tissues.  Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor.  PD-1 has been 
suggested to regulate tumor-specific T-cell expansion in subjects with melanoma (MEL).  This suggests that the 


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PD-1/PD-L1 pathway plays a critical role in tumor immune evasion and should be considered as an attractive 
target for therapeutic intervention.
Pembrolizumab is a potent and highly selective humanized monoclonal antibody (mAb) of the IgG4/kappa 
isotype designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2.  
Pembrolizumab is approved in the United States for the treatment of patients with unresectable or metastatic 
melanoma and disease progression following ipilumumab and, if BRAF V600 mutation positive, a BRAF 
inhibitor.  The FDA recently also granted accelerated approval for pembrolizumab to treat patients with 
advanced (metastatic) non-small cell lung cancer (NSCLC) whose disease has progressed after other treatments 
and with tumors that express PD-L1.
2.2. Rationale for the Trial and Selected Subject Population
Approximately 20,000 patients will be diagnosed with acute myeloid leukemia (AML), with greater than 
10,000 AML patient deaths in the United States during 2015. The majority of those AML patients will 
ultimately be diagnosed with relapsed or refractory disease (RR-AML), which is generally fatal. Response 
rates for patients who receive intensive salvage therapy after relapse, which offers the best chance for 
response, range from 30-50%. Response rates for those with refractory disease are even lower, typically under 
10%. While a variety of different treatment regimens have been studied in an effort to improve outcomes of 
patients with RR-AML there appears to be no single superior approach. There is no current standard 
of care for adult relapsed or refractory AML other than offering referral to an appropriate clinical trial.
The powerful “graft versus leukemia” effect thought responsible for the therapeutic effect of allo-HSCT in 
reducing relapse rates of high-risk AML patients, and provides the rationale for the use of immune therapy 
with Pembrolizumab.  While pembrolizumab has been tested in many cancer types and already has FDA 
approvals for use in melanoma, non-small cell lung cancer and head and neck cancer, this pilot trial will be the 
first use of pembrolizumab immunotherapy in AML.
There is strong pre-clinical rationale for the combination of pembrolizumab (anti-PD1 immune checkpoint 
therapy) and decitabine (hypomethylating epigenetic modulating therapy) in patients with AML.  1) There are 
now reports from two groups suggesting that therapy with hypomethylating agents in MDS/AML patients 
results in up-regulation of PD-1/PD-L1 checkpoints potentially resulting in therapeutic resistance by inhibiting 
immune based control of disease1,2.   2) Pre-clinical data from Bert Vogelstein and colleagues at Johns Hopkins 
suggest that co-treatment with epigenetic-modulating drugs and checkpoint inhibitors markedly improved 
treatment outcomes in BALB/c mouse models with 4T1 and large CT26 tumors compared with the use of 
checkpoint inhibitors alone3.  3) Low dose decitabine appears to modulate natural killer cell anti-AML function 


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by increased expression of killer immunoglobulin-like receptors (KIR) and the activating receptor NKp44 on 
NK cells4, while also up-regulating NKG2D-specific UL16-binding protein (ULBP) ligands on AML cells 
potentially sensitizing to increased NK mediated killing5.  4) Epigenetic therapy with DNA methyltransferase 
inhibitor has been shown to upregulate cancer-testis antigen (CTA) expression in AML6,7, and to be associated 
with induction of CTA-specific cytotoxic T lymphocytes (CTLs) with the majority (8/11) having an induced 
CTL immune response also having a major clinical response7.  5) PD-L1 expression is seen by IHC on 35-50% 
of human AML8 and levels are higher in relapsed than primary AML9.  6) PD-1 (hi) and TIM-3(+) T cells 
are associated with (and found prior to) AML relapse post allo-HSCT, with a functional phenotype 
characterized by the inability to produce interleukin 2 (IL-2), tumor necrosis factor-α (TNF-α) and interferon-γ 
(IFN-γ) in both mice10 and humans11. 6) PD-1 knockout mice have improved survival and augmented immune 
response compared with wild-type mice in an AML challenge model1 2 and PD-1 pathway blocking antibody 
treatment restored CD8+ T cell function and resulted in improved survival in the same AML model10.  7) 
Recent evidence suggests that treatment with DNA methyltransferase inhibitors (like decitabine) may cause an 
up-regulation of immune signaling via a type I interferon response due to expression and recognition of double 
stranded RNA including from endogenous retrovirus genes13,14.  In patients treated with immune checkpoint 
therapy this same viral defense expression signature has been associated with durable clinical response.  8) 
Treatment with DNA methyltransferase inhibitor sensitized to immune checkpoint therapy in a mouse cancer 
model14. Taken together these findings provide strong pre-clinical rationale for the combination of 
hypomethylating agent and immune checkpoint therapy used in our trial15,16.
Finally, AML has historically been approached as a homogeneous diagnostic entity with a resulting “one size 
fits all” treatment strategy, often resulting in disappointing outcomes17. In reality, the acute myeloid leukemias 
are a heterogeneous group of diseases with distinct molecular and phenotypic characteristics18,19. Even within 
a single patient AML may be polyclonal at any examined time-point, and this clonal composition can change 
over time with the clone predominant at presentation not necessarily the one responsible for relapse and death20. 
We therefore hypothesize that effective pembrolizumab therapy for refractory or relapsed AML in those who 
have not received allo-HSCT may be associated with changes in the clonal composition due to differences in 
immunogenicity between clones.  This oligoclonal nature of AML biology, together with a blood and bone 
marrow distribution highly amenable to repeated sampling of the sites of disease burden, provides a near unique 
opportunity to investigate fundamental mechanisms underpinning treatment efficacy of this new class of 
immunotherapeutic drugs. 
2.3. Pembrolizumab
2.3.1.  Mechanism of Action
The programmed cell death 1 (PD-1) pathway represents a major immune control switch, which may be 


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engaged by tumor cells to overcome active T cell immune surveillance. 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 a type I 
transmembrane glycoproteins. Upon engagement of its ligands, PD-L1 and PD-L2, the cytoplasmic tail of PD-1 
recruits tyrosine phosphatases SHP-1 and SHP-2 to the immunoreceptor tyrosine-based switch motif (ITSM) 
motif, and dephosphorylates effector molecules such as CD3ζ, PKCθ and ZAP70 which are involved in the 
CD3 T-cell signaling cascade. The ligands for PD-1 are constitutively expressed or can be induced in a variety 
of cell types. 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/PD-L1 pathway plays a critical role in tumor immune evasion and 
should be considered as an attractive target for therapeutic intervention.
Pembrolizumab (KEYTRUDA®, MK-3475; previously known as SCH 900475 and ORG 307488-0 [herein 
referred to as pembrolizumab unless otherwise noted]) is a potent and highly selective humanized monoclonal 
antibody of the immunoglobulin G4 (IgG4)/kappa isotype designed to directly block the interaction between 
PD-1 and its ligands, PD-L1 and PD-L2. This blockade enhances functional activity of the target lymphocytes 
to facilitate tumor regression and ultimately immune rejection. 
Pembrolizumab potentiates existing immune responses only in the presence of antigen-receptor stimulation and 
does not nonspecifically activate all T cells. Pembrolizumab was tested for its capacity to enhance T cell activity 
in vitro using blood cells from healthy volunteers stimulated with staphylococcus enterotoxin B (SEB). 
Pembrolizumab enhanced IL-2 production over control on average 2- to 4-fold at the highest antibody 
concentration tested (25 μg/mL). In addition to IL-2, levels of tumor necrosis factor alpha (TNFα), IL-17, IL-
6, and interferon gamma (IFNγ) increased by 1.2 to 1.7 folds after the addition of pembrolizumab to SEB-
stimulated whole blood cells.
2.3.2.  Pharmacokinetics
An open-label Phase I trial (Protocol 001) is being conducted to evaluate the safety and clinical activity of 
single agent MK-3475.  The dose escalation portion of this trial evaluated three dose levels, 1 mg/kg, 3 mg/kg, 
and 10 mg/kg, administered every 2 weeks (Q2W) in subjects with advanced solid tumors.  All three dose levels 
were well tolerated and no dose-limiting toxicities were observed.  This first in human study of MK-3475 
showed evidence of target engagement and objective evidence of tumor size reduction at all dose levels (1 
mg/kg, 3 mg/kg and 10 mg/kg Q2W).  No MTD has been identified to date.  Recent data from other clinical 


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studies within the MK-3475 program has shown that a lower dose of MK-3475 and a less frequent schedule 
may be sufficient for target engagement and clinical activity.
PK data analysis of MK-3475 administered Q2W and Q3W showed slow systemic clearance, limited volume 
of distribution, and a long half-life (refer to IB).  Pharmacodynamic data (IL-2 release assay) suggested that 
peripheral target engagement is durable (>21 days).  This early PK and pharmacodynamic data provides 
scientific rationale for testing a Q2W and Q3W dosing schedule.  
A population pharmacokinetic analysis has been performed using serum concentration time data from 476 
patients. Within the resulting population PK model, clearance and volume parameters of MK-3475 were found 
to be dependent on body weight. The relationship between clearance and body weight, with an allometric 
exponent of 0.59, is within the range observed for other antibodies and would support both body weight 
normalized dosing or a fixed dose across all body weights.  MK-3475 has been found to have a wide therapeutic 
range based on the melanoma indication.  The differences in exposure for a 200 mg fixed dose regimen relative 
to a 2 mg/kg Q3W body weight based regimen are anticipated to remain well within the established exposure 
margins of 0.5 – 5.0 for MK-3475 in the melanoma indication. The exposure margins are based on the notion 
of similar efficacy and safety in melanoma at 10 mg/kg Q3W vs. the proposed dose regimen of 2 mg/kg Q3W 
(i.e. 5-fold higher dose and exposure). The population PK evaluation revealed that there was no significant 
impact of tumor burden on exposure. In addition, exposure was similar between the NSCLC and melanoma 
indications. Therefore, there are no anticipated changes in exposure between different indication settings.
The rationale for further exploration of 2 mg/kg and comparable doses of pembrolizumab is based on: 1) similar 
efficacy and safety of pembrolizumab when dosed at either 2 mg/kg or 10 mg/kg Q3W in melanoma patients, 
2) the flat exposure-response relationships of pembrolizumab for both efficacy and safety in the dose ranges of 
2 mg/kg Q3W to 10 mg/kg Q3W, 3) the lack of effect of tumor burden or indication on distribution behavior 
of pembrolizumab (as assessed by the population PK model) and 4) the assumption that the dynamics of 
pembrolizumab target engagement will not vary meaningfully with tumor type.
The choice of the 200 mg Q3W as an appropriate dose for the switch to fixed dosing is based on simulations 
performed using the population PK model of pembrolizumab showing that the fixed dose of 200 mg every 3 
weeks will provide exposures that 1) are optimally consistent with those obtained with the 2 mg/kg dose every 
3 weeks, 2) will maintain individual patient exposures in the exposure range established in melanoma as 
associated with maximal efficacy response and 3) will maintain individual patients exposure in the exposure 
range established in melanoma that are well tolerated and safe. 


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A fixed dose regimen will simplify the dosing regimen to be more convenient for physicians and to reduce 
potential for dosing errors.  A fixed dosing scheme will also reduce complexity in the logistical chain at 
treatment facilities and reduce wastage.
2.3.3.  Metabolism and Clearance
No traditional metabolism studies were conducted with pembrolizumab per current ICH S (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 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 and indicates that pembrolizumab is not likely to engage in Fab-arm exchange in humans.
Renal Impairment
The effect of renal impairment on the clearance (CL) of pembrolizumab was evaluated by population PK 
analyses in patients with mild (eGFR 60 to 89 mL/min/1.73 m2; n=210), moderate (eGFR 30 to 
59mL/min/1.73m2; n=43), or severe (eGFR 15 to 29mL/min/1.73 m2; n=2) renal impairment compared to 
patients with normal (eGFR greater than or equal to 90 mL/min/1.73m2; n=221) renal function. No clinically 
important differences in the CL of pembrolizumab were found between patients with renal impairment and 
patients with normal renal function. 
Hepatic Impairment
The effect of hepatic impairment on the CL of pembrolizumab was evaluated by population PK analyses in 
patients with mild hepatic impairment (total bilirubin (TB) less than or equal to upper limit of normal (ULN) 
and AST greater than ULN or TB between 1 and 1.5 times ULN and any AST; n=59) compared to patients with 
normal hepatic function (TB and AST less than or equal to ULN; n=410). No clinically important differences 
in the CL of pembrolizumab were found between patients with mild hepatic impairment and normal hepatic 
function. Pembrolizumab has not been studied in patients with moderate (TB greater than 1.5 to 3 times ULN 
and any AST) or severe (TB greater than 3 times ULN and any AST) hepatic impairment.


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2.3.4.   Clinical experiences
The efficacy of pembrolizumab was investigated in other solid tumors, including melanoma and lung cancer. 
In a multicenter randomized phase II trial in metastatic melanoma, patients were randomized to pembrolizumab 
2mg/kg Q3W and 10mg/kg Q3W versus standard-of-care in a 1:1:1 ratio. 361 patients received pembrolizumab 
and 179 received chemotherapy. 6-month PFS rates were 34.3% (95% CI: 27.4 to 41.3%) and 37.7% (95% CI: 
30.6% to 44.8%) for pembrolizumab 2 mg/kg and 10 mg/kg, respectively, versus 15.6% (95% CI: 10.5% to 
21.5%) for the control arm. ORR per RECIST 1.1 by IRO were 21% in the pembrolizumab 2 mg/kg arm, 25% 
in the 10 mg/kg arm, and 4% in the chemotherapy arm (p<0.0001 for each pembrolizumab dose versus 
chemotherapy). 
Pembrolizumab is approved by the U.S. FDA for the treatment of patients with unresectable or metastatic 
melanoma and disease progression following ipilimumab and, if BRAFV600 mutation positive, a BRAF 
inhibitor.  The FDA also recently also granted accelerated approval for pembrolizumab to treat patients with 
advanced (metastatic) non-small cell lung cancer (NSCLC) whose disease has progressed after other treatments 
and with tumors that express PD-L1 and also patients with recurrent or metastatic recurrent or metastatic head 
and neck squamous cell carcinoma (HNSCC) with disease progression on or after platinum-containing 
chemotherapy. Clinical trials using pembrolizumab in other solid and hematologic malignancies are now 
ongoing. 
2.4. Decitabine
Decitabine is a nucleoside metabolic inhibitor that is U.S. FDA approved for treatment of patients with 
myelodysplastic syndromes (MDS).
2.4.1. Mechanism of Action
Decitabine is believed to exert its antineoplastic effects after phosphorylation and direct incorporation into DNA 
and inhibition of DNA methyltransferase, causing hypomethylation of DNA and cellular differentiation or 
apoptosis. Decitabine inhibits DNA methylation in vitro, which is achieved at concentrations that do not cause 
major suppression of DNA synthesis. Decitabine-induced hypomethylation in neoplastic cells may restore 
normal function to genes that are critical for the control of cellular differentiation and proliferation. In rapidly 
dividing cells, the cytotoxicity of decitabine may also be attributed to the formation of covalent adducts between 
DNA methyltransferase and decitabine incorporated into DNA. Non-proliferating cells are relatively insensitive 
to decitabine. 


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2.4.2.  Pharmacokinetics
Pharmacokinetic parameters were evaluated in patients. Eleven patients received 20 mg/m2 infused over 1 hour 
intravenously (treatment Option 2). Fourteen patients received 15 mg/m2 infused over 3 hours (treatment 
Option 1). PK parameters are shown in Table 1 below. Plasma concentration-time profiles after discontinuation 
of infusion showed a biexponential decline. The CL of decitabine was higher following treatment Option 2. 
Upon repeat doses there was no systemic accumulation of decitabine or any changes in PK parameters. 
Population PK analysis (N=35) showed that the cumulative AUC per cycle for treatment Option 2 was 2.3-fold 
lower than the cumulative AUC per cycle following treatment Option 1. 
Table 1: Mean (CV% or 95% CI) Pharmacokinetic Parameters of Decitabine (from FDA Label 
10/2014)
The exact route of elimination and metabolic fate of decitabine is not known in humans. One of the pathways 
of elimination of decitabine appears to be deamination by cytidine deaminase found principally in the liver but 
also in granulocytes, intestinal epithelium and whole blood. 
2.4.3.  Metabolism and Clearance
Geriatric Use
Of the total number of patients exposed to decitabine in the controlled clinical trial, 61 of 83 patients were age 
65 and over, while 21 of 83 patients were age 75 and over. No overall differences in safety or effectiveness 
were observed between these subjects and younger subjects, and other reported clinical experience has not 
identified differences in responses between the elderly and younger patients, but greater sensitivity of some 
older individuals cannot be ruled out. 
Renal Impairment 
There are no data on the use of decitabine in patients with renal dysfunction; therefore, decitabine should be 
used with caution in these patients. 


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Hepatic Impairment 
There are no data on the use of decitabine in patients with hepatic dysfunction; therefore, decitabine should be 
used with caution in these patients. 
2.5. Summary of Clinical Safety 
2.5.1.  Pembrolizumab
Pooled safety data (N=2461) treatment with pembrolizumab is available on patients with melanoma or non-
small cell lung cancer in 8 clinical trials: P001, P002, P011, P012, P013, P021, P023, and P028. In general, the 
safety profile observed in P011 (monotherapy arm), P012, P013, and P028 was similar to that observed in 
P001/P002.
In the pembrolizumab monotherapy trials, the most commonly reported AEs included fatigue, diarrhea, 
decreased appetite, nausea, dyspnea, and anemia. In P021, the most commonly reported AEs in this population 
across the dose regimens were fatigue (49.2%), constipation and nausea (26.2% each), decreased appetite 
(23.1%), diarrhea (18.5%), and anemia and alopecia (15.4% each). In P023, the most commonly reported AEs 
experienced in this population across the dose regimens were neutropenia and thrombocytopenia (50.0% each), 
followed by anemia, respiratory tract infection, and back pain (30.0% each). 
In the pembrolizumab monotherapy trials, the incidence of Grade 3-5 treatment-related AEs across studies 
ranged from 6.8% (6 of 88 in P013) to 12.0% (187 of 1562 subjects) in P001/P002. In the combination therapy 
trials, Grade 3-5 treatment-related AEs were reported in 23.1% (15 of 65 subjects in this population) in P021 
and 50.0% (5 of 10 subjects in this population) in P023. The most commonly reported Grade 3-5 treatment-
related AEs were anemia, ALT or AST increases, and colitis. In P021, the most common Grade 3-5 treatment-
related AEs across dose regimens were AST increase (6.2%) and anemia and ALT increase (4.6% each). In 
P023, the only Grade 3-5 treatment-related AEs that occurred in more than 1 subject in this population across 
dose regimens were neutropenia (40.0%) and anemia (20.0%).
In the pembrolizumab monotherapy trials, most subjects who experienced an AE continued in the study, with 
the incidence of AEs leading to discontinuation ranging from 4.2% (18 of430 subjects in P028) to 12.3% (192 
of 1562 subjects in P001/P002). The majority of AEs leading to discontinuation were not considered drug 
related. Discontinuations due to a treatment-related AE were infrequent and ranged from 0% (no subjects in 
P011) to 4.5% (4 of 88 subjects in P013). The most commonly reported treatment-related AE leading to 
discontinuation was pneumonitis. In P021, most subjects continued treatment despite AEs, and only 4.6% 
discontinued due to an AE. Only 3.1% of subjects discontinued study treatment due to an AE that was 
considered related to study treatment by Investigators. Interstitial lung disease, allergic dermatitis and drug 


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eruption were the only treatment-related AEs resulting in discontinuation and were reported in 1 subject each 
(1.5%). In P023, no subjects discontinued due to an AE. 
For more detailed information refer to the current version of the Investigator Brochure.
2.5.2.  Decitabine
Decitabine was studied in 3 single-arm studies (N=66, N=98, N=99) and 1 controlled supportive care study 
(N=83 decitabine, N=81 supportive care). The data described below reflect exposure to decitabine in 83 patients 
in the MDS trial. In the trial, patients received 15 mg/m2 intravenously every 8 hours for 3 days every 6 weeks. 
The median number of decitabine cycles was 3 (range 0 to 9). 
Most Commonly Occurring Adverse Reactions: neutropenia, thrombocytopenia, anemia, fatigue, pyrexia, 
nausea, cough, petechiae, constipation, diarrhea, and hyperglycemia.
Adverse Reactions Most Frequently (≥1%) Resulting in Clinical Intervention in the Phase 3 Trials in the 
decitabine Arm: 
Discontinuation: thrombocytopenia, neutropenia, pneumonia, Mycobacterium avium complex infection, 
cardio-respiratory arrest, increased blood bilirubin, intracranial hemorrhage, abnormal liver function 
tests. 
Dose Delayed: neutropenia, pulmonary edema, atrial fibrillation, central line infection, febrile 
neutropenia. 
Dose Reduced: neutropenia, thrombocytopenia, anemia, lethargy, edema, tachycardia, depression, 
pharyngitis. 
In the controlled trial using decitabine dosed at 15 mg/m2, administered by continuous intravenous infusion 
over 3 hours repeated every 8 hours for 3 days, the highest incidence of Grade 3 or Grade 4 adverse events in 
the decitabine arm were neutropenia (87%), thrombocytopenia (85%), febrile neutropenia (23%) and 
leukopenia (22%). Bone marrow suppression was the most frequent cause of dose reduction, delay and 
discontinuation. Six patients had fatal events associated with their underlying disease and myelosuppression 
(anemia, neutropenia, and thrombocytopenia) that were considered at least possibly related to drug treatment. 
Of the 83 decitabine-treated patients, 8 permanently discontinued therapy for adverse events; compared to 1 of 
81 patients in the supportive care arm. 
In a single-arm phase 1 study of patients with hematological malignancies (N=48) decitabine was dosed at 5, 
10, 15 or 20mg/m2 daily intravenously over one hour for 10 days (5 days on, 2 days off, 5 days on), 
approximately every six weeks21. 73% of these patients had AML and 14% had MDS.  The treatment was well 
tolerated overall. Nonhematopoietic side effects are detailed in Table 2 below. Asymptomatic but severe 


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elevations in liver function tests, possibly related to therapy, were observed in 6 patients. In 5 cases, values 
returned to baseline within 2 weeks; the sixth patient died on day 21 with a bilirubin level of 290.7 μM and 
evidence of sepsis. Febrile episodes were noted in 26 patients (52%). These included fever of unknown origin 
in 8 patients (16%) and documented infections in 18 patients (36%): bacterial in 6, fungal in 1, others in 3, 
minor infections in 1, pneumonia in 12. 
Myelosuppression was evaluated by studying time to CR and myelosuppression in patients receiving additional 
courses in remission. In patients achieving CR, the median time to platelet recovery more than 100 x 109/L was 
39 days (range, 31-70 days), and the median time to granulocyte recovery more than 109/L was 45 days (range, 
33-70 days). A total of 10 courses of therapy administered to 6 patients in remission were analyzable for 
myelosuppression. In these, the median platelet nadir was 45 x 109/L (range, 20-200 x 109/L), and, in the 6 
courses with thrombocytopenia less than 100 x 109/L, median time to platelet recovery more than 100 x 109/L 
was 32 days (range, 24-58 days). The median nadir granulocyte count was 0.32 x 109/L (range, 0-3.0 x 109/L), 
and, in the 7 courses with granulocytopenia less than 109/L, median time to granulocyte recovery more than 
109/L was 36 days (range, 32-45 days). Of these 10 courses, 8 were administered at the dose of 15 mg/m2 for 
10 days, precluding meaningful analysis of myelosuppression at lower versus higher doses. 
Table 2:  Non-hematological side effects with decitabine (50 cases, including two patients treated twice 
at different dose levels) from Phase I study21.
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the 
clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not 
reflect the rates observed in practice.
This single arm Phase 1 trial at MD Anderson showed impressive efficacy with 16/52 responding (32%) 
including 9 with CR (18%).  In the cohort of 17 patients receiving 15mg/m2 on a 5 days per week for two 
consecutive weeks schedule (ie: same schedule we propose for this trial) the response rate was 65% with 35% 
CR21.   A subsequent phase I/II trial used a decitabine dose of 15mg/m2 for 10 consecutive days every 4 weeks 
in addition to the histone deacetylase inhibitor valproic acid22.   In total 12 of 53 patients achieved a CR or CR 


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with incomplete platelet recovery (23% CR+CRp).  A phase 1 study at Ohio State determined the optimal 
biological decitabine dose for AML (based on a gene re-expression assay) to be 20mg/m2 when given daily for 
10 consecutive days over 4 weeks with 11 of 21 patients achieving a response (52%) with a combined CR 
(19%) and CRi (19%) rate of 38%23.  A follow-up phase 2 trial in older patients with previously untreated AML 
at this same dose and schedule demonstrated a CR of 25/53 (47%) and a CRi rate of 17% for an overall response 
rate of 65%.   In contrast the response rates for the FDA approved dosing of 15 mg/m2 three times daily for 3 
days every 6 weeks (Phase 2, n=227 AML patients24) and 20 mg/m2 for 5 days every 4 weeks (Phase 3, n=242 
AML patients25) are more modest with CR rates of 13% and 18% respectively. 
2.6. Rationale for Dose Selection/Regimen/Combination/Modifications
The intent of this pilot study is to determine the feasibility of adding pembrolizumab to an agent with known 
efficacy in myeloid malignancies. Decitabine is an FDA approved agent that is listed in the current National 
Comprehensive Cancer Network (NCCN) consensus (“standard of care”) guidelines as therapy for 
relapsed/refractory AML (see Appendix F).
The proposed regimen is pembrolizumab 200 mg every 3 weeks for up to eight cycles with low dose decitabine 
20mg/m2 given on days 8 through 12 and 15 through 19 of alternative cycles (ie: cycles 1, 3, 5, 7).
Decitabine will be given according to the schedule and optimal biological dosing for AML of 20mg/m2 as 
identified in the phase 1 study at Ohio State23 (as described in section 2.5.2 above).  
The rationale for the investigational fixed dose of pembrolizumab 200 mg every 3 weeks is described in section 
2.3.2 above.
This combination of pembrolizumab and decitabine was selected based on several factors:  1) Largely non-
overlapping adverse reaction profiles for these agents.  2) Both agents already FDA approved potentially 
allowing for rapid translation/adoption.  3) Both agents have previously evaluated dosing schedules that are 
compatible with one another (pembrolizumab every three weeks and decitabine every six weeks).  4) 
Theoretical possibility of synergy given respective mechanisms of action (see Section 2.2). 
2.7. Rationale for Endpoints
This is a pilot study to assess the impact of the addition of pembrolizumab to decitabine for adult patients with 
relapsed/refractory AML.
Feasibility: Pembrolizumab and decitabine are both FDA approved agents.  Pembrolizumab is approved for 
certain solid tumors, and decitabine for myelodysplastic syndrome (although commonly used off-label for 
AML).   While the side effects of these agents appear to be non-overlapping, the combination of pembrolizumab 
and decitabine has not been tested.  This pilot study will generate descriptive data on the adverse events 


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observed in relapsed and refractory AML patients using this combination (number, severity and duration of 
adverse events) according to the NCI-Common Terminology Criteria for Adverse Events (CTCAE) v4.0.
Efficacy: There is proof of principle in animal models that pembrolizumab may have activity against AML but 
no human studies. While this pilot study is not powered for formal assessment of efficacy, standard response 
criteria (see Appendix A) will be used at set time-points to provide descriptive data on efficacy of the 
pembrolizumab and decitabine combination.
Time to first response: Previous studies for single agent pembrolizumab in solid tumors reported an average 
time to first response occurred at first imaging for restaging at 12 weeks (Hamid et. al., 2013). There is no 
information regarding time to first response for this pembrolizumab and decitabine combination in 
relapsed/relapsed AML patients. 
Time to best response: There is no current information on the time to best response for this pembrolizumab 
and decitabine combination in relapsed/relapsed AML patients.
Duration of response: It is unknown, if any, how long the response duration of a response to this 
pembrolizumab and decitabine combination would be in relapsed/relapsed AML patients.  It is possible this 
combination including pembrolizumab, due to novel mechanisms of action, may result in clinical responses in 
patients who are or would be refractory to traditional cytotoxic chemotherapy.
Duration of best response:  as above.
Overall survival: Overall survival is unquestionably a clinical meaningful endpoint.  A small pilot study such 
as this is not powered to provide statistical information on this endpoint, but descriptive data on outcomes will 
be reported and may provide anecdotal support for further trials.
2.8. Biomarker Research
One of the main intentions of this initial pilot study is to provide deep laboratory assessment of any 
observed clinical responses and toxicity in patients to help guide, plan and justify subsequent clinical trials for 
this indication.
The Intramural Research Program (IRP) of the National Institutes of Health (NIH) and the NIH Clinical 
Center (NIH-CC) offers unique resources; facilities and opportunities conduct such early translational clinical 
research.   In addition, malignancies of the hematopoietic system such as Acute Myeloid Leukemia allow the 
repeated direct sampling to evaluate both changes in disease burden and character and to characterize any 
associated immune response and microenvironment. An integral component to this trial is the commitment to 


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collect, store and analyze biological specimens including paired blood and bone marrow samples on regular 
and frequent bases.
We will attempt to answer the following correlative research questions:
How does the clonal diversity of acute myeloid leukemia change during treatment with the combination of 
pembrolizumab and decitabine?  This will be determined by next generation sequencing of AML associated 
somatic mutations prior to treatment, and tracking changes in variant allele frequency over time.
Are measurable changes in immune parameters associated with treatment, clinical efficacy and/or toxicity (eg: 
autoimmunity) using repeated disease site sampling of blood and bone marrow?
How much does AML disease burden change during treatment of relapsed/refractory AML patients with 
pembrolizumab and decitabine?  A variety of high sensitivity tests for quantification of residual disease 
including flow cytometry and real-time quantitative RT-PCR will be used.
Are observed clinical responses associated with potentially predictive biomarkers such as marrow infiltrating 
lymphocytes (MILs), mutational burden in AML and PDL-1 expression?
3.0
STUDY DESIGN 
This is an investigator sponsored pilot study to evaluate the feasibility of a novel combination of pembrolizumab 
and decitabine in adult patients with relapsed/refractory AML.
Secondary objectives determining, efficacy, time to first response, time to best response, duration of best 
response and overall survival. Treatment plan is discussed in detail in Section 5.0.
4.0
ELIGIBILITY ASSESSMENT AND ENROLLMENT
4.1. Inclusion Criteria

Unequivocal diagnosis of relapsed or refractory acute myeloid leukemia (AML) confirmed by an NIH 
attending pathologist within 30 days of study enrollment (includes residual AML as confirmed by 
institutional standards by NIH pathologists, see Appendix A).

Received at least one prior AML therapy before study enrollment.

Ability to comprehend the investigational nature of the study and provide informed consent.

Be at least 18 years of age on day of signing informed consent.

Availability of a physician willing to assume clinical care after completion of the study.

Be willing to provide blood and bone marrow for research as described in the study.


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
Have a performance status of less than or equal to 1 on the ECOG Performance Scale (Appendix B).

Demonstrate adequate organ function as defined in Table 3, all screening labs should be performed 
within 14 days of treatment initiation.  

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.  

Female subjects of childbearing potential (Section 5.7.2) must be willing to use an adequate method of 
contraception as outlined in Section 5.7.2 – Contraception, for the course of the study through 120 days 
after the last dose of study medication.  Note: Abstinence is acceptable if this is the usual lifestyle and 
preferred contraception for the subject.

Male subjects of childbearing potential (Section 5.7.1) must agree to use an adequate method of 
contraception as outlined in Section 5.7.1- Contraception, starting with the first dose of study therapy 
through 120 days after the last dose of study therapy.  Note: Abstinence is acceptable if this is the usual 
lifestyle and preferred contraception for the subject.
Table 3: Adequate Organ Function Laboratory Values
System
Laboratory Value
Renal
Serum creatinine 
≤1.5 X upper limit of normal (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)
≤ 3 X ULN 
4.2. Exclusion Criteria
The subject must be excluded from participating in the trial if the subject:

Has a diagnosis of acute promyelocytic leukemia (APL)

Has previously received an allogeneic hematopoietic stem cell transplant.

Has received AML treatment with an investigational therapy or device within 4 weeks of the first dose 
of treatment.

Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other form of 
immunosuppressive therapy within 7 days prior to the first dose of trial treatment.

Has a known history of active TB (Bacillus Tuberculosis)


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
Has hypersensitivity to pembrolizumab or any of its excipients.

Has hypersensitivity to decitabine or any of its excipients.

Has received more than two prior cycles of decitabine. 

Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study Day 1. 

Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 weeks prior 
to study Day 1.
Note:  Subjects who have received cytoreductive therapy with hydroxyurea at any time prior 
to study Day 1 are an exception to this criterion.

Has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to previously administered 
AML therapy agents. 

Note:  Subjects with ≤ Grade 2 neuropathy are an exception 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.  

Has a known additional malignancy that is progressing or requires active treatment. Patients with basal 
cell carcinoma of the skin or squamous cell carcinoma of the skin that has undergone potentially 
curative therapy or in situ cervical cancer would not be excluded.

Has known malignant central nervous system (CNS) involvement.  

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. 

Has history of (non-infectious) pneumonitis that required steroids, evidence of interstitial lung disease 
or active, non-infectious pneumonitis.

Has an active infection requiring intravenous systemic therapy.

Has a history or current evidence of any condition, therapy, or laboratory abnormality that might 
confound the results of the trial, interfere with the subject’s participation for the full duration of the 
trial, or is not in the best interest of the subject to participate, in the opinion of the treating investigator.  


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
Has known psychiatric or substance abuse disorders that would interfere with cooperation with the 
requirements of the trial.

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.

Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.

Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies).

Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA [qualitative] is 
detected).

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.
5.0
TREATMENT PLAN 
5.1. Treatment Schedule
Up to eight cycles of pembrolizumab will be given during the initial induction phase.  Each cycle is 21 days.  
Decitabine will ordinarily be given on days 8 through 12 and 15 through 19 on alternative cycles (ie: cycles 1, 
3, 5 and 7).
Figure 1:  Induction Treatment Schema
This is a single institution pilot study of pembrolizumab and decitabine in adult patients with relapsed/refractory 
AML. The primary aim is to assess the feasibility of this novel pembrolizumab and decitabine combination in 
this patient population. This trial is open labeled, single arm study.


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An optional continuation phase (see section 5.9) will be offered for those who have maintained a best response 
of at least stable disease (see Appendix A) after the initial eight cycles of the induction phase. 
Table 4: Experimental Treatment Doses and Schedule.
Drug
Dose/Potency
Dose 
Frequency
Route of 
Administration
Regimen/Treatment 
Period
Use
Pembrolizumab
200 mg 
Q3W
IV infusion
Day 1 of each 3 week 
cycle
Experimental
Decitabine
20 mg/m2
Q6W
IV infusion
Days 8 through 12 
and 15 through 19 of 
alternative cycles 
starting with cycle 1
Experimental
5.2. Dose Modification Guidelines For Drug-Related Adverse Events
5.2.1. Hematologic toxicities
Given the pathobiology of Acute Myeloid Leukemia, severe blood count abnormalities (up to grade 4 levels in 
leukocytes, neutrophils, lymphocytes, red blood cells and platelets) are expected and may be present at baseline.  
Decitabine will be initiated on Cycle 1 and 3 regardless of peripheral blood count values. After this point, if 
hematologic recovery (absolute neutrophil count  ≥1,000/μL and platelets ≥50,000/μL) does not occur six weeks 
after initiation of prior cycle of decitabine in complete remission patients, then subsequent decitabine doses will 
be modified to consist of five days of 20mg/m2 given, at the discretion of the investigator, anytime during days 
8-19 of a cycle.          
In accordance with the FDA label and past clinical trial experience no dose modification will be made for 
pembrolizumab in the event of hematological toxicity.
5.2.2. Non-hematologic toxicities
Adverse events (both non-serious and serious) associated with pembrolizumab exposure may represent an 
immunologic etiology.  These adverse events may occur shortly after the first dose or several months after the 
last dose of treatment. Pembrolizumab must be withheld for drug-related toxicities and severe or life-
threatening AEs as per table 5 below. See Section 5.6 for supportive care guidelines, including use of 
corticosteroids.  Decitabine should be withheld for serum creatinine ≥2 mg/dL, an ALT ≥5 times upper limit 


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25
of normal (ULN) or total bilirubin ≥2 times ULN, or an uncontrolled infection.  Decitabine may be resumed at 
resolution of these abnormalities. 
5.2.3. Other acceptable dose delays
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 Sponsor. The reason for interruption should be documented in the patient’s study record.
Table 5:  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 
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 


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Grade 4
Permanently 
discontinue
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 and electrolytes 
should be substituted 
via IV infusion.
Grade 2
Withhold

Administer 
corticosteroids 
(initial 
dose 
of 
0.5- 
1 
mg/kg 
prednisone 
or 
equivalent) 
followed by taper
AST / ALT 
elevation or 
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 insufficiency) 
Hyperthyroidism 
Grade 2
Continue 

Treat with non-
selective 
beta-

Monitor for signs and 
symptoms of thyroid 


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Grade 3 or 4 
Withhold or 
permanently 
discontinue1
blockers 
(eg, 
propranolol) 
or 
thionamides 
as 
appropriate 
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 
AEs
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.  
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).  
5.3. Timing of Dose Administration
Pembrolizumab should be administered on Day 1 of each cycle after all procedures/assessments have been 
completed. 
Pembrolizumab 200 mg will be administered as a 30 minute IV infusion every 3 weeks.  Every effort should 
be made to target infusion timing to be as close to 30 minutes as possible.  However, given the variability of 
infusion pumps, a window of -5 minutes and +10 minutes is permitted (i.e., infusion time is 30 minutes: -5 
min/+10 min).


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The Pharmacy Manual contains specific instructions for the preparation of the pembrolizumab infusion fluid 
and administration of infusion solution.
Decitabine will be administered at a dose of 20 mg/m2 by intravenous infusion over approximately1 hour 
repeated daily ordinarily on days 8 through 12 and 15 through 19 of alternative cycles (ie: cycles 1, 3, 5, 7). 
Decitabine may be given +/- 3 days, if needed for administrative or logistical issues.  Decitabine should be 
repeated every 6 weeks. Patients may be premedicated with standard anti-emetic therapy. Every effort should 
be made to target infusion timing to be as close to 60 minutes as possible.  However, given the variability of 
infusion pumps, a window of -5 minutes and +10 minutes is permitted (i.e., infusion time is 60 minutes: -5 
min/+10 min).  
These timings may change in accordance with section 5.2 above.
5.4. Randomization or Treatment Allocation
All patients will receive the same treatment.
This is an open-label trial; therefore, the sponsor, investigator, care team and subject will all know the 
treatment administered.
5.5. Concomitant Medications/Vaccinations (allowed & prohibited)
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 Merck Clinical team.  The final decision on any supportive therapy 
or vaccination rests with the investigator and/or the subject's primary physician. 
Acceptable Concomitant Medications
All treatments that the investigator considers necessary for a subject’s welfare may be administered at the 
discretion of the investigator in keeping with the community standards of medical care.  All concomitant 
medication will be recorded in the electronic medical record including all prescription, over-the-counter (OTC), 
herbal supplements, and IV medications and fluids.  If changes occur during the trial period, documentation of 
drug dosage, frequency, route, and date will also be included in the electronic medical record.
All concomitant medications received within 28 days before the first dose of trial treatment and 30 days after 
the last dose of trial treatment should be recorded.  
Prohibited Concomitant Medications


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Subjects are prohibited from receiving the following therapies during the Screening and Treatment Phase of 
this trial:

Antineoplastic systemic chemotherapy or biological therapy 

Immunotherapy not specified in this protocol

Chemotherapy not specified in this protocol

Investigational agents other than pembrolizumab or decitabine

Radiation therapy 
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 investigator.
Subjects who, in the assessment by the investigator, require the use of any of the aforementioned treatments for 
clinical management should be removed from the trial.  Subjects may receive other medications that the 
investigator deems to be medically necessary.
There are no prohibited therapies during the Post-Treatment Active Surveillance follow-up stage.
5.6. Rescue Medications & Supportive Care
Supportive Care Guidelines
Subjects should receive appropriate supportive care measures as deemed necessary by the treating investigator.  
This includes standard prophylaxis for infection and tumor lysis. Suggested supportive care measures for the 
management of adverse events with potential immunologic etiology are outlined below. Where appropriate, 
these guidelines include the use of oral or intravenous treatment with corticosteroids as well as additional anti-
inflammatory agents if symptoms do not improve with administration of corticosteroids.   Note that several 
courses of steroid tapering may be necessary as symptoms may worsen when the steroid dose is decreased. For 
each disorder, attempts should be made to rule out other causes such as metastatic disease or bacterial or viral 


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infection, which might require additional supportive care. The treatment guidelines are intended to be applied 
when the investigator determines the events to be related to pembrolizumab. 
Note: if after the evaluation the event is determined not to be related, the investigator does not need to follow 
the treatment guidance (as outlined below). Refer to Section 5.2 for dose modification. 
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or skin photography 
as part of evaluation of the event. 
Pneumonitis: 
For Grade 2 events, treat with systemic corticosteroids. When symptoms improve to Grade 1 or less, 
steroid taper should be started and continued over no less than 4 weeks.
For Grade 3-4 events, immediately treat with intravenous steroids.  Administer additional anti-
inflammatory measures, as needed.
Add prophylactic antibiotics for opportunistic infections in the case of prolonged steroid 
administration.
Diarrhea/Colitis: 
Subjects should be carefully monitored for signs and symptoms of enterocolitis (such as diarrhea, 
abdominal pain, blood or mucus in stool, with or without fever) and of bowel perforation (such as 
peritoneal signs and ileus).  
All subjects who experience diarrhea/colitis should be advised to drink liberal quantities of clear 
fluids.  If sufficient oral fluid intake is not feasible, fluid and electrolytes should be substituted via 
IV infusion.  For Grade 2 or higher diarrhea, consider GI consultation and endoscopy to confirm or 
rule out colitis.
For Grade 2 diarrhea/colitis, administer oral corticosteroids. 
For Grade 3 or 4 diarrhea/colitis, treat with intravenous steroids followed by high dose oral steroids.  
When symptoms improve to Grade 1 or less, steroid taper should be started and continued over no 
less than 4 weeks.
Type 1 diabetes mellitus (if new onset, including diabetic ketoacidosis [DKA]) or ≥ Grade 3 
Hyperglycemia, if associated with ketosis (ketonuria) or metabolic acidosis (DKA)
For T1DM or Grade 3-4 Hyperglycemia
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:
For Grade 2 events, treat with corticosteroids. When symptoms improve to Grade 1 or less, 
steroid taper should be started and continued over no less than 4 weeks. Replacement of 
appropriate hormones may be required as the steroid dose is tapered.
For Grade 3-4 events, treat with an initial dose of IV corticosteroids followed by oral 
corticosteroids. When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks. Replacement of appropriate hormones may be required as 
the steroid dose is tapered.
Hyperthyroidism or Hypothyroidism: 
Thyroid disorders can occur at any time during treatment. 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.
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.
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:
For Grade 2 events, monitor liver function tests more frequently until returned to baseline values 
(consider weekly).
Treat with IV or oral corticosteroids
For Grade 3-4 events, treat with intravenous corticosteroids for 24 to 48 hours. 
When symptoms improve to Grade 1 or less, a steroid taper should be started and continued over 
no less than 4 weeks.
Renal Failure or Nephritis:
For Grade 2 events, treat with corticosteroids.
For Grade 3-4 events, treat with systemic corticosteroids.
When symptoms improve to Grade 1 or less, steroid taper should be started and continued over 
no less than 4 weeks. 


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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 6 above shows treatment guidelines for subjects who experience an infusion reaction associated with 
administration of pembrolizumab (MK-3475).


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Table 6: Infusion Reaction Treatment Guidelines
NCI CTCAE Grade
Treatment
Premedication at 
subsequent dosing
Grade 1
Mild reaction; infusion 
interruption not 
indicated; intervention 
not indicated
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator.
None
Grade 2
Requires infusion 
interruption but 
responds promptly to 
symptomatic treatment 
(e.g., antihistamines, 
NSAIDS, narcotics, IV 
fluids); prophylactic 
medications indicated 
for < =24 hrs
Stop Infusion and monitor symptoms.
Additional appropriate medical therapy may 
include but is not limited to:

IV fluids

Antihistamines

NSAIDS

Acetaminophen

Narcotics
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator.
If symptoms resolve within one hour of stopping 
drug infusion, the infusion may be restarted at 
50% of the original infusion rate (e.g., from 100 
mL/hr to 50 mL/hr).  Otherwise dosing will be 
held until symptoms resolve and the subject 
should be premedicated for the next scheduled 
dose.
Subjects who develop Grade 2 toxicity despite 
adequate premedication should be 
permanently discontinued from further trial 
treatment administration.
Subject may be 
premedicated 1.5h (± 30 
minutes) prior to infusion 
of pembrolizumab (MK-
3475) with:
Diphenhydramine 50 mg 
po (or equivalent dose of 
antihistamine).
Acetaminophen 500-1000 
mg po (or equivalent dose 
of antipyretic).
Grades 3 or 4
Grade 3:
Prolonged (i.e., not 
rapidly responsive to 
symptomatic medication 
and/or brief interruption 
of infusion); recurrence 
of symptoms following 
initial improvement; 
hospitalization indicated 
for other clinical 
sequelae (e.g., renal 
impairment, pulmonary 
infiltrates)
Grade 4:
Life-threatening; pressor 
or ventilatory support 
indicated
Stop Infusion.
Additional appropriate medical therapy may 
include but is not limited to:

IV fluids

Antihistamines

NSAIDS

Acetaminophen

Narcotics

Oxygen

Pressors

Corticosteroids

Epinephrine
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator.
Hospitalization may be indicated.
Subject is permanently discontinued from 
further trial treatment administration.
No subsequent dosing


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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.
5.7. Diet/Activity/Other Considerations
5.7.1. Diet
Subjects should maintain a normal diet unless modifications are required to manage an AE such as diarrhea, 
nausea or vomiting.
5.7.2. Contraception
Pembrolizumab may have adverse effects on a fetus in utero.  Furthermore, it is not known if pembrolizumab 
has transient adverse effects on the composition of sperm.  
For this trial, male subjects will be considered to be of non-reproductive potential if they have azoospermia 
(whether due to having had a vasectomy or due to an underlying medical condition).  
Female subjects will be considered of non-reproductive potential if they are either: 
postmenopausal (defined as at least 12 months with no menses without an alternative medical cause; in 
women < 45 years of age a high follicle stimulating hormone (FSH) level in the postmenopausal range 
may be used to confirm a post-menopausal state in women not using hormonal contraception or hormonal 
replacement therapy. In the absence of 12 months of amenorrhea, a single FSH measurement is 
insufficient.); 
OR 
have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy or bilateral tubal 
ligation/occlusion, at least 6 weeks prior to screening; 
OR 
has a congenital or acquired condition that prevents childbearing.
Female and male subjects of reproductive potential must agree to avoid becoming pregnant or impregnating a 
partner, respectively, while receiving study drug and for 120 days after the last dose of study drug by complying 
with one of the following contraception regimens if sexually active:
 Single method (one of the following is acceptable):
•
intrauterine device (IUD)
•
vasectomy of a female subject’s male partner 
•
contraceptive rod implanted into the skin


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Combination method (requires use of two of the following):
•
diaphragm with spermicide (cannot be used in conjunction with cervical cap/spermicide)
•
cervical cap with spermicide (nulliparous women only)  
•
contraceptive sponge (nulliparous women only) 
•
male condom or female condom (cannot be used together)
•
hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin-only pill), 
contraceptive skin patch, vaginal contraceptive ring, or subcutaneous contraceptive injection
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 subjects of childbearing 
potential must adhere to the contraception requirement (described above) from the day of study medication 
initiation (or 14 days prior to the initiation of study medication for oral contraception) throughout the study 
period up to 120 days after the last dose of trial therapy.  If there is any question that a subject of childbearing 
potential will not reliably comply with the requirements for contraception, that subject should not be entered 
into the study.
5.7.3. Use in Pregnancy
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab, the subject will 
immediately be removed from this study and followed on an alternative hematology branch protocol (eg: 94-
H-0010).  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 IRB 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 IRB and to 
Merck and followed as described section 9.1.3.
5.7.4. 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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5.8. Subject Withdrawal/Discontinuation Criteria
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the discretion of the 
investigator should any untoward effect occur.  In addition, a subject may be withdrawn by the investigator or 
the Sponsor if enrollment into the trial is inappropriate, the trial plan is violated, or for administrative and/or 
other safety reasons.  
5.8.1. Off-Treatment Criteria
A subject must be discontinued from treatment for any of the following reasons:

Unacceptable adverse experiences as described in Section 5.2

Any grade 4 treatment-emergent adverse event

Intercurrent illness that prevents further administration of treatment

The subject has completed 35 cycles of pembrolizumab (ie: induction and continuation phase)

The subject or legal representative (such as a parent or legal guardian) withdraws consent for treatment.

Investigator’s decision to withdraw the subject from treatment
5.8.2. Off-Study Criteria
A subject must be removed from the study for any of the following reasons:

Confirmed disease progression despite at least two cycles of hypomethylating agent therapy and/or four 
doses of pembrolizumab.  For these purposes disease progression is defined as greater than 50% relative 
increase in blasts in the peripheral blood or bone marrow or development of extramedullary disease 
(see Appendix A) at a therapy response assessment time-point (see Appendix G) compared to before 
start of treatment or relapse in those previously in complete remission (mCR/mCRi, CR/CRi).

Patient meets off-treatment criteria but is not eligible, or declines, active surveillance phase

The subject has a confirmed positive serum pregnancy test

Subject becomes significantly noncompliant with study drug administration, study procedures, or 
study requirements, which might increase risk or substantially compromise the interpretation of study 
results.

The subject is lost to follow-up

The subject completes two years on study

Administrative reasons

The subject or legal representative (such as a parent or legal guardian) withdraws consent

Investigator’s decision to withdraw the subject from the study
The end of treatment and follow-up visit procedures are listed in Section 6. 


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The End of Treatment and Follow-up visit procedures are listed in Section 6. After the end of treatment, each 
subject will be followed for 30 days for adverse event monitoring.  Subjects who discontinue for reasons other 
than progressive disease will have post-treatment follow-up for disease status until disease progression, 
initiating another cancer treatment, withdrawing consent or becoming lost to follow-up.  After study withdrawal 
each subject will be offered the opportunity to consent to an alternative hematology branch protocol (eg: 94-H-
0010) to allow follow-up by telephone at approximately three monthly intervals for overall survival until death, 
withdrawal of consent, or the closing of the study protocol, whichever occurs first.
5.9. Optional Continuation Phase after Eight Cycles of Pembrolizumab
As described in section 5.1 this pilot study is intended to offer a total of eight doses of pembrolizumab on every 
three weekly cycles with decitabine given on alternative cycles as initial induction therapy.
In the event that a patient achieves a response of mCR, mCRi, CR, CRi, PR or SD (see Appendix A) at the end 
of cycle 8 assessment then additional cycles of pembrolizumab and decitabine therapy will be offered.  These 
additional cycles will be given according to the same schedule (see section 5.1) with the below exceptions.   
Pembrolizumab in cycle 9 (ie: first cycle of continuation phase) may be delayed up to 7 days to allow post-
induction phase staging to be completed.   No more than 35 cycles (ie: two years) of therapy will be offered. 
Decitabine 20 mg/m2 will be given for not more than ten consecutive days every six weeks and may be 
prescribed and supplied by non-study physician.
5.10.
Subject Replacement Strategy
If a patient discontinues treatment prior to receiving fourth dose of Pembrolizumab, due to patient or 
investigator action/decision, that patient may be replaced with another subject. Maximum accrual will be fifteen 
subjects.
5.11.
Criteria for Early Trial Termination
Early trial termination will be the result of the criteria specified below:

Incidence or severity of adverse drug reaction in this or other studies indicates a potential health hazard 
to subjects.  Please see section 8.0 Biostatistical Considerations for stopping rule calculations. 
6.0
CLINICAL MONITORING  
6.1. Study Evaluations: Screening/Baseline 
Screening: Screening period will consist of the 28 days prior to C1 starting. During this time, patients will 
complete the necessary screening studies and testing.  These will ordinarily be performed, prior to a patient 
signing consent for this protocol, on another screening Hematology Branch protocol (eg: 97-H-0041).
•
Complete medical history 
•
ECOG performance evaluation


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•
Physical exam 
•
Concomitant medication review
•
Complete blood count (CBC) with differential 
•
Acute care & mineral panels (includes Na, K, Cl, CO2, creatinine, glucose, BUN, phosphorus, 
magnesium, albumin, and calcium)
•
Total protein, CK, Uric Acid, and LDH 
•
Hepatic panel (includes alkaline phosphatase, ALT, AST, total bilirubin, and direct bilirubin)
•
Reticulocyte count
•
PT, PTT, fibrinogen
•
Thyroid function tests
•
Type and screen
•
Urinalysis 
•
HLA typing
•
EKG
•
G6PD testing (as clinically indicated)
•
CMV IgG, IgM and PCR 
•
Viral studies (serologies for HIV 1/2, hepatitis B and C). For individuals with a positive hepatitis B 
core antibody, HBV DNA PCR will be performed. 
•
Peripheral blood flow cytometry (AML and T/B/NK). 
•
 For females of childbearing potential, one negative pregnancy tests sensitive to 50 mIU within 72 
hours prior to starting study drug.
•
Baseline non-contrast computerized tomography scans of chest and sinus will be performed prior to, 
or in first five days after treatment initiation. Further baseline imaging will not be routinely performed except 
for those with a history of extra-medullary myeloid disease (also known as granulocytic sarcoma, myeloid 
sarcoma, or chloroma), another malignancy or disease where imaging represents the clinical standard of care, 
or suspicion for extra-medullary myeloid disease or ongoing infection.
Baseline bone marrow aspiration and biopsy
o
Morphology and immunohistochemistry
o
Cytogenetics (karyotype) and/or FISH.
o
AML molecular testing panel (e.g.: c-Kit, FLT3-ITD, NPM1 or CEBPA mutation) 
o
Flow cytometry
6.2. On therapy evaluations during induction phase
Cycles 1-8: before starting each cycle (+/- 3 day window):
The following assessments will be performed prior to each cycle of pembrolizumab. 

Interval History 

ECOG performance status evaluation 

Structured adverse event assessment

Concomitant medication review 

Physical exam

Complete blood count with differential

Acute care & mineral panels (includes Na, K, Cl, CO2, creatinine, glucose, BUN, phosphorus, 
magnesium, albumin, and calcium)

Total protein, CK, Uric Acid, and LDH 

Hepatic panel (includes alkaline phosphatase, ALT, AST, total bilirubin, and direct bilirubin)

Reticulocyte count


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
PT, PTT, fibrinogen

Pregnancy test for females of childbearing potential
6.3. Clinical Assessments
Clinical endpoints on this trial are defined as below:
Table 7:  Clinical Endpoints
Outcome
Included 
Patients
Point of 
Measurement
Definition
Feasibility
All
Interim 
Analysis/Safety 
Follow-Up Visit
(see Section 6.5.1)
Descriptive summary of all adverse events (number, severity 
and duration of adverse events) according to NCI-Common 
Terminology Criteria for Adverse Events (CTCAE) v4.0
Efficacy
All
Following cycles 
2, 4, 6, 8 and at 
progression/off-
study time-point
Descriptive summary of conventional response criteria as 
described in Appendix A.  In addition any clinical information 
regarding MRD status (eg: flow cytometry, cytogenetics, 
PCR) will be captured at these time-points. 
Time to first 
response
Responders
(mCR, mCRi,, 
CR, CRi, PR)
As above
Defined as time from start of study to initial achievement of 
first response.
Time to best 
response
As above
As above
Defined as time from start of study to initial achievement of 
best response.
Duration of 
response
As above
As above
Defined as time from initial achievement of response to loss 
of response.
Duration of 
best response
As above
As above
Defined as time from initial achievement of best response to 
loss of best response. 
Overall 
survival
All
Entry onto trial
Death from any cause
Bone marrow examinations for clinical response assessment will be performed pre-treatment and after 
cycles 2, 4, 6 and 8 (or the progression/off-study time-point).    Bone marrows after cycles 2, 4, 6 and 8 may 
be performed anytime in the week prior to the next cycle of Pembrolizumab (ie: the “after cycle 2” marrow 
may be performed prior to the pembrolizumab dose on day 1 of cycle 3 or anytime in the preceding week).  
Assessments will include clinical pathological assessment by morphology, flow cytometry and cytogenetics.  
An additional bone marrow for research purposes may be performed on or around day 8 of cycle 1. Additional 
bone marrows may be done after cycle 8, until progression as clinically indicated.
6.4. On therapy evaluations during optional continuation phase 
Patients treated on the continuation phase will ordinarily be evaluated, including Structured adverse event 
assessment, as described in section 6.2, every 4 cycles (ie: every 12-13 weeks).


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6.5. Post-Induction Treatment Follow-Up
6.5.1. Safety Follow-Up Visit (SFV)
The mandatory Safety Follow-Up Visit should be conducted after the eighth cycle of treatment (ie: end of 
induction phase), or (for patients discontinuing therapy prior to this point) approximately 30 days after the last 
dose of trial treatment or before the initiation of a new anti-cancer treatment, whichever comes first.  All AEs 
that occur prior to this Safety Follow-Up Visit should be recorded.  Subjects with a persistent treatment related 
AE will be followed until the resolution of the AE or until the beginning of a new anti-neoplastic therapy, 
whichever occurs first. No new adverse event information will be collected after this safety follow-up visit. 
6.5.1. Post-Treatment Active Surveillance Phase
Subjects who discontinue trial treatment in a complete remission or partial remission (mCR/mCRi/ CR/CRi/PR, 
see Appendix A) at the time of the safety follow-up visit will remain as a subject of this protocol but move into 
the Active Surveillance Phase and will be assessed every 1-3 months for up to two years (from the start of 
treatment) according to the NCCN consensus guidelines.  This phase will continue until the start of new anti-
neoplastic therapy, disease progression, death or end of the study at which point a subject would go off study 
and enter the post-study follow up stage.
6.5.2. Off Study Visit (all patients)
Subjects who meet off-study criterion listed above (Section 5.8) will be assessed in a final office study visit and 
referred back to his or her referring physician, consented to the Hematology Branch evaluation and treatment 
protocol (94-H-0010) for consideration for standard therapy or evaluated for eligibility for another branch 
protocol, depending on what is considered to be in the best interest of the subject.  Such subjects will, where 
possible, enter the post-study follow-up stage (below).  For those who come off study in the first eight cycles 
this may also serve as the safety follow-up visit (see 6.5.1 above).
6.5.3. Post-study follow-up stage (all patients)
After the end of treatment, each subject will be followed for 30 days for adverse event monitoring.  After a 
subject completes the study they will be offered the opportunity to consent to an alternative hematology branch 
protocol  (eg: 94-H-0010) to allow follow-up contact, ordinarily by telephone, approximately every 13 weeks 
to assess for remission and survival status until death, withdrawal of consent, or the end of the study, whichever 
occurs first. 
7.0
LABORATORY RESEARCH SAMPLES
7.1. Collection of Research Samples 
Peripheral Blood samples: Volume collected for clinical and research purposes will not exceed 550 ml during 
any 8-week period.  
Leukapheresis: A 4-5 liter leukapheresis procedure for research may be obtained prior to initiating therapy, 
and/or at the completion of the study, in consenting subjects. 
Bone marrow biopsies and aspirate: Bone marrow biopsy and up to 25 mls of BM aspirate may be obtained 
for research at the time of the BM biopsy as described in Section 6.3. 
Tissue for germline sequencing:  A non-invasive buccal cheek swab and/or saliva samples may be collected.  
A skin punch biopsy may also be collected at the end of treatment.
Please see Appendix E for time-points where research samples are anticipated to be collected. Research blood 
collection at each of these time points is not obligatory and may be cancelled or reduced at the discretion of the 


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investigator on clinical and/or research grounds.  Additional research samples may be collected at time of 
clinical event subject to the limits described above.
7.2. Research Testing
All or a selection of the following laboratory studies will be performed:

Detection, quantification and characterization of protein, carbohydrate and/or lipid biomarkers.

Evaluation of gene expression in unsorted and sorted biologic samples (e.g.: blood and marrow).

Evaluation of protein expression in unsorted and sorted biologic samples.

Evaluation of gene variants and mutations in unsorted and sorted biologic samples.

Determination of epigenetic, histone and chromatin modifications. 

Evaluation of cellular phenotype in unsorted and sorted biologic samples.

Evaluation of cellular function in unsorted and sorted biologic samples.

Use of biologic samples to develop, test, and validate novel therapeutic agents.

Use of biologic samples to develop, test, and validate surrogate predictive and prognostic markers 
of disease behavior.
A variety of molecular biology techniques including real-time quantitative PCR and sequencing of both 
DNA and RNA will be performed on research samples.  Sequencing may involve single cell sanger 
sequencing, targeted panels, exome or genome level sequencing of sorted and unsorted biological samples 
(including from those enriched for tumor, and those predominantly tumor-free).
 
All the above laboratory studies are investigational.  Studies described in Appendix D: NHLBI Hematology 
Branch Laboratory Research Studies may also be performed. 
 
Sequencing results performed in a CLIA certified laboratory and ordered for a clinical indication as 
described in Section 6 will be returned to patients. If in the course of research analysis of whole 
genome/exome sequencing a gene variant of medical importance is found, the investigator will return to 
the IRB to discuss the next steps.
8.0
BIOSTATISTICAL CONSIDERATIONS
8.1. Primary statistical hypothesis
The primary statistical hypothesis is that pembrolizumab and decitabine can be co-administered safely in non-
HSCT relapsed or refractory patients.
8.2. Sample size
The sample size is 10 patients. This is a pilot study.
8.3. Statistical safety monitoring 
Given that the primary hypothesis is for feasibility, we will monitor the progress of the patients in the study. 
Following Geller et. al.26, we use a Bayesian stopping rule for safety. For a given patient the safety endpoint is 
defined as grade 4 or 5 treatment related adverse event (excluding hematological toxicity, see section 9.1.2). 
This endpoint encompasses causes of death and severe toxicity from pembrolizumab and/or decitabine therapy 
during the induction phase (eight cycles) and, as such, is a suitable safety endpoint.  Before the data are 


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collected, we assume that the prior distribution of the proportion of patients who will experience the safety 
endpoint follows a beta distribution. We combine the beta prior and the proportion data to form a beta posterior.
We anticipate the rate of treatment-related toxicities and deaths within the study period to be 50% or less. Since 
the proportion is a realization of a beta distribution, the proportion parameter is not a fixed quantity but a random 
variable. We assume the prior mean to be 0.3, and our prior knowledge is “worth” two patients. The conditions 
are satisfied where we set a=0.6 and b=1.4 for the beta distribution. Note that a+b is interpreted as the measure 
of contribution of the prior distribution. The subjective contribution of two patients, added to the sample of ten 
patients, is quite modest and does not exert undue influence on the data characteristics. 
We set the stopping boundary for the event that the posterior probability, given accruing data, exceeds 0.8 when 
the posterior proportion of the specified events is greater than 0.5. That is, Prob(p>0.5|data)>0.8. The resulting 
boundaries are shown in the Table 8 below.
No. Patients
Stop if toxicities 
reaches or exceeds
Posterior 
Probability
3
3
0.86
5
4
0.81
7
5
0.78
8
6
0.86
10
7
0.83
We evaluated the performance of this stopping rule with computer simulations. In each simulation we generated 
a study with 10 independent Bernoulli trials, each with prior proportion p for having toxicity and compared the 
outcome with the stopping boundary. We repeated the simulation 100,000 times and counted the number of 
times the study was stopped. We did this for a number of different prior proportions to investigate whether our 
benchmark of 0.5 is appropriate (Table 9 below).
Proportion 
of SAE=p
0.2
0.35
0.5
0.65
0.8
Proportion 
of Stopped 
Studies
1.36%
9.74%
31.77%
64.73%
92.33%
Average 
number of 
subjects
9.92
9.49
8.44
6.76
4.83
Average 
number 
toxicities
1.99
3.33
4.22
4.39
3.86
These results suggest our stopping rule has a low probability of stopping a study when the proportion of 
toxicities is below the benchmark value of 50% toxicities is high when above this cut off.


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8.4. Exploratory analyses
Given the size of the data, other analyses will be descriptive in nature and used to aid future research.
9.0
DATA AND SAFETY MONITORING
Principal Investigator: Accrual, efficacy and safety data will be monitored by the principal investigator Dr. 
Christopher S. Hourigan.
NHLBI’s IRB:  Prior to implementation of this study, the protocol and the proposed patient consent and assent 
forms will be reviewed and approved by the properly constituted Institutional Review Board (IRB) operating 
according to 45 CFR 46. Quality assurance and control monitoring will be consistent with the NHLBI Division 
of Intramural Research Clinical Research Quality Assurance and Quality Control Policy.
NHLBI DSMB:  The NHLBI Data And Safety Monitoring Board (DSMB) will review the protocol, progress 
report, accrual, efficacy and safety data at six- or twelve-month intervals as scheduled.  All AEs and SAEs 
observed during the clinical trial and for which there is a relationship with the use of pembrolizumab and/or 
decitabine, or the conduct of the study will be reported to the DSMB at the regularly scheduled DSMB meeting. 
The DSMB may recommend early termination of the study for considerations of safety and efficacy. 
Merck: Merck will approve all amendments to the protocol or informed consent prior to submission to the IRB 
and conduct continuing annual review so long as the protocol is open to accrual or sample and/or data analysis 
continues.  Accrual and safety data will also be monitored and reviewed annually by the IRB. An annual 
progress report, any amendments to the protocol, and any change in the status of the protocol will be forwarded 
to Merck Global Safety facsimile number: +1-215-993-1220.
FDA: An annual progress report, any amendments to the protocol, and any change in the status of the protocol 
will be forwarded by the Sponsor to FDA to:  
Center for Drug Evaluation and Research
Food and Drug Administration
Division of Hematology Products
Office of Hematology Oncology Products
5901 B Ammendale Road
Beltsville, MD 20705-1266
9.1. Assessment of safety
Definitions
For definitions please refer to policy 801 “Reporting Research Events”.
Adverse event (AE):  Any untoward medical occurrence in a human subject, including any abnormal sign 
(e.g., abnormal physical exam or laboratory finding), symptom, or disease, temporally associated with the 
subject’s participation in the research, whether or not considered related to the subject’s participation in the 
research. An abnormal laboratory value will be considered an AE if the laboratory abnormality is 
characterized by any of the following:
Results in discontinuation from the study
Is associated with clinical signs or symptoms
Requires treatment or any other therapeutic intervention


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Is associated with death or another serious adverse event, including hospitalization
Is judged by the Investigator to be of significant clinical impact
If any abnormal laboratory result is considered clinically significant, the investigator will provide 
details about the action taken with respect to the test drug and about the patient’s outcome.
Serious adverse event (SAE):  An event is serious if it meets the definition of a SAE as follows, or if it 
requires immediate corrective action by a PI and/or IRB to protect the safety, welfare or rights of subjects;
Results in death
Is life-threatening (places the subject at immediate risk of death from the event as it occurred)
Results in in-patient hospitalization or prolongation of existing hospitalization
Results in a persistent or significant incapacity
Results in a congenital anomaly/birth defect
Based upon appropriate medical judgment, may jeopardize the subject’s health and may require 
medical or surgical intervention to prevent one of the other outcomes listed in this definition
Suspected adverse reaction: Suspected adverse reaction means any AE for which there is a reasonable 
possibility that the drug caused the AE. For the purposes of IND safety reporting, ‘reasonable possibility’ 
means there is evidence to suggest a causal relationship between the drug and the adverse event. A 
suspected adverse reaction implies a lesser degree of certainty about causality than adverse reaction, which 
means any AE caused by a drug.
Unexpected adverse reaction: An AE or suspected adverse reaction is considered “unexpected” if it is not 
listed in the investigator brochure or is not listed at the specificity or severity that has been observed; or, if 
an investigator brochure is not required or available, is not consistent with the risk information described in 
the general investigational plan or elsewhere in the current application. "Unexpected”, also refers to adverse 
events or suspected adverse reactions that are mentioned in the investigator brochure as occurring with a 
class of drugs or as anticipated from the pharmacological properties of the drug, but are not specifically 
mentioned as occurring with the particular drug under investigation.
Unanticipated problem (UP):  Any incident, experience, or outcome that meets all of the following criteria:
1. Unexpected in terms of nature, severity, or frequency in relation to
a.  the research risks that are described in the IRB-approved research protocol and informed consent 
document; Investigator’s Brochure or other study documents; and
b. the characteristics of the subject population being studied; and
2. Related or possibly related to participation in the research; and
3.  Places subjects or others at a greater risk of harm (including physical, psychological, economic, or 
social harm) than was previously known or recognized.
UP that is not an AE:  An unanticipated problem that does not fit the definition of an AE, but which may, in 
the opinion of the investigator, involves risk to the subject, affect others in the research study, or 


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significantly impact the integrity of research data.  For example, report occurrences of breaches of 
confidentiality, accidental destruction of study records, or unaccounted-for study drug.
Protocol deviation (PD):  Any change, divergence, or departure from the IRB approved research protocol.
Non-compliance: The failure to comply with applicable NIH HRPP policies, IRB requirements, or 
regulatory requirements for the protection of human research. Noncompliance may be further characterized 
as:
1. Serious non-compliance: Non-compliance that:
a. Increases risks, or causes harm, to participants
b. Decreases potential benefits to participants
c. Compromises the integrity of the NIH HRPP
d. Invalidates the study data
2. Continuing non-compliance: Non-compliance that is recurring. An example may be a pattern of non-
compliance that suggests a likelihood that, absent an intervention, non-compliance will continue. 
Continuing noncompliance could also include a failure to respond to IRB requests to resolve previous 
allegations of non-compliance.
3. Minor (non-serious) non-compliance: Non-compliance that, is neither serious nor continuing.
Safety assessments will consist of monitoring and recording AEs and SAEs; measurements of protocol-
specified hematology, clinical chemistry, and other laboratory variables; measurement of protocol-specified 
vital signs; and other protocol-specified tests that are deemed critical to the safety evaluation of the study 
drug.
9.1.1.  Timing
The AE reporting period for this study begins when the patient takes the first dose of study drug and ends with 
the safety follow-up visit. If an SAE is present at the safety follow-up visit or within 30 days of the last dose of 
study drug (whichever is later), it should be followed to resolution or until the Investigator assesses the subject 
as stable, a new anticancer therapy is initiated, or the subject is lost to follow-up or withdraws consent. 
Resolution/stable means the subject has returned to baseline state of health or the Investigator does not expect 
any further improvement or worsening of the event.  
All adverse events will be recorded at each examination on the Adverse Event case report forms/worksheets 
from the time the consent form is signed through the safety follow-up visit. 
9.1.2. Severity
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse 
Events (CTCAE) version 4.03 will be utilized for grading the severity (intensity) of non-hematologic AEs 
(http://ctep.cancer.gov/reporting/ctc.html). 
Given the pathobiology of Acute Myeloid Leukemia, severe blood count abnormalities (up to grade 4 levels in 
leukocytes, neutrophils, lymphocytes, red blood cells and platelets) are expected and may be present at baseline.  
Thus we will record these values in the protocol database, but will not report these abnormalities as adverse or 
serious adverse events unless the grade of toxicity (based on NCI-Common Terminology Criteria for Adverse 
Events, CTCAE v4.0) is grade 4 or above and was not present at baseline.  If the myelosuppressive event is 
fatal (Grade 5), or if the Investigator finds the event to be medically important, then it will be collected as an 
SAE.


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9.1.3.  Pregnancy
         
A patient will be advised to immediately inform the investigator if the patient or patient’s partner becomes 
pregnant from the time of consent to 120 days of completing the trial completing the trial, or 30 days following 
cessation of treatment if the subject initiates new anticancer therapy, whichever is earlier. If a subject 
inadvertently becomes pregnant while on treatment with the study regimen, 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. 
Although pregnancy and lactation are not considered AEs, it is the responsibility of investigators or their 
designees to report any pregnancy or lactation in a subject (spontaneously reported to them), including the 
pregnancy of a male subject's female partner that occurs during the trial. Abortion, whether therapeutic, elective 
or spontaneous, will be reported as an SAE, which includes pregnancy outcomes of spontaneous abortion, 
missed abortion, benign hydatidiform mole, blighted ovum, fetal death, intrauterine death, miscarriage and 
stillbirth. If the pregnancy continues to term, the outcome (health of infant) must also be reported. 
The outcome of the pregnancy will be reported 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).  Such events must be 
reported to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220).
9.1.4. Causality assessments
The following general guideline will be followed:
Table 10: Causality Assessment Guideline
Unrelated
Another cause of the AE is more plausible; a temporal sequence cannot be established 
with the onset of the AE and administration of the investigational product; or, a causal 
relationship is considered biologically implausible.
Unlikely to be 
Related:
A temporal sequence with the onset of the adverse event and administration of the 
investigational product is improbable, but not impossible. Concurrent or underlying 
disease, or the use of other drugs or procedures provide plausible explanations for the 
adverse event.
Possibly Related
There is a clinically plausible time sequence between onset of the AE and administration 
of the investigational product, but the adverse event could also be attributed to concurrent 
or underlying disease, or the use of other drugs or procedures. Possibly related should be 
used when the investigational product is one of several biologically plausible adverse 
event causes.
Probably Related:
There is a clinically plausible time sequence between onset of the adverse event and 
administration of the investigational product, and the adverse event is unlikely to be 
attributed to concurrent or underlying disease, or the use of other drugs or procedures. 
Clinical response to withdrawal of the investigational product may indicate the adverse 
event is probably related. Rechallenge with the investigational drug is not required.
Definitely 
Related
The AE is clearly related to use of the investigational product.
9.2. Documentation 
Investigators will assess the occurrence of AEs and SAEs at all patient evaluation time points during the study.  
There are ten scheduled patient evaluation time-points; at baseline, after cycles 1-8 and at the safety follow-up 
visit (see also Appendix G).   In addition, all AEs and SAEs whether volunteered by the patient, discovered by 
study personnel during questioning, or detected through physical examination, clinically significant laboratory 
test, or other means will be recorded in the patient’s medical record.


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9.3. NIH-IRB and Clinical Director Reporting
Expedited Reporting 
Events requiring expedited reporting will be submitted to the IRB per Policy 801 “Reporting Research 
Events”. 
Reports to the IRB at the time of Continuing Review: 
The PI or designee will refer to HRPP Policy 801 “Reporting Research Events” to determine IRB reporting 
requirements. 
Reports to the CD: 
The PI or designee will refer to NHLBI DIR guidelines to determine CD reporting requirements and 
timelines.
9.4. Company Reporting
Reports to Merck:
A SAE is any AE occurring at any dose or during any use of Merck’s product that:

Results in death;

Is life threatening;

Results in persistent or significant disability/incapacity;

Results in or prolongs an existing inpatient hospitalization;

Is a congenital anomaly/birth defect;

Is a new cancer (that is not a condition of the study);

Is associated with an overdose;

Is an other important medical event 
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 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. 
Additionally, any SAE, considered by an investigator who is a qualified physician to be related to Merck 
product that is brought to the attention of the investigator at any time outside of the time period specified in the 
previous paragraph also must be reported immediately to the Sponsor and to Merck.
SAE reports and any other relevant safety information are to be forwarded to the Merck Global Safety 
facsimile number:  +1-215-993-1220
A copy of all 15 Day Reports and Annual Progress Reports is submitted as required by FDA, European Union 
(EU), Pharmaceutical and Medical Devices agency (PMDA) or other local regulators. Investigators will cross-
reference this submission according to local regulations to the Merck Investigational Compound Number (IND, 
CSA, etc.) at the time of submission.  Additionally investigators will submit a copy of these reports to Merck 
& Co., Inc. (Attn: Worldwide Product Safety; FAX 215 993-1220) at the time of submission to FDA.
All subjects with serious adverse events must be followed up for outcome.
Non-serious Events of Clinical Interest will be forwarded to Merck Global Safety and will be handled in the same 
manner as SAEs.


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9.5. FDA Reporting Criteria
9.5.1.  IND Safety Reports to the FDA (Refer to 21 CFR 312.32)
The Sponsor will notify the FDA of any unexpected fatal or life-threatening suspected adverse reactions 
as soon as possible but no later than 7 calendar days of initial receipt of the information using the 
MedWatch Form 3500a or other permitted method.
The Sponsor is also responsible for reporting any: 

suspected adverse reaction that is both serious and unexpected

any findings from clinical, epidemiological, or pooled analysis of multiple studies or any findings from 
animal or in vitro testing that suggest a significant risk in humans exposed to the drug

clinically important increase in the rate of a serious suspected adverse reaction over that listed in the 
protocol or investigator brochure to the FDA and to all investigators no later than 15 calendar days after 
determining that the information qualifies for reporting using the MedWatch Form 3500a. If FDA 
requests any additional data or information, the sponsor must submit it to the FDA as soon as possible, 
but no later than 15 calendars days after receiving the request.
9.5.2.  FDA Annual Reports (Refer to 21 CFR 312.33)
The study Sponsor will submit a brief report annually of the progress of the trial within 60 days of the 
anniversary date that the IND went into effect as indicated in 21CFR 312.33, and any associated FDA 
correspondences regarding the IND annual report.
9.6. Events of Clinical Interest
Selected non-serious and serious AEs are also known as Events of Clinical Interest (ECI) and must be recorded 
as such on the AE case report forms/worksheets and reported within 24 hours to the Sponsor and within 2 
working days to Merck Global Safety (Attn: Worldwide Product Safety; FAX 215 993-1220). Events of clinical 
interest for this trial include:
Overdose: An overdose of pembrolizumab is 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 AE is associated with the overdose of pembrolizumab, the AE is reported as a serious adverse event, even 
if no other seriousness criteria are met.
If a dose pembrolizumab 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 ECI, using the terminology 
“accidental or intentional overdose without adverse effect.”
All reports of overdose with and without an adverse event must be reported within 24 hours to the Sponsor and 
within 2 working days hours to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220)
Elevation of AST, ALT, bilirubin, alkaline phosphatase: An elevated AST or ALT lab value that is greater 
than or equal to 3X the upper limit of normal (ULN) and an elevated total bilirubin lab value that is greater than 
or equal to 2X the ULN and, at the same time, an alkaline phosphatase lab value that is less than 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).
Additional adverse events: A separate guidance document has been provided entitled “Event of Clinical Interest 
Guidance Document” (previously entitled, “Event of Clinical Interest and Immune-Related Adverse Event 
Guidance Document”).  This document can be found in Appendix C and provides guidance regarding 
identification, evaluation and management of ECIs and immune-related AEs.  
ECIs (both non-serious and serious adverse events) identified in this guidance document from the date of first 
dose through 90 days following cessation of treatment, or 30 days after the initiation of a new anticancer 
therapy, whichever is earlier, need to be reported within 24 hours to the Sponsor and within 2 working days to 
Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220), regardless of attribution to study 
treatment, consistent with standard SAE reporting guidelines.
Subjects should be assessed for possible ECIs prior to each dose.  Lab results should be evaluated and subjects 
should be asked for signs and symptoms suggestive of an immune-related event.  Subjects who develop an ECI 
thought to be immune-related should have additional testing to rule out other etiologic causes.  If lab results or 
symptoms indicate a possible immune-related ECI, then additional testing should be performed to rule out other 
etiologic causes.  If no other cause is found, then it is assumed to be immune-related.
9.7. Protocol Amendments
Per the IST Agreement, any amendments to the protocol or informed consent form must be sent to Merck for 
review and approval prior to submission to the IRB.  Written verification of IRB approval will be obtained 
before any amendment is implemented.  Amendments that might change reporting criteria will be submitted to 
the FDA. 
9.8. Publication Policy
Given the research mandate of the NIH, patient data including the results of testing and responses to treatment 
will be entered into an NIH-authorized and controlled research database. Any future research use will occur 
only after appropriate human subject protection institutional approval such as prospective NIH IRB review and 
approval or an exemption from the NIH Office of Human Subjects Research Protections (OHSRP). In addition 
to publication of primary pre-specified analysis once all subjects have completed or been removed from 
induction therapy stage (ie: 6mos), and also later at the 1 and 2 year since the start of treatment landmarks, 
given the pilot nature of this exploratory study interim analysis may also be performed and published for 
individual patients at other timespoints, for example in cases of exceptional response or notable toxicity.
Per the IST Agreement, the Investigator is required to submit to Merck a copy of a planned publication (abstract, 
poster, oral presentation or manuscript) prior to the submission thereof for publication or disclosure.  Merck 
may provide scientific comments and suggestions understanding that the Investigator has sole editorial 
responsibility, and retains the authority to make the final determination on whether or not to incorporate Merck 
comments or requests for additional information.
9.9. Protocol Monitoring 
As per ICH-GCP 5.18 and FDA 21 CFR 312.5 clinical protocols are required to be adequately monitored by 
the study sponsor. The monitoring of this study will be conducted by Clinical Research Associates 
(CRAs)/Monitors working under an agreement with NHLBI to monitor aspects of the study in accordance with 
the appropriate regulations and the approved protocol. The objectives of a monitoring visit will be: 1) to verify 
the existence of signed informed consent form (ICF) and documentation of the ICF process for each monitored 
subject; 2) to verify the prompt and accurate recording of all monitored data points, and prompt reporting of all 
SAEs; 3) to compare abstracted information with individual subjects’ records and source documents (subject’s 


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charts, laboratory analyses and test results, physicians’ progress notes, nurses’ notes, and any other relevant 
original subject information); and 4) to help ensure investigators are in compliance with the protocol. The 
monitors also will inspect the clinical site regulatory files to ensure that regulatory requirements (Office for 
Human Research Protections-OHRP), FDA and applicable guidelines (ICH-GCP) are being followed. During 
the monitoring visits, the investigator (and/or designee) and other study personnel will be available to discuss 
the study progress and monitoring visit.
The investigator (and/or designee) will make study documents (e.g., consent forms and pertinent hospital or 
clinical records readily available for inspection by the local IRB, the FDA, the site monitors, and the NHLBI 
staff for confirmation of the study data.
10.0
BIOSPECIMEN AND DATA MANAGEMENT PLAN
10.1.
Storage 
All samples will be stored in the laboratory of Dr. Hourigan. Collected samples will be coded prior to storage 
in the laboratory of the principal investigator following current NHLBI DIR BSI Policy. 
Efforts to ensure protection of patient information include;

Each sample is assigned a unique code. 

An electronic database is used to store patient information related to the coded samples 

The laboratory is located in a controlled access building and laboratory doors are kept locked. 
Visitors to the laboratory are required to be accompanied by laboratory staff at all times.  

Hard copy records or electronic copies of documents containing patient information are kept in 
the locked laboratory or other controlled access locations.  
10.2.
Tracking 
Samples will be ordered and tracked through the CRIS Research Screens.  Should a CRIS screen not be 
available, the NIH form 2803-1 will be completed and will accompany the specimen and be filed in the medical 
record.  Samples will not be sent outside NIH without IRB notification and an executed MTA or CTA. 
10.3.
End of study procedures  
Samples from consenting subjects will be stored until they are no longer of scientific value or if a subject 
withdraws consent for their continued use, at which time they will be destroyed. Data will be stored in locked 
cabinets and in a password protected database until it is no longer of scientific value. Upon completion of the 
data analysis, the investigator will send to Merck a copy of the de-identified data set and final Clinical Study 
Report as requested.  
10.4.
Loss or destruction of samples or data  
Should we become aware that a major breech in our plan for tracking and storage of samples or data has 
occurred, the IRB will be notified.
10.5.
Biospecimen Management
Specimens and their derivatives (e.g., genomic material, cell lines) will be coded and stored in conformity with 
DIR Policy (e.g., BSI). Coded biospecimens may be sent to collaborators outside of the NIH with IRB approval 


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in accordance with applicable NIH and DIR Policy for sharing research resources, including an executed 
material transfer agreement. Biospecimens with subject personal identifiers may be sent to associate 
investigators and collaborators outside of the NIH only after approvals of both NHLBI and local IRBs, an 
executed reliance agreement with NHLBI’s IRB, or an extension of the NIH’s FWA through an Individual 
Investigator Agreement.
10.6.
Data Management 
The principal investigator will be responsible for overseeing entry of data into an in-house password protected 
electronic system and ensuring data accuracy, consistency and timeliness. The principal investigator, associate 
investigators/research nurses and/or a contracted data manager will assist with the data management efforts to 
ensure that data is verifiable and evaluable. Data will be abstracted from Clinical Center progress notes as well 
as from progress notes forwarded from the subjects’ home physician. Laboratory data from NIH will be 
imported electronically from CRIS into an in-house clinical trial database. Laboratory values from referring 
home physicians will be entered into the system. 
We will maintain the confidentiality of identifiable private information collected in this Clinical Trial and 
protect the privacy of the individual human subjects. Primary data containing individually identifiable 
information obtained during the conduct of the protocol will be kept in secure network drives or in approved 
alternative sites that comply with NIH information security standards. Neither individual personal identifiers 
nor the key linking coded data to individuals will be released to Merck without prior IRB approval and an 
executed CDA or MTA. Identifiable data will not be sent outside NIH without prior IRB approval or appropriate 
conditions for disclosure outlined in the executed CDA or MTA.
10.7.
Data sharing and future use of data 
Research data may be shared with qualified non-collaborator recipients following publication of the primary 
research results after removal of PII and IRB approval.  Future research use of data not defined in the research 
protocol may occur only after IRB review and approval or an exemption from the NIH Office of Human 
Subjects Research Protections (OHSRP).  Refusal of a research subject participant to permit future use of data--
other than required in the protocol or by the FDA--will be honored.  Limitations in data sharing and future use 
of data due to contractual obligations (e.g., CRADAs) or intellectual property proceedings (such as patent 
filings) will be honored.
10.8.
Future use of biospecimens 
Following analyses of biospecimens for primary research purposes, remaining samples suitable for future 
research will be stored in manner that conforms with DIR policy (such as BSI) or in a publicly accessible 
research biospecimen repository following IRB or OHSRP approval, as applicable. Biospecimens may be 
destroyed only when permitted by the clinical director and the IRB.
Any future research use of biospecimens not defined in the protocol in which NHLBI investigators are engaged 
in research (e.g., they are undertaking research activities and hold the key that identifies research subjects) 
requires IRB review and approval. Coded biospecimens (NHLBI investigators hold the key that identifies 
research subjects) to be shared outside of NIH for future research use requires IRB review and approval (for 
research collaborations) or submission of a determination to OHSRP (for non-collaborative research), and an 
executed transfer agreement. Unlinked biospecimens (no key to identify research subjects exists) to be shared 
outside of NIH for future research use requires submission of a determination to OHSRP and an executed 
transfer agreement. There are a few types of biospecimens that do not require IRB or OHSRP approval for 
future research use outside of NIH, such as specimens from deceased individuals (refer to OHSRP SOP5, 
Appendix 1 for complete list); an executed transfer agreement is required in these special cases.  Refusal of a 


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research subject participant to allow for future use of identifiable biospecimens--other than required in the 
protocol or for appropriate regulatory purposes, e.g., by the FDA--will be honored.
11.0
HUMAN SUBJECT PROTECTION 
The investigator(s) accept their responsibilities for protecting the rights and welfare of human research subjects 
and will permit, with reasonable advance notice and at reasonable times, the designated research monitors to 
monitor the conduct of the research, as well as to audit source documents to the extent necessary to verify 
compliance with FDA Good Clinical Practice and the approved protocol.
11.1.
Rationale for subject selection
11.1.1. Predicted distribution by gender, age and race
AML is a rare neoplasm and is generally a disease of older adults with an average age at diagnosis of 67 years 
old.  Epidemiologic studies suggest that the male: female ratio is approximately 5:3. The disease can occur in 
all races, with the highest incidence in non-Hispanic whites while Hispanic whites, blacks and Asian Pacific 
Islanders have a lower incidence. This study will be open to all patients who fit the inclusion criteria and provide 
informed consent to protocol participation. We would predict that distribution should be comparable to that 
seen on the NHLBI Hematology Branch screening protocol as follows: 

by gender: 33% females; 66% males

by age: ages 23-79, median 60  

by race: 2% Asian, 11% Black, 8% Hispanic, 79% White
11.1.2. Special Populations: 
Justification for inclusion of patients with relapsed/refractory AML:  The survival rates for those with 
relapsed or refractory AML are dismal and the majority of such patients, despite best available treatment, will 
die of their disease. Pembrolizumab is a promising immunotherapy agent now recently FDA-approved for the 
treatment for melanoma and NSCLC. There is some pre-clinical evidence that pembrolizumab may have 
activity in leukemia patients.   We believe the combination described in this trial has potential for benefit in this 
population poorly served by current treatments.
Justification for exclusion of children: Patients under the age of 18 years are excluded from this study, as 
inclusion of an occasional younger patient will not provide generalizable information that would justify their 
inclusion on this study. 
Justification for exclusion of pregnant women:  Pregnant women or breastfeeding women are not eligible for 
inclusion in this study. Women who are pregnant and have AML are optimally managed in leukemia centers 
with on-site high-risk obstetrics unit support. Should a patient become pregnant while on study an attending 
investigator on this study will counsel the patient, discussing any risks of continuing the pregnancy, any possible 
effects on the fetus and risk to the patient of stopping therapy. Pregnancy in a subject receiving chemotherapy 
will be reported to the IRB within 24 hours. 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.   
There are no clinical studies in pregnant women, and it is unknown whether decitabine, pembrolizumab or their 
metabolites are excreted in human milk.  
Justification for Exclusion of patients with impaired hepatic or renal function: No specific clinical studies 
have been conducted to date in patients with impaired hepatic or renal function. To minimize risks, patients 
enrolled must have adequate hepatic and renal function as defined in eligibility and exclusion criteria.


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Those unable to consent: Subjects must be able to provide informed consent, and understand and comply with 
the treatment plan and follow-up in accordance with NIH SOP 14E - Research Involving Adults Who Are or 
May Be Unable to Consent”.
Recruitment: The study will be listed on the clinicaltrials.gov, Clinical Center research studies and the National 
Heart, Lung and Blood Institute patient recruitment websites.  If recruitment goals are not met recruitment plans 
will be developed by the Clinical Center Office of Patient Recruitment. 
Payment for participation: Subjects will not be compensated for their participation in this study. 
There is no payment for the biological samples obtained for research.
Reimbursement for protocol participation travel, food, and lodging will be consistent with NIH and NHLBI 
guidelines.  
Competition with other Branch or NIH protocols: This pilot study will be one of only two active treatment 
protocols for patients with relapsed/refractory AML at the NIH clinical center.  Both clinical protocols will be 
conducted by the Myeloid Malignancies Section and have the same Principal Investigator.  This small pilot trial 
will have priority in the event that a patient is eligible for both protocols. 
 
11.2.
Risks and discomforts
11.2.1. Risks related to pembrolizumab
Guidelines for supportive management of adverse event of clinical interest appear in Section 5.6.
Cardiac 
Pericarditis was identified in only 1 subject. The event was identified as serious, Grade 3, and was considered 
by the Investigator to be drug-related.
Colitis
Out of a total of 1562 subjects, colitis was identified in 21 subjects (1.3%), of which 16 (1.0%) were considered 
drug related. Serious colitis were identified in 0.9% of subjects. 0.6% were considered to have serious colitis 
related to the drug by investigators. Concomitant corticosteroid can be used to manage colitis. A high initial 
dose of corticosteroids was used in 12 subjects, while a low initial dose of corticosteroids was used in 2 subjects. 
Dermatologic 
Skin changes include pruritus, rash, rash generalised, rash maculo-papular, dermatitis exfoliative, toxic 
epidermal necrolysis, erythema multiforme, Stevens-Johnson syndrome, acute generalized exanthematous 
pustulosis, dermatitis bullous, dermatitis exfoliative generalised, epidermal necrosis, exfoliative rash, skin 
necrosis, toxic skin eruption, acquired epidermolysis bullosa,epidermolysis, and mucocutaneous ulceration. Out 
of a total of 1562 subjects, skin changes were identified in 20 subjects (1.3%), of which 15 (1.0%) were 
considered drug related. Serious events were identified in 0.4% of subjects, and serious events were considered 
by the Investigators to be drug related were identified in 0.2% of subjects overall.
Hematologic


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A grade 3 autoimmune hemolytic anemia was identified in only 1 subject to date, and was considered by the 
Investigator to be drug-related. 
Hepatic and pancreatic
Out of a total of 1562 subjects, hepatic adverse events were identified in 8 subjects (0.5%). All the hepatic 
adverse events were considered drug-related. Serious hepatic adverse events were identified in 2 subjects 
(0.1%). Out of a total of 1562 subjects, pancreatitis were identified in 2 subjects (0.1%). Both cases were 
considered serious and drug related. The 2 instances of pancreatitis were Grade 2 and Grade 3.
Endocrinologic 
Type 1 diabetes mellitus AEOSI was identified in only 1 subject. The event was identif ied as serious, Grade 2, 
and was considered by the Investigator to be drug related. No corticosteroids were used to manage the subject’s 
AEOSI.
Out of a total of 1562 subjects, hyperthyroidism was identified in 34 subjects (2.2%), of which 30 (1.9%) were 
considered drug related. Serious hyperthyroidism was identified in 0.3% of subjects, which were all considered 
by the Investigators to be drug related. Two of 34 subjects were treated with concomitant corticosteroid.
Out of a total of 1562 subjects, hypothyroidism was identified in 113 subjects (7.2%), of which 104 (6.7%) 
were considered drug related. Serious events were identified in 0.1% of subjects, which were all considered by 
the Investigators to be drug related. A high initial dose of corticosteroids was used in 1 subject, while a low 
initial dose of corticosteroids was used in 2 subjects. 
Out of a total of 1562 subjects, thyroiditis was identified in 11 subjects (0.7%), all of which were considered 
drug related. None of the thyroiditis was considered by the Investigators to be serious. Thyroiditis was identified 
as the following preferred terms: “thyroiditis” in 7 subjects, and “autoimmune thyroiditis” in 4 subjects. Four 
subjects (0.3%) experienced Grade 1 thyroiditis and 3 subjects (0.2%) experienced Grade 2 thyroiditis. One 
subject (0.1%) experienced Grade 1 autoimmune thyroiditis and 3 subjects (0.2%) experienced Grade 2 
autoimmune thyroiditis.
Out of a total of 1562 subjects, hypophysitis was identified in 11 subjects (0.7%), of which 9 (0.6%) were 
considered drug related. Serious events were identified in 0.4% of subjects, which were all considered by the 
Investigators to be drug related.
Out of a total of 1562 subjects, adrenal insufficiency was reported for 2 subjects (0.1%). Both events were 
identified as Grade 3 acute event, and were considered by the Investigators to be serious and not drug related. 
Infusion reaction
Out of a total of 1562 subjects, infusion reaction was identified in 39 subjects (2.5%), of which 27 (1.7%) were 
considered drug related. Eight subjects (0.5%) experienced Grade 1 hypersensitivity, and 4 subjects (0.3%) 
experienced Grade 2 hypersensitivity. Four subjects (0.3%) experienced Grade1 drug hypersensitivity, and 3 
subjects (0.2%) experienced Grade 2 drug hypersensitivity. Serious events were identified in 2 subjects (0.1%), 
and 1 of the two was considered by the Investigators to be drug related (<0.1%).
Neuromuscular


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Myasthenic syndrome was quantitatively assessed using the following preferred terms: myasthenic syndrome, 
myasthenia gravis, myasthenia gravis crisis, and ocular myasthenia. Out of a total of 1562 subjects, myasthenic 
syndrome was identified in 2 subjects (0.1%). Both cases were considered drug related. The myasthenic 
syndrome was identified as serious for one subject (0.1%). The two instances of myasthenic syndrome were 
Grade 2 and Grade 3.
Uveitis
Out of a total of 1562 subjects, uveitis was identified in 8 subjects (0.5%), all of which were considered drug 
related. A serious uveitis was identified in 1 subject, and was considered by the Investigators to be drug related.
Pneumonitis
Out of a total of 1562 subjects, pneumonitis was identified in 45 subjects (2.9%), of which 42 (2.7%) were 
considered drug related. Serious events were identified in 1.2% of subjects, and all serious events were 
considered by the Investigators to be drug related. One subject died due to pneumonitis (interstitial lung 
disease). Fourteen subjects (0.9%) experienced Grade 1 pneumonitis, 15 subjects (1.0%) experienced Grade 2 
pneumonitis, 11 subjects (0.7%) experienced Grade 3 pneumonitis, and 2 subjects (0.1%) experienced Grade 4 
pneumonitis. For “interstitial lung disease,” 1 subject (0.1%) experienced Grade 1 interstitial lung disease, 1 
subject (0.1%) experienced Grade 3 interstitial lung disease, and 1 subject (0.1%) experienced Grade 5 
interstitial lung disease. A high initial dose of corticosteroids was used in 21 subjects, while a low initial dose 
of corticosteroids was used in 5 subjects.
Vasculitis
Out of a total of 1562 subjects, vasculitis was identified in 2 subjects (0.1%); both cases were considered drug 
related. The events were identified as serious for one subject (0.1%). The two instances of vasculitis were Grade 
1 and Grade 3. 
Common adverse events
The most commonly reported treatment-emergent AEs in pembrolizumab monotherapy trials are fatigue 
(35.4%), nausea (13.8%), decreased appetite (13.8%), diarrhea (12.3%), constipation (10.8%), and AST 
increase (10.8%). In combination therapy trials, the most commonly reported treatment-emergent AEs across 
the dose regimens were neutropenia and thrombocytopenia (50.0% each), anemia (30.0%), dysphonia, hiccups, 
and pruritis (20.0% each). Most of these events also have been mild to moderate in severity. The incidence of 
grade 3-5 treatment-emergent AEs ranges from 6.8-12.0% in monotherapy trials, and 23.1-50.0% in 
combination therapy trials. The above is preliminary safety information. The information has been reviewed, 
but has not been completely monitored; therefore, changes may occur to the safety information may occur going 
forward. Safety information will continue to be collected and evaluated as the study continues.
Potential for Drug-Drug Interactions
No formal pharmacokinetic drug interaction studies have been conducted with pembrolizumab.
Contraindications
None.
11.2.2. Risks related to decitabine
In a single-arm MDS study (N=99) decitabine was dosed at 20 mg/m2 intravenous, infused over one hour daily 
for 5 consecutive days of a four week cycle. Listed below are all adverse events reported, regardless of causality, 
occurring in at least 5% of patients. 


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Blood and lymphatic system disorders 

Anemia
Febrile neutropenia 

Leukopenia 

Neutropenia 

Pancytopenia 

Thrombocythemia 

Thrombocytopenia 
Cardiac disorders 

Cardiac failure congestive 

Tachycardia 
Ear and labyrinth disorders 

Ear pain 
Gastrointestinal disorders 

Abdominal pain

Abdominal pain upper 

Constipation

Diarrhea

Dyspepsia

Dysphagia

Gastro-esophageal reflux disease 

Nausea

Oral pain

Stomatitis

Toothache

Vomiting 
General disorders and administration site 
conditions 

Asthenia

Chest pain

Chills

Fatigue

Mucosal inflammation 

Edema 

Edema peripheral 

Pain
Pyrexia 
Infections and infestations 

Cellulitis

Oral candidiasis

Pneumonia

Sinusitis

Staphylococcal bacteremia 

Tooth abscess

Upper respiratory tract infection 

Urinary tract infection 
Injury, poisoning and procedural complications 

Contusion 
Investigations 

Blood bilirubin increased 

Breath sounds abnormal 

Weight decreased 
Metabolism and nutrition disorders

Anorexia

Decreased appetite

Dehydration

Hyperglycemia

Hypokalemia

Hypomagnesemia
Musculoskeletal and connective tissue disorders

Arthralgia

Back pain

Bone pain

Muscle spasms

Muscular weakness

Musculoskeletal pain

Myalgia

Pain in extremity
Nervous system disorders

Dizziness

Headache

Psychiatric disorders

Anxiety

Confusional state

Depression

Insomnia
Respiratory, thoracic and mediastinal disorders

Cough

Dyspnea

Epistaxis

Pharyngolaryngeal pain

Pleural effusion

Sinus congestion
Skin and subcutaneous tissue disorders

Dry skin

Ecchymosis

Erythema


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
Night sweats

Petechiae

Pruritus

Rash

Skin lesion
Vascular disorders

Hypertension

Hypotension
Potential for Drug-Drug Interactions
Drug interaction studies with decitabine have not been conducted. In vitro studies in human liver microsomes 
suggest that decitabine is unlikely to inhibit or induce cytochrome P450 enzymes. In vitro metabolism studies 
have suggested that decitabine is not a substrate for human liver cytochrome P450 enzymes. As plasma protein 
binding of decitabine is negligible (<1%), interactions due to displacement of more highly protein bound drugs 
from plasma proteins are not expected.
Contraindications
None.
11.2.3.Risks related to blood draws
No major risks are involved with blood draws. Minor complications including bleeding, pain, and hematoma 
formation at the site of blood draws, vasovagal reactions or infections may rarely occur. 
11.2.4. Risks related to CT scans
CT (computed tomography) scanning is performed as part of the clinical standard of care and does not have a 
research use in this protocol. CT uses special x-ray equipment to obtain image data from different angles around 
the body and then uses computer processing of the information to show a cross-section of body tissues and 
organs. Oral and/or intravenous contrast agents will not routinely be used on this study.   Contrast agents may 
be used medically indicated to due unique clinical circumstances.  These agents are usually well tolerated. 
However, some subjects will experience allergic reactions to intravenous contrast. To lower the risk of allergic 
reactions, low allergenic contrast agents are administered at NIH clinical center.  In addition, subjects will be 
advised that approximately 2-7% of patients who receive contrast agents will experience a temporary reduction 
in kidney function lasting up to 2 weeks following infusion and that in rare instances, permanent renal damage 
can result from the use of the IV contrasting agent. Therefore, in subjects with impaired kidney function, we 
will not use intravenous contrast.
11.2.5. Risks related to pregnancy and nursing mothers
There are no clinical studies in pregnant women, and it is unknown whether pembrolizumab is excreted in 
human milk. Men and women of child-bearing potential must use highly effective contraception as described 
in section 5.7.2.  Pregnant or breastfeeding women are not eligible for this protocol.  If a female subject or the 
partner of a male subject becomes pregnant, the sponsor must be notified. Male subjects should refrain from 
sperm donation.
11.2.6. Risks related to central line placement 
When indicated, a catheter may be placed in a large vein of the neck, chest, or arm using local anesthetic. 
Patients will sign a separate consent for the placement procedure. Only trained experienced staff will place 
the line in order to minimize these procedure related risks.
The risks from the procedure are low; they include bleeding, bruising, or infection at the site of insertion. Some 
patient may experience a vasovagal reaction (lightheadedness, or, rarely, fainting due to temporary lowering of 
blood pressure).  Very rarely (less than 1% of the time), the line placement may nick the lung causing it to 


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collapse during line insertion. If the lung collapses, a tube may have to be inserted into the chest and remain in 
place until the lung re-expands. Because of this risk, patients will have a chest x-ray following the procedure to 
make sure the line is in the correct place and that the lung is not collapsed. Once placed, the line will ideally 
remain in place until drug administration is complete.
11.2.7. Risks related to bone marrow and skin punch biopsy
The anesthetic can cause some temporary stinging and burning. A pulling sensation and discomfort may be felt 
as the sample is withdrawn. Although rare, there is a potential for bleeding at the site and local infection. 
Bleeding can be stopped by applying local pressure, and infection can be treated with antibiotics.  In the long 
term minimal scarring may occur but in most cases the biopsy site is indistinguishable within a few months. 
11.2.8. Risks related to transfusions 
Some risks with the transfusion with blood and /or blood products include fever or allergic reactions. These 
risks are uncommon and are usually mild, but on rare occasions may be severe or life threatening. Extremely 
rare risks include infections with viruses, such as hepatitis or HIV or serious incompatibility reactions. 
11.2.9.Risks related to leukapheresis procedure
The leukapheresis procedures will be performed in accordance with standard leukapheresis donation policies 
and procedures operative in the NIH department of transfusion medicine and will be in compliance with the 
Blood Donor Standards of the American Association of Blood Banks and the rules and regulations of the 
Food and Drug Administration. Adverse reactions to leukapheresis procedures are rare, but include: 
•
Pain and hematoma at the needle placement site. 
•
Vasovagal episodes, characterized by transient hypotension, dizziness, nausea and rarely, syncope are 
seen in less than 5% of the procedures. Hypotension secondary to volume depletion is known for the rare 
potential for a cerebrovascular or cardiovascular event. 
•
Cutaneous or circumoral parasthesias, chills, nausea, heartburn and rarely muscle spasms may result 
from the use of citrate anticoagulant used to prevent clotting in the extracorporeal circuit. Citrate reactions are 
usually relieved by slowing the rate of the anticoagulant infusion and by administering oral calcium carbonate 
tablets or with intravenous calcium solution. 
•
Subjects may receive hydroxyethyl starch (HES) to aid in the collection of cells.  HES can rarely 
cause anaphylactoid reactions (hypersensitivity, mild influenza-like symptoms, bradycardia, tachycardia, 
bronchospasm, non-cardiogenic pulmonary edema), renal dysfunction, coagulopathy, and hypertension.  
Prior to each leukapheresis, the potential risks associated with the procedure will be explained to the patient 
and a separate informed consent obtained.
11.2.10.
Risks related to genetic testing
Accidental disclosure of genetic information derived from research testing will be unlikely as all samples and 
research data will be coded and kept separately from the patient demographic information. Individually 
identifiable genetic data directly related to this study will not be released to participants. If an unexpected but 
clinically relevant, inheritable DNA change (also known as an “incidental” or “secondary” finding) is 
discovered by research exome and/or genome sequencing we will consult with the IRB on the best way to 
handle this information and potentially share the need for confirmatory testing by a CLIA accredited facility 
with the patient. Patients may opt-out of receiving such notification of such secondary findings from research 
sequencing.  With increasing technology, it is possible that a person may be identifiable from their sequence 
data submitted as part of a publication of this material. We will attempt to limit this, by again using only 
coded specimens.


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11.3.
Risks in Relation to Benefit
Relapsed and refractory Acute Myeloid Leukemia is fatal without treatment.  Even with the best available 
treatment it is fatal in the majority of cases.  The benefits to the adult patient on this study could be a control, 
reduction or elimination of detectable AML potentially resulting in an improved quality of life, decreased 
transfusion requirements, a decreased susceptibility to infections, become eligible to receive additional therapy 
such as allogeneic transplant and foremost a significant improvement in survival time.  Potentially, treatment 
with other therapies could also be avoided or postponed. 
As of November 30, 2017 this study was closed to new subject accrual and in subject follow up only. As of 
March 15, 2019, the study will continue in data analysis only and the level of risk is minimal. 
11.4.
Informed consent processes and procedures
The investigational nature and research objectives of this trial, the procedure and its attendant risks and 
discomforts will be carefully explained to the subject and a signed informed consent document will be obtained 
prior to entry onto this study.  
At any time during participation in the protocol, should new information become available relating to risks, 
adverse events, or toxicities, this information will be provided orally or in writing to all enrolled or prospective 
patient participants.  Documentation will be provided to the IRB and if necessary the informed consent amended 
to reflect relevant information.
11.5.
Conflict of interest
Merck is providing pembrolizumab and research funding for this study to NIH. No NIH investigator involved 
in this study receives any payment or other benefits from Merck. The principal investigator assures that each 
associate investigator listed on the protocol title page received a copy of the NIH’s Guide to preventing 
conflict of interest. No members of the research team reported a potential conflict of interest. There are no 
conflicts of interest with any financial organization regarding the material mentioned in this protocol.  
11.6.
Technical Transfer Agreements
The protocol will have the following tech transfer agreements: Cooperative Research and Development 
Agreement (CRADA) between NHLBI and Merck. 
Material transfer agreement (MTA) with collaborators at Collaborative Health Initiative Research Program, 
Uniformed Services University School of Medicine who will conduct genomic sequencing on de-identified 
(coded) samples to determine molecular etiology of diseases encountered on this protocol.
Material transfer agreement (MTA) with collaborator at New York Genome Center who will conduct analysis 
of gene and protein expression on de-identified (coded) samples on this protocol.
12.0
PHARMACEUTICALS 
12.1.
Pembrolizumab
Background Information: Note for detailed and comprehensive background information please refer to the 
Investigator’s Brochure.


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Investigational Product Name and Description: Pembrolizumab is a humanized monoclonal antibody that 
blocks the interaction between PD-1 and its ligands, PD-L1 and PD-L2. Pembrolizumab is an IgG4 kappa 
immunoglobulin with an approximate molecular weight of 149 kDa. 
Preparation: Pembrolizumab is provided as a white to off white lyophilized powder (50 mg/vial) or as a 
liquid solution (100 mg/vial) in Type I glass vials intended for single use only. Pembrolizumab Powder for 
Solution for Infusion, 50 mg/vial, is reconstituted with sterile water for injection prior to use.
The lyophilized drug product after reconstitution with sterile water for injection, and the liquid drug product 
are a clear to opalescent solutions, essentially free of visible particles. The reconstituted lyophilized product 
and the liquid product are intended for IV administration. The reconstituted drug product solution or the 
liquid drug product can be further diluted   with   normal   saline   or   5% dextrose   in   the   concentration   
range   of 1 to 10 mg/mL in intravenous (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. Diluted pembrolizumab solutions may be stored at 
room temperature for a cumulative time of up to 4 hours. This includes room temperature storage of 
admixture solutions in the IV bags and the duration of infusion. In addition, IV bags can be stored at 2 to 8°C 
for up to a cumulative time of 20 hours. 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.
Packaging, and Storage: The drug product is stored as a stable lyophilized powder or liquid solution under 
refrigerated conditions (2 to 8°C). 
Administration: The prescribed dose of pembrolizumab is given through an intravenous line containing a 
sterile, non-pyrogenic, low-protein binding 0.2 micron to 5 micron in-line or add-on filter. It is not allowed to 
co-administer other drugs through the same infusion line.
Supply: The drug product pembrolizumab is manufactured and supplied by Merck.
Shipping:  
National Institutes of Health
PHARM DEV SVC, Room 1C230
10 Center Drive, MSC 1196, Building 10
Bethesda, Maryland 20892-1196
Shipping Designee Name:  Hope Decederfelt, RPh
Shipping Designee Phone No:  (301) 496-1031
Shipping Designee FAX No:  (301) 402-3268
Shipping Designee e-mail: hcederfelt@nih.gov
12.2.
Decitabine
Background Information: Note for detailed and comprehensive background information please refer to the 
FDA product label.  
Product Name and Description: Decitabine (5-aza-2’-deoxycitidine) is an analogue of the natural 
nucleoside 2’-deoxycytidine. Decitabine is a fine, white to almost white powder with the molecular formula 
of C8H12N4O4 and a molecular weight of 228.21. Its chemical name is 4-amino-1-(2-deoxy-β- D-erythro-
pentofuranosyl)-1,3,5-triazin-2(1H)-one.
Preparation: Decitabine is a cytotoxic drug and caution should be exercised when handling and preparing. 
Procedures for proper handling and disposal of antineoplastic drugs should be applied. should be aseptically 
reconstituted with 10 mL of Sterile Water for Injection (USP); upon reconstitution, each mL contains 
approximately 5.0 mg of decitabine at pH 6.7-7.3. Immediately after reconstitution, the solution should be 
further diluted with 0.9% Sodium Chloride Injection or 5% Dextrose Injection to a final drug concentration of 


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0.1-1.0 mg/mL. Unless used within 15 minutes of reconstitution, the diluted solution must be prepared using 
cold (2 ̊C - 8 ̊C) infusion fluids and stored at 2 ̊C - 8 ̊C (36 ̊F - 46 ̊F) for up to a maximum of 4 hours until 
administration. 
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to 
administration, whenever solution and container permit. Do not use if there is evidence of particulate matter 
or discoloration. 
Packaging, and Storage:  Decitabine is supplied as a sterile, lyophilized white to almost white powder, in a 
single-dose vial, packaged in cartons of 1 vial. Each vial contains 50 mg of decitabine. 
Administration: Decitabine is administered at a dose of 20 mg/m2 by intravenous infusion over 
approximately 1 hour repeated daily for 10 days. This cycle should be repeated every 6 weeks. Patients may 
be premedicated with standard anti-emetic therapy. Store vials at 25°C (77°F); excursions permitted to 15-
30°C (59-86°F).
Supply:   Decitabine will be supplied by the NIH clinical center pharmacy. During the optional continuation 
phase decitabine may be supplied by another pharmacy.
12.3.
Accountability procedures
Drug accountability records will be maintained for all clinical supplies. All empty and partially used vials and 
clinical trial supplies will be destroyed locally according to the institution’s standard operating procedures for 
drug destruction.  The pharmacy will maintain detailed documentation of the number and identification of vials 
which are destroyed, and copies of these documents will be provided to the sponsor.  Disposition of all unused 
boxes of study drug will be carried out according to instructions provided by the sponsor at the end of the study 
after drug accountability is performed by the study monitor.


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13.0
REFERENCES
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Orskov AD, Treppendahl MB, Skovbo A, et al. Hypomethylation and up-regulation of PD-1 in T cells 
by azacytidine in MDS/AML patients: A rationale for combined targeting of PD-1 and DNA methylation. 
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2.
Yang H, Bueso-Ramos C, DiNardo C, et al. Expression of PD-L1, PD-L2, PD-1 and CTLA4 in 
myelodysplastic syndromes is enhanced by treatment with hypomethylating agents. Leukemia : official journal 
of the Leukemia Society of America, Leukemia Research Fund, UK 2014;28:1280-8.
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Kim K, Skora AD, Li Z, et al. Eradication of metastatic mouse cancers resistant to immune checkpoint 
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4.
Kopp LM, Ray A, Denman CJ, et al. Decitabine has a biphasic effect on natural killer cell viability, 
phenotype, and function under proliferative conditions. Mol Immunol 2013;54:296-301.
5.
Rohner A, Langenkamp U, Siegler U, Kalberer CP, Wodnar-Filipowicz A. Differentiation-promoting 
drugs up-regulate NKG2D ligand expression and enhance the susceptibility of acute myeloid leukemia cells to 
natural killer cell-mediated lysis. Leukemia research 2007;31:1393-402.
6.
Srivastava P, Paluch BE, Matsuzaki J, et al. Induction of cancer testis antigen expression in circulating 
acute myeloid leukemia blasts following hypomethylating agent monotherapy. Oncotarget 2016.
7.
Goodyear O, Agathanggelou A, Novitzky-Basso I, et al. Induction of a CD8+ T-cell response to the 
MAGE cancer testis antigen by combined treatment with azacitidine and sodium valproate in patients with 
acute myeloid leukemia and myelodysplasia. Blood 2010;116:1908-18.
8.
Salih HR, Wintterle S, Krusch M, et al. The role of leukemia-derived B7-H1 (PD-L1) in tumor-T-cell 
interactions in humans. Experimental hematology 2006;34:888-94.
9.
Chen X, Liu S, Wang L, Zhang W, Ji Y, Ma X. Clinical significance of B7-H1 (PD-L1) expression in 
human acute leukemia. Cancer Biology & Therapy 2008;7:622-7.
10.
Zhou Q, Munger ME, Veenstra RG, et al. Coexpression of Tim-3 and PD-1 identifies a CD8+ T-cell 
exhaustion phenotype in mice with disseminated acute myelogenous leukemia. Blood 2011;117:4501-10.
11.
Kong Y, Zhang J, Claxton DF, et al. PD-1(hi)TIM-3(+) T cells associate with and predict leukemia 
relapse in AML patients post allogeneic stem cell transplantation. Blood cancer journal 2015;5:e330.
12.
Zhang L, Gajewski TF, Kline J. PD-1/PD-L1 interactions inhibit antitumor immune responses in a 
murine acute myeloid leukemia model. Blood 2009;114:1545-52.
13.
Roulois D, Loo Yau H, Singhania R, et al. DNA-Demethylating Agents Target Colorectal Cancer Cells 
by Inducing Viral Mimicry by Endogenous Transcripts. Cell 2015;162:961-73.
14.
Chiappinelli KB, Strissel PL, Desrichard A, et al. Inhibiting DNA Methylation Causes an Interferon 
Response in Cancer via dsRNA Including Endogenous Retroviruses. Cell 2015;162:974-86.
15.
Licht JD. DNA Methylation Inhibitors in Cancer Therapy: The Immunity Dimension. Cell 
2015;162:938-9.
16.
Chiappinelli KB, Zahnow CA, Ahuja N, Baylin SB. Combining Epigenetic and Immunotherapy to 
Combat Cancer. Cancer research 2016.
17.
Lai C, Karp JE, Hourigan CS. Precision medicine for acute myeloid leukemia. Expert review of 
hematology 2016;9:1-3.
18.
Cancer Genome Atlas Research N. Genomic and epigenomic landscapes of adult de novo acute myeloid 
leukemia. The New England journal of medicine 2013;368:2059-74.
19.
Goswami M, Hensel N, Smith BD, et al. Expression of putative targets of immunotherapy in acute 
myeloid leukemia and healthy tissues. Leukemia : official journal of the Leukemia Society of America, 
Leukemia Research Fund, UK 2014;28:1167-70.
20.
Ding L, Ley TJ, Larson DE, et al. Clonal evolution in relapsed acute myeloid leukaemia revealed by 
whole-genome sequencing. Nature 2012;481:506-10.
21.
Issa JP, Garcia-Manero G, Giles FJ, et al. Phase 1 study of low-dose prolonged exposure schedules of 
the hypomethylating agent 5-aza-2'-deoxycytidine (decitabine) in hematopoietic malignancies. Blood 
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22.
Garcia-Manero G, Kantarjian HM, Sanchez-Gonzalez B, et al. Phase 1/2 study of the combination of 
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23.
Blum W, Klisovic RB, Hackanson B, et al. Phase I study of decitabine alone or in combination with 
valproic acid in acute myeloid leukemia. Journal of clinical oncology : official journal of the American Society 
of Clinical Oncology 2007;25:3884-91.
24.
Lubbert M, Ruter BH, Claus R, et al. A multicenter phase II trial of decitabine as first-line treatment 
for older patients with acute myeloid leukemia judged unfit for induction chemotherapy. Haematologica 
2012;97:393-401.
25.
Kantarjian HM, Thomas XG, Dmoszynska A, et al. Multicenter, randomized, open-label, phase III trial 
of decitabine versus patient choice, with physician advice, of either supportive care or low-dose cytarabine for 
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26.
Geller N, Follmann D, Carter SL, Leifer ES. Design of Early Trials in Stem Cell Transplantation.  
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APPENDIX A:  AML Diagnostic and Treatment Response Criteria 
Acute Myeloid Leukemia (AML) is a clonal expansion of myeloid blasts in bone marrow, blood or other 
tissue, ICD-O code 9861/3. 
Diagnostic and Staging Criteria 
Bone marrow cellularity: The volume of hematopoietic nucleated cells, expressed as a percentage of 
marrow volume less volume of fibrosis. 
Blasts: For AML, the following cell types are considered equivalent to blasts and are included in the 
calculation of blast percentages. Note that erythroblasts are not counted as blasts in calculating blast 
percentages. 

Myeloblasts include both agranular and granular variants. 

Monoblasts and promonocytes for Acute Monoblastic and Monocytic Leukemia. 
Megakaryoblasts for Acute Megakaryoblastic Leukemia. 
Bone Marrow Blast Percentage: calculated as the percent of blasts among all nucleated marrow cells.
Residual Disease: The NIH institutional standard for AML residual disease diagnosis is currently 
assessment with flow cytometry.  Other clinically accepted methods of making this diagnosis exist (eg: 
Cytogenetics, FISH, RQ-PCR) and may be used at the discretion of the NIH attending pathologist.
 
Response Definitions for AML: 
1.
Measurable residual disease (MRD) negative complete remission.   No evidence of residual 
disease after clinical assessment by flow cytometry (plus any other technique used in initial 
diagnosis of residual disease, if applicable).    < 5% bone marrow blasts, no Auer rods, no evidence 
of extramedullary disease. This may be with (mCR) or without count recovery to ANC ≥ 
1,000/mcl and platelet count ≥ 100,000/mcl (mCRi).
2.
Morphologic complete remission (CR): ANC ≥ 1,000/mcl, platelet count ≥ 100,000/mcl, < 5% 
bone marrow blasts, no Auer rods, no evidence of extramedullary disease. (No requirements for 
marrow cellularity, hemoglobin concentration). 
3.
Morphologic complete remission with incomplete blood count recovery (CRi): Same as CR but 
ANC may be < 1,000/mcl and/or platelet count < 100,000/mcl. 
*Patients with both an ANC < 1000/mcl and platelet count < 100,000/ mcl with at least a 
10% marrow cellularity will be reported as a Morphological Leukemia Free State (MLFS).
4.
Partial remission (PR): ANC ≥ 1,000/mcl, platelet count > 100,000/mcl, and at least a 50% 
decrease in the percentage of marrow aspirate blasts to 5-25%, or marrow blasts < 5% with 
persistent Auer rods. 
5.
Stable disease (SD): The absence of a complete or partial response, and no progressive disease.
6.
Progressive disease (PD): Defined as ONE of the following:

Greater than 50% relative increase in blasts in the peripheral blood or bone marrow from best 
assessment with minimum threshold of 20% blasts in the marrow or 1.0x109/L blasts in 
peripheral blood.

Development of biopsy proven extramedullary leukemia (if the subject has extramedullary 
disease at baseline, then PD will be defined by blood and marrow criteria or if new sites of 
extramedullary disease appear).

If subject who present with an initial marrow blast percentage sufficiently high to preclude the 
ability to base disease progression on a >50% increase in marrow blast percentage, disease 
progression should be based on peripheral blood criteria or development of extramedullary 
leukemia as above.
7.
Not Evaluable: Data incomplete or inadequate for time-point or overall assessment.


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Note:  Patients entering this study already in morphologic complete remission (ie: CR or CRi) but with 
evidence of residual disease the only responses possible are mCR, mCRi, SD, PD or NE (see above).
APPENDIX B:  ECOG Performance Status Scale


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APPENDIX C:  Events of Clinical Interest


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APPENDIX D:  NHLBI Hematology Branch Laboratory Research Studies
DESCRIPTION OF LABORATORY STUDY BY BRANCH SECTION
Does this test 
pose a greater 
than minimal 
risk to 
pediatric 
subjects per 
45 CFR 
46.404?
Does this 
test pose a 
greater than 
minimal 
risk to 
healthy 
pediatric 
donors per 
45 CFR 
46.404?
A
Stem Cell Allotransplantation Section (Dr. A. John Barrett)
A.1
Measurement of lymphocyte function and immune responses directed toward 
allogeneic tissues, malignant cells, and infectious agents.  Assay of a variety of 
antigens, including standard proliferation, cytotoxicity, and intracellular cytokine  
detection including GVHD predictive markers. Measurement of antigen-specific 
responses including employment of tetramers, ELISPOT technique, gene 
amplification-based assays, and flow cytometry.  Selection of cells using 
immunomagnetic beads or flow cytometry.  Culture, expansion, and selection of 
cells. Surface marker analysis of PB MC using flow cytometry. Cytokine/chemokine 
analysis of plasma/serum samples using ELISA and/or Luminex techniques.
No
No
A.2
Generation of cell lines for the study of immune cell interactions with other cells.  
Transformation of B-lymphocytes using Epstein-Barr virus.  Derivation of malignant 
cell lines from patient leukemic or solid tumor samples.
No
No
A.3
Infection of cells and cell lines with recombinant genes to ascertain the effects of 
expressed molecules on immune responses and on growth and development. 
Transfection of cell lines with specific molecules to study antigen-specific responses.
No
No
A.4
Assays of peripheral blood and bone marrow progenitor cells including primitive and 
late erythroid progenitor-derived colonies, myelomonocytic colonies, and primitive 
multi- potential progenitor-derived colonies.
No
No
A.5
Injection of human cells into experimental animals to study the immune system and 
the growth of normal and malignant cells under varying conditions.
No
No
A.6
Testing of selection methods, cell isolation, and cell expansion leading to the 
development of new cell-based therapies requiring scale-up for clinical application.
No
No
A.7
Identification of individual T cell clones by their T cell receptor sequence.
No
No
A.8
Measurement of tumor and tissue specific antigens in cells of subjects and donors by 
mRNA,protein, or peptide expression in cells or fluids.
No
No
A.9
Laser capture micro dissection of cells from biopsies for GVHD to determine 
clonotypes.
No
No


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A.10
DNA and RNA typing of genes that control immune responses in lymphocytes.
No
No
A.11
Microassay studies utilizing cellular DNA, cDNA, and RNA for neoplasia and host-
tumor interactions.
No
No
B
Molecular Hematopoiesis  Section  (Dr. Cynthia Dunbar) 
B.1
Flow cytometric analysis of cell surface and cytoplasmic proteins, including cell 
adhesion molecules, putative retroviral receptors, and markers of differentiation, 
using bone marrow and mobilized peripheral blood cells.
No
No
B.2
Hematopoietic progenitor-derived colony ascertainment in vitro (as described above), 
and engraftment of immunodeficient mice for detection of human stem cell number 
and function.
No
No
B.3
Testing ability of hematopoietic progenitor cells to be transduced with retroviral, 
lentiviral, and novel gene transfer vectors in vitro.
No
No
B.4
Reprogramming of adult mature cells, including skin fibroblasts and blood cells, into 
induced pluripotent stem cells in vitro.
No
No
C
Cell Biology Section (Dr. Neal Young) 
C.1
Studies of blood and bone marrow hematopoietic progenitor numbers, including early 
and late erythroid progenitors, myelomonocytic progenitors, and multi-potential 
progenitor cells.  In addition, bone marrow may be placed in long-term bone marrow 
culture to assess the function of stroma and stem cells and to assay more primitive 
progenitors, as well as organelle culture.  Whole or selected bone marrow 
populations are cultured short-term for CD34 cell expansion.
No
No
C.2
Assays of apoptosis in hematopoietic cells and their progeny, using flow cytometric 
methods such as annexin and caspase-3 staining, propidium iodide uptake, and 
mitochondrial permeability tests.
No
No
C.3
Separation and functional study of cell populations characteristic of paroxysmal 
nocturnal hemoglobinuria, identified by absence of glycosylphosphatidylinositol 
anchored proteins.
No
No
C.4
Studies of mutation rates in hematopoietic cells and in buccal mucosa cells, using 
conventional hypoxanthine phosphoribosyltransferase activity functional assays, 
sequencing of mitochondrial DNA after specific gene amplification, and 
measurement of GPI-anchored deficient cells in blood and bone marrow.
No
No


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C.5
Assays of immune function of T-cells, including intracellular cytokine staining, 
ELISPOT, semiquantitative gene amplification for gamma-interferon, tumor necrosis 
factor, interleukin-2, and other cytokines, and functional assessment in co-culture 
using specific neutralizing monoclonal antibodies.  In addition, peripheral blood 
lymphocytes are subjected to spectratyping for CDR3 size distribution as well as 
nucleotide sequence of CDR3 peaks obtained.
No
No
C.6
Studies of engraftment of human normal and diseased bone marrow and peripheral 
blood in immunodeficient mice in order to determine the presence of hematopoietic 
repopulating stem cells as well as functional differences among selected populations.
No
No
C.7
Flow cytometric analysis of blood and bone marrow for lymphocyte phenotype, 
especially for evidence of activation of lymphocytes, for markers of apoptosis, and 
for antigens associated with primitive and mature hematopoietic cell populations.
No
No
C.8
Flow cytometric analysis of blood and bone marrow for hematopoietic stem cell 
progenitors and CD34 positive cells.
No
No
C.9
Studies of chromosomal instability in myelopdysplastic syndromes including BM cell 
and CD34 cell response to PAS crosslinking and examination of the cytotoxic effect 
of lymphocytes to the abnormal clone of cells.
No
No
C.10
Surface Enhanced Laser/Desorption Ionization (SELDI)  time-of-flight mass 
spectrometry (Ciphergen)  (proteomics methodology).
No
No
C.11
Mitochondrial DNA (mtDNA) sequence heterogeneity.
No
No
C.12
Measurement of EBV viral load.
No
No
C.13
Measurement of EBV LMP-1 via RT-PCR for LMP-1 RNA or flow cytometry for 
LMP-1.
No
No
C.14
Outgrowth assay of EBV transformed B cells.
No
No
C.15
Quantification of serumchemokines and cytokines (e.g. SDF-1, IL-10, IL-6, CXCR4, 
CXCL12).
No
No
C.16
Quantification of EBV cytotoxic T cells (tetramerstaining).
No
No
C.17
Telomere length measurement by Southern blot, Q-PCR, flow-fish, in situ 
hybridization and STELA
No
No
C.18
Telomere repair complex gene mutations by nucleotide sequencing of some or all of 
the following:  DKC1 ,TERC, TERT, SBDS, NOp10 , NHP2.
No
No
C.19
Analysis of  inflammatory markers and/or bacterial, viral, fungal or protozoal 
elements in plasma or serum using molecular, colorimetric, enzymatic, flow 
cytometric or other assays in subjects receiving immunosuppressive therapy, 
chemotherapy and/or bone marrow transplantation.
No
No
C.20
Confocal microscopic imaging of bone marrow.
No
No
C.21
Characterization of intracellular signaling proteins by cell permeabilization and flow 
cytometry, and quantitative immunoblots.
No
No


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C.22
Assays for chromosomal aneuploidy by florescence in situ hybridization (FISH) and 
other molecular techniques.
No
No
C.23
Conversion of human dermal fibroblasts into hematopoietic progenitors using Oct4 
transfection.
No
No
D
Virus Discovery Section (Dr. Neal Young) THESE ASSAYS WILL NOT BE 
PERFORMED ON SAMPLES FROM HEALTHY PEDIATRIC DONORS
D.1
Assays of serum, blood cells, and bone marrow cells for B19 parvovirus and possible 
B19  variants using gene amplification, cell culture, and hematopoietic colony 
inhibition assays.
No
N/A
D.2
Assays of blood, bone marrow, liver, and other tissues for potentially novel viruses, 
using a variety of techniques including RNA and DNA assays, differential display, 
gene amplification with conserved and random primers, cell culture assays, 
immunohistochemical methods, and inoculation of mice, rabbits, and monkeys, as 
well as antibody measurements.
No
N/A
D.3
Assays of blood, bone marrow, and liver for known viruses, including herpesviruses 
such as cytomegalovirus, human herpesviruses 6, 7, and 8, enteric viruses such as A-
6, circiviruses, and parvoviruses, using assays as in (2).
No
N/A
D.4
Spectra-typing of blood cells to determine response to known or putative viral 
infections.
No
N/A
D.5
HLA typing or subtyping to determine risk factors/determinants for hepatitis-AA 
studies.
No
N/A
D.6
Cytotoxic lymphocyte assays with intracellular cytokine measurement for 
determining anti-viral response and lymphocyte cloning to obtain clones with 
specific antiviral activity.
No
N/A
E
Solid Tumor Section (Dr. Richard Childs)
E.1
Cr51 cytotoxicity assay to evaluating killing of patient tumor cells by patient NK cell 
clones and T-cells.
No
No
E.2
ELISA for IL-12 maturity of DC's made from subjects monocytes.
No
No
E.3
ELISA for IFN ã to evaluate specificity of CTL clones.
No
No
E.4
H thymidine uptake to evaluate proliferation potential of antigen specific T-cells.
No
No
E.5
PCR of STR to assess chimerism status of cellular subsets grown in-vitro or retrieved 
from subjects post-transplant.
No
No
E.6
Flow sorting of PBL and/or tissue samples to evaluate chimerism of different subsets.No
No
E.7
Surface marker analysis of peripheral blood mononuclear cells using flow cytometry. No
No


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E.8
cDNA expression arrays to evaluate T-cells expression/gene patterns in subjects with 
GVHD and a GVT effect.
No
No
E.9
Geno typing of tumor or tissue samples by high density cDNA arrays.
No
No
E.10
VHL mutation analysis on kidney cancer tissue.
No
No
E.11
Transduction of dendritic and tissue cells with tumor antigens using plasmids, viral 
vectors and hybrid fusions.
No
No
E.12
Lasar capture microdisection of cells from tumor biopsies and tissue samples  to 
determine origin (donor vs patient).
No
No
E.13
Quantification of polyoma virus BK exposure by serology and PCR in stem cell 
transplant donors and recipients from blood and urine samples.
No
No
E.14
Quantification of polyoma virus BK specific T cells in stem cell transplant donors 
and recipients from peripheral blood samples.
No
No
E.15
Determination of origin of neovasculature endothelial cells in tumor and tissue 
samples obtained from subjects post-transplant.
No
No
E.16
Quantification of lymphocyte subsets CD34 progenitors and endovasculator 
progenitors in G-CSF mobilized peripheral cell allografts.
No
No
E.17
Testing for polyoma virus BK latency in CD34 progenitors, B cells and T cells in the 
G-CSF mobilized peripheral cell allografts.
No
No
E.18
Determination of etiology of membraneous nephropathy using serum from subjects.
No
No
E.19
Serum Proteomic patterns analysis to diagnose complications related to allogeneic 
transplantation.
No
No
E.20
Determine cell origin (donor vs patient) of tissue samples using IHC, IF, sorting, and 
FISH.
No
No
F
Lymphoid Malignancies Section (Dr. Adrian Wiestner)
F.1
Culture of cells from research subjects to investigate molecular disease mechanisms, 
model host tumor interactions, and to test effect of drugs on cell survival and cellular 
functions.
No
No
F.2
Generation of stable cell lines for the study of hematologic malignancies.
No
No
F.3
Modifications of cells using standard expression systems or biologic molecules, e.g. 
interfering RNA, to investigate the effects of candidate genes on cellular functions.
No
No
F.4
Identification and monitoring of B or T cell populations as identified by flow 
cytometry and by their B cell or T cell receptor expression.
No
No


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F.5
Measurement of gene expression in cells or tissues. Techniques frequently used 
include gene expression profiling on microarrays, quantitative RT-PCR, Western 
blotting, flow cytometry and ELISA assays.
No
No
F.6
Analysis of chromosomal abnormalities or mutations in malignant cells and non-
malignant cells including FISH technology and DNA sequencing.
No
No
F.7
Assays of immune function of B-cells and T-cells, including intracellular cytokine 
staining, ELISPOT, quantitative RT-PCR for cytokines or other immune regulatory 
genes.
No
No
F.8
Analysis of antibody specificities in serum and antigen specificity of the B-cell 
receptor on cells. Techniques may include expression of antibodies in phage display 
systems, generation of antibodies in cell culture systems and use of such antibodies to 
screen for cognate antigens.
No
No
F.9
Transplantation of human cells into mice (xenograft model) to study disease biology 
and to investigate the effect of experimental therapy.
No
No
F.10
Measurements of drug concentrations, biologic molecules and disease markers in 
blood, serum, and plasma.
No
No


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73
APPENDIX E:  Anticipated Research Sample Collection
Bone Marrow
Bone marrow biopsy and aspirate for research (up to 25ml) will be collected at each of the following time-
points:
Time-point
Clinical
Research
Prior to cycle 1 
X
X
Cycle 1 Day 8
X
After cycle 2 
(ie: C3D1 or 7 days prior)
X
X
After cycle 4 
(ie: C5D1 or 7 days prior)
X
X
After cycle 6 
(ie: C7D1 or 7 days prior)
X
X
After cycle 8 and / off-
treatment 
X
X
* Bone marrows after cycles 2, 4, 6 and 8 may be performed anytime in the week prior to the next cycle dose of Pembrolizumab. 
Peripheral Blood
Time-point
EDTA (4ml)
PAXgene 
(2.5ml)
CPT (8ml)
SST (3.5ml)
Volume (ml)
Cycle 1 Day 1
XXXXXX
X
X
X
38
Cycle 1 Day 8
XXXXXX
X
X
X
38
Cycle 1 Day 15
X
X
X
X
18
Cycle 2 Day 1
X
X
X
X
18
Cycle 3 Day 1
X
X
X
X
18
Cycle 4 Day 1
X
X
X
X
18
Cycle 5 Day 1
X
X
X
X
18
Cycle 6 Day 1
X
X
X
X
18
Cycle 7 Day 1
X
X
X
X
18
Cycle 8 Day 1
X
X
X
X
18
Cycle 9 Day 1
X
X
X
X
18
Off-Treatment
X
X
X
X
18
Total Volume:
256
Other Tissue
Start of treatment:  
Buccal swab – non-invasive (cheek).
End of treatment:  
Skin punch biopsy (no greater than 3mm core).
Note:  Above represents points where biological research samples may be collected. Research sample 
collection at each of these time points is optional and may be modified at the discretion of the investigator 
on clinical and/or research grounds.  Additional volume or time-points of clinical response or toxicity may 
be collected, with the total amount of not to exceed the institutional limits described in section 7.1.  A record 
of all research samples collected will be kept.


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APPENDIX F:  Current NCCN Guidelines for Relapsed/Refractory AML Treatment
(US national guidelines – updated frequently.  Below is for general information only – please refer to latest 
guidelines at http://www.nccn.org/professionals/physician_gls/pdf/aml.pdf.)


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APPENDIX G:  Scheduled Clinical Assessments
Trial Period:
Screening 
Phase
Induction Phase Treatment 
(Assessment at end of cycle…)
Post-Induction
Up to 28 
days prior 
to start of 
treatment
1
2
3
4
5
6
7
8
SFV / 
Off-
study 
Visits 
Contin. 
Phase
(q3mo)
Pre-screening and Consents
X
Inclusion/Exclusion Criteria
X
Demographics and Full Medical 
History
X
Interval Medical History
X
X
X
X
X
X
X
X
X
X
Focused Physical Exam
X
X
X
X
X
X
X
X
X
X
ECOG Performance Status
Baseline
X
X
X
X
X
X
X
X
X
X
Structured Review of Adverse Events
Baseline
X
X
X
X
X
X
X
X
X
X
Prior and Concomitant Medication 
Review
X
X
X
X
X
X
X
X
X
X
X
Trial Treatment Administration Log
X
X
X
X
X
X
X
X
Therapy Response Assessment
X
X
X
X
X
X
X
Bone Marrow Examination*
(flow cytometry, morphology)
X
X
X
X
X
Cytogenetics (bone marrow)
X
If + 
@BL
If + 
@BL
If + 
@BL
X
Pregnancy Test - – Urine or Serum -
HCG
W/in 72 
hours of 
first dose.
X
X
X
X
X
X
X
X
X
X
Acute Care, Mineral and Hepatic 
Panels
W/in 14 
days of first 
dose
X
X
X
X
X
X
X
X
X
X
Total protein, CK, Uric Acid, LDH, 
PT, PTT, Fibrinogen, CBC w/ diff, 
Reticulocyte, Type&Screen.
X
X
X
X
X
X
X
X
X
X
X
CMV IgG, IgM and PCR, HIV 
serology, Hepatitis serologies, 
X
Thyroid Function (T3, FT4 and TSH), 
EKG, HLA typing, Urinalysis
X
Peripheral Blood Flow Cytometry 
(T/B/NK and AML)
X
X
X
X
X
“If + @ BL” = Cytogenetics will be checked after cycles 2, 4 and 6 only if abnormal at baseline.
* = an additional bone marrow examination assessment will be performed on cycle 1 day 8 (+/- 3 days).