Clinical trial NCT02708641
Conditions: Acute Myeloid Leukemia
Sponsor: Michael Boyiadzis
Start date: 2016-10-04; Completion date: 2020-12-01
Enrollment: 12 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This study evaluates the effect of pembrolizumab on the duration of remission in acute myeloid leukemia. Pembrolizumab is given after complete remission is obtained in those with AML at least 60 years old who are not candidates for allogeneic stem cell transplant. The primary purpose of this study is determine if the time to relapse can be extended. Additionally, the safety and tolerability of pembrolizumab will be closely monitored.

Detailed description:
Patients \>60 years old with AML often have a dismal prognosis. Even though many of these patients are able to obtain a Complete Response to treatment, relapse occurs in the vast majority of patients. Transplants may reduce relapse rates in this population, but is only feasible in a minority of patients. AML's immunosuppressive microenvironment in general and PD-1/PD-L1 upregulation in particular appears to increase the risk of relapse. Importantly, PD-1 and its ligands are particularly increased after therapy compared to initial diagnosis. As such, PD-1 inhibition with pembrolizumab offers to limit leukemic cell immune escape, thereby allowing the patient's immune system to eradicate the submicroscopic residual disease and reducing relapse rates.

Treatment for this study is 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.

Arms: arm 1: pembrolizumab 200 mg given IV once every three weeks
Interventions: intervention 1: pembrolizumab
Intervention descriptions: intervention 1: 200 mg IV given every three weeks

Protocol documents:
Prot_SAP_000.pdf: 
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SUMMARY OF CHANGES 
 
HCC #: 15-101 Version 5.0  
 
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A Phase II study of Pembrolizumab as Post-remission 
Treatment of Patients > 60 with AML Who Are Not 
Transplantation Candidates 
HCC# 15-101; Version 5.0 dated 06/03/2019 
 
 
IND SPONSOR AND PRINCIPAL INVESTIGATOR 
Michael Boyiadzis, M.D., M.H.Sc 
Associate Professor of Medicine 
Division of Hematology-Oncology  
UPMC Hillman Cancer Center 
UPMC Cancer Pavilion 
5150 Centre Avenue, Suite 572 
Pittsburgh, PA 15232 
Phone: 412-623-0040 
Email: boyiadzism@upmc.edu 
 
BIOSTATISTICIAN 
Daniel P. Normolle, PhD 
Biostatistics Facility 
UPMC Hillman Cancer Center 
Suite 325 Sterling Plaza 
201 North Craig St. 
Pittsburgh, PA 15213 
Phone: 412-383-1581 
Email: dpn7@pitt.edu 
 
CLINICAL PHARMACY SPECIALIST 
Shrina Duggal, PharmD 
UPMC Cancer Pavilion, room 456 
5150 Centre Ave 
Pittsburgh, PA 15232 
Tel: 412-623-4745 
E-mail: patelsh@upmc.edu 


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TABLE OF CONTENTS 
1.0 
TRIAL DESIGN.......................................................................................................... 7 
1.1 
Trial Design ............................................................................................................. 7 
1.2 
Trial Diagram .......................................................................................................... 7 
2.0 
OBJECTIVE(S) & HYPOTHESIS(ES) .................................................................... 7 
2.1 
Primary Objective(s) & Hypothesis(es) ................................................................ 7 
2.2 
Secondary Objective(s) & Hypothesis(es) ............................................................. 8 
2.3 
Exploratory Objective ............................................................................................ 8 
3.0 
BACKGROUND & RATIONALE ............................................................................ 8 
3.1 
Background ............................................................................................................. 8 
3.1.1 Pharmaceutical and Therapeutic Background ....................................................... 8 
3.1.2 Clinical Trial Data ................................................................................................. 9 
3.2 
Rationale ................................................................................................................ 10 
3.2.1 Rationale for the Trial and Selected Subject Population .................................... 10 
3.2.2 Rationale for Dose Selection/Regimen/Modification ......................................... 13 
3.2.3 Rationale for Endpoints ...................................................................................... 15 
4.0 
METHODOLOGY ................................................................................................... 19 
4.1 
Entry Criteria ........................................................................................................ 18 
4.1.1 
Diagnosis/Condition for Entry into the Trial ...................................................... 18 
4.1.2 
Subject Inclusion Criteria.................................................................................... 18 
4.1.3 
Subject Exclusion Criteria .................................................................................. 19 
4.2 
Trial Treatments ................................................................................................... 22 
4.2.1 
Dose Selection/Modification............................................................................... 23 
4.2.2 
Timing of Dose Administration .......................................................................... 25 
4.2.3 
Trial Blinding/Masking ....................................................................................... 25 


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4.3 
Randomization or Treatment Allocation ............................................................ 25 
4.4 
Stratification .......................................................................................................... 25 
4.5 
Concomitant Medications/Vaccinations (allowed & prohibited) ..................... 25 
4.5.1 
Acceptable Concomitant Medications ................................................................ 26 
4.5.2 
Prohibited Concomitant Medications .................................................................. 26 
4.6 
Rescue Medications & Supportive Care ............................................................. 27 
4.6.1 
Supportive Care Guidelines ................................................................................ 27 
4.7 
Diet/Activity/Other Considerations ..................................................................... 29 
4.7.1 
Diet ...................................................................................................................... 29 
4.7.2 
Contraception ...................................................................................................... 29 
4.7.3 
Use in Pregnancy ................................................................................................ 29 
4.7.4 
Use in Nursing Women ....................................................................................... 31 
4.8 
Subject Withdrawal/Discontinuation Criteria ................................................... 31 
4.9 
Subject Replacement Strategy ............................................................................. 32 
4.10 
Clinical Criteria for Early Trial Termination ................................................... 32 
5.0 
TRIAL FLOW CHART ........................................................................................... 33 
5.1 
Study Flow Chart .................................................................................................. 33 
6.0 
TRIAL PROCEDURES ........................................................................................... 35 
6.1 
Trial Procedures ................................................................................................... 35 
6.1.1 Administrative Procedures .................................................................................. 35 
6.1.2 Clinical Procedures/Assessments ........................................................................ 36 
6.1.3 Laboratory Procedures/Assessments ................................................................... 37 
6.1.4 Other Procedures ................................................................................................. 39 
6.1.5 Visit Requirements .............................................................................................. 39 
6.2 
Assessing and Recording Adverse Events ...................................................... 4140 


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6.2.1 
Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Investigator and to Merck ................................................................................... 42 
6.2.2 
Reporting of Pregnancy and Lactation to the Investigator and to Merck ........... 42 
6.2.3 
Immediate Reporting of Adverse Events to the Investigator and to Merck ........ 43 
6.2.4 
Evaluating Adverse Events ................................................................................. 45 
6.2.5 
Sponsor Responsibility for Reporting Adverse Events ....................................... 48 
7.0 
STATISTICAL ANALYSIS PLAN ......................................................................... 47 
7.1 
Analysis Samples ................................................................................................... 47 
7.2 
Statistical Analysis Plan Summary ...................................................................... 48 
7.2.1 
Primary Efficacy Objective ................................................................................. 48 
7.2.2 
Primary Safety Objective .................................................................................... 49 
7.2.3 
Secondary Efficacy Objective ............................................................................. 49 
7.2.4 
Secondary Biomarker Objectives ........................................................................ 49 
7.3 
Stopping Rule for Excess Toxicity ....................................................................... 50 
7.4 
Justification of Design .......................................................................................... 50 
8.0 LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL 
SUPPLIES ................................................................................................................. 51 
8.1 
Investigational Product ........................................................................................ 51 
8.2 
Packaging and Labeling Information ................................................................. 51 
8.3 
Clinical Supplies Disclosure ................................................................................. 51 
8.4 
Storage and Handling Requirements .................................................................. 51 
8.5 
Returns and Reconciliation .................................................................................. 51 
9.0 
ADMINISTRATIVE AND REGULATORY DETAILS ....................................... 52 
9.1 
Confidentiality ....................................................................................................... 52 
9.2 
Compliance with Law, Audit and Debarment.................................................... 52 
9.3 
Compliance with Trial Registration and Results Posting Requirements ........ 52 


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9.4 
Quality Management System ............................................................................... 52 
9.5 
Data Management ................................................................................................. 52 
10.0 
LIST OF REFERENCES ....................................................................................... 543 
11.0 
APPENDICES ........................................................................................................... 58 
11.1 
ECOG Performance Status .................................................................................. 58 
11.2 
Common Terminology Criteria for Adverse Events V4.0 (CTCAE) ............... 58 


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TRIAL SUMMARY 
 
 
Title 
A Phase II study of Pembrolizumab as Post-remission Treatment of 
Patients > 60 with AML Who Are Not Transplantation Candidates 
Short Title 
Pembrolizumab as Maintenance Therapy for AML in CR1 
Protocol Number 
Phase 
Phase II 
Methodology 
Open label 
Study Center(s) 
Single-center 
Primary Objective 
To evaluate the time to relapse (TTR) in patients > 60 years with AML in 
complete 
remission 
undergoing 
post-remission 
therapy 
with 
pembrolizumab. 
Number of Subjects 
40 subjects 
Diagnosis and Main Inclusion 
Criteria 
Patients with AML in first complete remission/complete remission with 
incomplete count recovery who are not unable or unwilling to undergo 
allogeneic stem cell transplant or who allogeneic stem cell transplant is 
not indicated. 
Study Product, Dose, Route, 
Regimen 
Pembrolizumab, intravenous, 200mg, every 3 weeks with dosing 
adjustments as needed for toxicity 
Duration of administration 
Total duration of pembrolizumab is up to 2 years if patients tolerate the 
therapy and remain in complete remission 
Reference therapy 
Patients who achieve a complete response to induction chemotherapy 
followed by chemotherapy consolidation therapy who do not undergo 
allogeneic transplant are observed. Despite the high relapse rates in this 
group, there is not therapy that has been proven to be effective to prevent 
relapse. 
Statistical Methodology 
The relapse function will be estimated by using the Kaplan-Meier method. 
A 26% two-year TTR under the standard induction therapy is associated 
with a median of 12.3 months. The null hypothesis that the treatment with 
pembrolizumab offers no increase in TTR will be tested by determining if 
12.3 months is within an 80% confidence interval around the median, a 
one-sided α=0.10 test. 
Estimated Enrollment Period 
18-24 months 
Estimated duration of trial 
4 years, but with planned analysis at 18 months after last patient enrolled 
Duration of Participation 
2 years/patient 


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1.0 TRIAL DESIGN 
Trial Design 
This is a phase II, single-center, single-arm trial to evaluate the efficacy and safety of 
pembrolizumab in post-remission treatment of patients ≥ 60 years with AML who are not 
candidates for HCT. Patients must have achieved CR or CRi with induction chemotherapy and 
have an ECOG performance status of 0-1. Patients can receive no consolidation or up to 4 
cycles of consolidation per treating physicians’ preference. Patients are eligible if their last 
dose of chemotherapy was received within 3 months of trial enrollment. Remaining in CR or 
CRi is required prior to enrollment. The enrollment target for this study is 40 patients evaluable 
for efficacy. Planned analysis will occur 18 months after the initiation of treatment of the last 
patient on the trial. 
 
Trial Diagram 
 
 
 
 
 
 
 
 
2.0 OBJECTIVE(S) & HYPOTHESIS(ES) 
Primary Objective(s) & Hypothesis(es) 
(1) Efficacy Objective: To evaluate the time to relapse in patients > 60 years with AML in 
complete remission undergoing post-remission therapy with pembrolizumab 


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Hypothesis: Post-remission treatment with pembrolizumab will improve time to 
relapse compared to historical controls in patients > 60 years with AML who are not 
candidates for HCT. 
 
(2) Safety Objective: To evaluate the safety and tolerability of pembrolizumab in patients > 
60 years with AML 
 
Hypothesis: Post-remission treatment with pembrolizumab will be safe and tolerable 
in patients > 60 years with AML who are not transplantation candidates 
 
Secondary Objective(s) & Hypothesis(es) 
 
(1) Objective: To evaluate overall survival with post-remission pembrolizumab treatment in 
patients > 60 years with AML 
 
Hypothesis: Post-remission treatment with pembrolizumab will improve overall 
survival compared to historical controls (where the median OS is 17.2 months) in 
patients > 60 years with AML who are not candidates for HCT. 
 
Exploratory Objective 
 
(1) Objective: To evaluate the effect of pembrolizumab on AML blast-reactive T-cells by 
quantification of activated T and NK cells, which are predicted to increase, and 
regulatory T cells (Treg), which are predicted to decrease 
 
(2) Objective: To evaluate the effect of pembrolizumab on AML blast-reactive T-cells 
through functional analysis, through assessment of cytokine and Granzyme B/perforin 
expression in response to blast antigens. 
 
(3) Objective: To evaluate the effect of pembrolizumab on the immunosuppressive activity 
of exosomes, measured by their effects on NK-cell activity and T-cell expansion. 
 
3.0 BACKGROUND & RATIONALE 
Background 
3.1.1 
Pharmaceutical and Therapeutic Background 
 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades [1]. Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in 
various malignancies [2; 3; 4; 5; 6]. In particular, the presence of CD8+ T-cells and the ratio 
of CD8+ effector T-cells / FoxP3+ regulatory T-cells (Treg) 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, 


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including autoimmune reactions. PD-1 (encoded by the gene Pdcd1) is an Ig superfamily 
member related to CD28 and CTLA-4 and has been shown to negatively regulate antigen 
receptor signaling upon engagement of its ligands (PD-L1 and/or PD-L2) [7; 8]. The structure 
of murine PD-1 has been resolved [9]. 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 [7; 10; 11; 12]. 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 [13; 14]. 
 
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 [15; 16]. Expression has also been 
shown during thymic development on CD4-CD8- (double negative) T-cells as well as subsets 
of macrophages and dendritic cells [17]. 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 [18; 19; 20; 13]. 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 [13]. 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) [21]. This suggests that the PD-1/PD-L1 pathway plays a critical role in 
tumor immune evasion and should be considered as an attractive target for therapeutic 
intervention. 
 
Pembrolizumab is a potent and highly selective humanized monoclonal antibody (mAb) of the 
IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, 
PD-L1 and PD-L2. KeytrudaTM (Pembrolizumab) has recently been approved in the United 
Stated for the treatment of patients with unresectable or metastatic melanoma and disease 
progression following ipilumumab and, if BRAF V600 mutation positive, a BRAF inhibitor. 
 
3.1.2 
Clinical Trial Data 
 
Pembrolizumab is currently being investigated in a number of clinical trials in many solid 
tumors and hematologic malignancies. In the first open-label Phase I trial (PN001) of 
pembrolizumab in progressive or locally advanced metastatic carcinomas, enriched for 
melanoma and non-small cell lung cancer (NSCLC). The overall response rate across all dose 


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levels (2mg/kg every 3 weeks, 10mg/kg every 3 weeks, and 10mg/kg every 2 weeks) ranged 
from 26% for the melanoma patients previously exposed to ipilumimab [22] and 38.7% for the 
melanoma patients not previously exposed to ipilumimab (Investigator’s Brochure). The 
median PFS and PFS at 24 weeks in the patients exposed to ipilumimab was 17.5 weeks and 
41.7% and 28.4 weeks and 52.2% in the patients not exposed to ipilumimab. These overall 
response rate data demonstrate that pembrolizumab is active in the treatment of advanced 
melanoma. Similar promising response rates in NSCLC were seen, with an objective response 
rate of 21%, with a median progression free survival not yet reached with a minimum of 62 
weeks, with most responders remaining on treatment. 
 
Pembrolizumab has been generally well-tolerated with manageable side effects in most 
patients. Safety data from PN001 is available on 479 patients, all of whom received the last 
dose of medication by July 26, 2013. In the dose-escalation portion of the study, no DLTs were 
reported and the MTD was not identified. In the full patient cohort, nearly all patients (97.3%) 
experienced adverse events (AEs), of which 76.8% were considered drug related. Serious 
adverse events (SAEs) were reported in 30.1% of patients, but were considered potentially 
drug-related in 6.7% of patients. Furthermore, there were no patient deaths attributable to study 
medication. 
 
Adverse events were similar between dose schedules and disease groups. In melanoma 
patients, the most common drug-related adverse events of any grade were fatigue (34%), 
pruritus (22%), rash (18%), diarrhea (15%), arthralgia (13%) and nausea (11%). Grade 3-5 
drug-related AEs were reported in 11% of melanoma patients, with fatigue and diarrhea the 
most commonly reported, experienced in 1.7% and 0.7% of patients, respectively. Immune- 
related adverse events also routinely occurred in patients on pembrolizumab. In melanoma 
patients, the most commonly reported immune-related AEs include rash (3.2%), pruritis 
(2.9%), vitiligo (2.9%), hypothyroidism (2.7%), arthralgia (2.2%), diarrhea (2.2.%), and 
pneumonitis (1.9%). NSCLC patients experienced similar drug-related adverse events: rash 
(21%), pruritis (18%), fatigue (16%), diarrhea (13%), and arthralgia (11%). The only Grade 3- 
5 AE experienced in the NSCLC group was pulmonary edema occurring in 1 patient (2.6%). 
Immune-related AEs in NSCLC patients occurred in 3 of 38 patients (7.9%), and included 
hypothyroidism, hyperthyroidism, pruritis, and rash in one patient each, and diarrhea in 2 
patients. Most patients enrolled on PN001 did not discontinue study medication to due AEs. 
9.4% discontinued due to an AE, but only 4.2% of patients discontinued due to an AE that was 
considered related to study treatment. 
 
Rationale 
 
3.2.1 
Rationale for the Trial and Selected Subject Population 
 
Acute myeloid leukemia (AML) is a malignant hematopoietic disorder characterized by the 
unregulated growth of myeloid precursors (blasts) and associated marked reduction in normal 
hematopoiesis. It is the most common acute leukemia in adults, with an estimated 18,860 new 
cases of AML diagnosed per year in the United State and 10,460 deaths. [23] Disease related 
morbidity and mortality arise from cytopenias, leading to complications such as bleeding 
and/or infection, as well as end organ damage from the circulating blasts. If left untreated, 
AML can lead to death within weeks. [24] 


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The standard treatment for newly diagnosed AML consists primarily of an anthracycline 
combined with a nucleoside analogue, cytarabine. The goal of remission induction 
chemotherapy is the rapid restoration of normal bone marrow function. [25] Once a complete 
remission is attained, relapse invariably occurs without additional consolidation therapy. 
Consolidation approaches are based on prognosis and age, but may include 1-4 cycles of high 
dose cytarabine chemotherapy or allogeneic stem cell transplant. While consolidation therapy 
reduces relapse, up to 50% of younger patients still relapse. [26] 
 
Although standard therapeutic approaches are tailored to younger patients, the median age of 
diagnosis of acute myelogenous leukemia (AML) is 67 years. [27] Unfortunately, the outcomes 
for patients older than 60 years are quite poor. Population studies in AML report 5-year 
survival rates of 3% to 8% compared to up to 50% for younger patients. [28] Intensive 
induction therapy, as described above, remains the standard of care for those elderly patients 
who are able to tolerate it, but rates of complete remission (CR) range from 20% to 60% 
dependent on the number of adverse prognostic conditions present. [29] The 2-year DFS of 
patients >60 yrs of age with AML who undergo induction therapy has been consistently at 24- 
26% in two large studies conducted in 2001 and 2010. [30; 31] Unfortunately, there have been 
no important advances in induction therapy since then. 
 
Although patients >60 years old can obtain a morphologic CR, defined as hematopoietic 
recovery with <5% blasts present, relapse still occurs in up to 80% of these patients. [32] These 
high relapse rates demonstrates that the majority of patients >60 years old have submicroscopic 
residual disease (MRD), leading to subsequent relapse. Reduced intensity conditioned (RIC) 
allogeneic stem cell transplant (HCT) offers a survival benefit when performed after induction 
chemotherapy for a proportion of patients with high-risk AML. [33; 34; 35] Unfortunately, 
transplant-related mortality remains high in elderly patients and those with multiple 
comorbidities, limiting the availability of this consolidation approach for many patients over 
the age of 60. [35] In a prospective study aimed to offer RIC transplant to all eligible patients 
with high-risk AML over age 50, only 15% of patients in CR proceeded with allogeneic stem 
cell transplant. [36] New strategies to prevent relapse in older patients who are not eligible or 
willing to undergo an allogeneic transplant are desperately needed. 
 
Acute myeloid leukemia (AML) has historically been sensitive to immunotherapy. The graft- 
versus-leukemia (GVL) effect of allogeneic hematopoietic stem cell transplant (HCT) is a 
well-established, successful form of immunotherapy. AML is the most common indication for 
HCT in North America. [37] Donor lymphocyte infusions performed for relapsed AML, which 
rely solely on the GVL effect, lead to complete remission (CR) rates of 15-29%. [38; 39] The 
CRs attained through DLI are frequently durable. [40] 
 
Despite the sensitivity of AML to immune attack, the microenvironment in AML is 
immunosuppressive, facilitating immune tolerance of leukemia cells. In vitro studies have 
demonstrated that factors secreted by primary AML cells, particularly arginase II, can prevent 
T-cell activation and proliferation. [41; 42] Tregs are also critical mediators of 
immunosuppression in AML. [43] Increased Tregs are present in patients with AML at various 
stages of diagnosis and treatment. Tregs are increased at diagnosis in patients with AML 
compared to healthy controls [44; 45; 46] and higher frequencies at diagnosis are associated 
with a poor prognosis. [44; 45] Early recovery from both cytotoxic chemotherapy and 


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maintenance therapy for AML also led to increased frequencies of functional 
immunosuppressive Tregs. [47; 48] 
 
PD-1 and its ligands have emerged as an important contributor to the immunosuppressive 
microenvironment in AML. Many preclinical studies have demonstrated upregulation of the 
PD-1 pathway and the negative impact that it has on disease control in AML. In mice injected 
with a strain of AML, the percentage of CD8 T-cells expressing PD-1 dramatically increased 
in the liver, a major site of disease for AML dissemination. [49] Similarly, when AML cells 
are injected into mice and allowed to grow in the mouse, PD-L1 expression increases compared 
to baseline. [50] Furthermore, PD-1 knock-out mice with AML have slower progression of 
AML burden than wild-type (WT) mice and significantly longer survival. [49; 50] When a PD- 
1 blocking antibody is administered to WT mice with AML, those mice have a lower AML 
burden, more CD8+ cells infiltrating the liver, and longer survival. [50] 
 
PD-1 and its ligands are also upregulated on immune cells and leukemic cells in humans with 
AML. One study of 124 patients with myeloid malignancies, including 69 with 
myelodysplastic syndrome (MDS) and 9 with AML sampled at various stages of treatment 
found that PD-L1 mRNA expression level was upregulated by >2 fold in 36% and 25% of 
CD34+ cells of those with MDS and AML respectively compared to CD34+ normal control 
cells. [51] Another cohort of 154 patients with AML demonstrated no significant increase in 
surface PD-L1 expression on AML blasts at initial diagnosis compared to myeloid precursors 
cells from healthy controls. However, stimulation with IFN- significantly increased PD-L1 
expression in AML blasts but not in myeloid precursors from normal controls. [52] 
Interestingly, PD-L1 expression increased more dramatically with IFN- stimulation from 
samples of myeloid precursors cells from patients in complete remission or at relapse than 
newly diagnosed patients. [52] These findings demonstrate that PD-L1 expression on AML 
blasts definitely occurs in a substantial portion of patients with AML. Understanding of the 
timing of expression requires more study larger cohorts where PD-1 and its ligands are 
measured longitudinally. However, existing data suggests the PD-1 pathway, like the Treg 
population in AML, [48] may be particularly increased upon recovery from cytotoxic 
chemotherapy. [52] 
 
PD-L1 expression on AML blasts pre-treatment does not appear to have prognostic 
significance in small cohorts of patients with AML. In 72 patients with MDS and AML tested 
prior to any treatment, PD-L1 expression in bone marrow samples was not associated with 
worse survival. [51] However, in a smaller cohort of those 72 patients treated on a clinical trial 
with hypomethylating agents and vorinostat, development of PD-L1 or PD-L2 upregulation on 
peripheral blood mononuclear cells during therapy was associated with a significantly worse 
median survival, 6.6 months compared to 11.7 months in those with without overexpression 
of PD-1 ligands. [51] Similarly, Norde et al. found that in patients who relapsed late after 
allogeneic transplant despite the presence of circulating alloreactive T-cells to hematopoietic 
cell-restricted minor histocompatibility antigens, PD-L1 was highly expressed on the leukemic 
cells at baseline or upon stimulating with IFN-. [53] Furthermore, stimulation of allogeneic 
CD3+ T-cells with those PD-L1-expressing AML cells led to significantly enhanced T-cell 
proliferation and cytokine production when performed in presence of PD-1 blockade compared 
to isotype controls. [53] These findings suggest that the development of functionally impaired 


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T-cells during therapy through manipulation of the PD-1 checkpoint leads to impaired control 
of leukemia, and that PD-1 blockade may offer therapeutic advantages. 
 
In summary, patients >60 years old with AML have a dismal prognosis. Even though many of 
these patients are able to obtain a CR, relapse occurs in the vast majority of patients. RIC 
transplant may reduce relapse rates in this population, but is only feasible in a minority of 
patients. AML’s immunosuppressive microenvironment in general and PD-1/PD-L1 
upregulation in particular appears to increase the risk of relapse. Importantly, PD-1 and its 
ligands are particularly increased after therapy compared to initial diagnosis. As such, PD-1 
inhibition with pembrolizumab offers to limit leukemic cell immune escape, thereby allowing 
the patient’s immune system to eradicate the submicroscopic residual disease and reducing 
relapse rates. 
 
3.2.2 
Rationale for Dose Selection/Regimen/Modification 
 
An open-label Phase I trial (Protocol 001) is being conducted to evaluate the safety and clinical 
activity of single agent pembrolizumab. 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 pembrolizumab showed 
evidence of target engagement and objective evidence of tumor size reduction at all dose levels 
(1 mg/kg, 3 mg/kg and 10 mg/kg Q2W). No MTD has been identified to date. 10.0 mg/kg 
Q2W, the highest dose tested in PN001, was the dose and schedule utilized in Cohorts A, B, C 
and D of this protocol to test for initial tumor activity. Recent data from other clinical studies 
within the pembrolizumab program has shown that a lower dose of pembrolizumab and a less 
frequent schedule may be sufficient for target engagement and clinical activity. 
 
PK data analysis of pembrolizumab administered Q2W and Q3W showed slow systemic 
clearance, limited volume of distribution, and a long half-life (refer to Investigator Brochure). 
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 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 pembrolizumab 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. Pembrolizumab 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 pembrolizumab 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 


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and melanoma indications. Therefore, there are no anticipated changes in exposure between 
different indication settings. 
 
The rationale for further exploration of 2 mg/kg and comparable doses of Pembrolizumab in 
solid tumors was 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. 
 
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. 
 
3.2.3 
Rationale for Endpoints 
 
3.2.3.1 Efficacy Endpoints 
 
3.2.3.1.1 
Primary Endpoint: Time to relapse (TTR) 
 
The primary endpoint for this study is time to relapse (TTR). Patients with AML >60 years old 
in CR have a high relapse rate, which is the primary cause of death. The goal of PD-1 inhibition 
in AML is to harness the patient’s immune system to eradicate submicroscopic disease and 
prevent relapse. As such, TTR was selected as the primary efficacy endpoint. TTR has been 
used as the endpoint in many similar clinical trials, and using this endpoint allow for valid 
comparison to historical controls. TTR is defined as survival in the absence of relapse, as 
defined by the Cheson criteria (see Section 12.3). 
 
3.2.3.1.2 
Second Efficacy Endpoints: Overall Survival 
 
Overall survival is limited in AML, and the goal of all new therapy options in AML is to 
enhance overall survival. However, overall survival may be altered by subsequent therapy 
choices after relapse. As such, it will be measured as a secondary but not the primary endpoint. 
 
3.2.3.2 Biomarker Research 
 
Under normal physiologic conditions, check-point inhibition is a protective mechanism which 
prevents expansion of dangerous T cells capable of harming normal tissues. Tumors, including 


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PD-L1+ AML blasts, have corrupted this protective pathway by “bombarding” PD-1+ T cells, 
including anti-leukemia T cells, with the ligand overexpressed on AML blasts, thus inducing 
functional T-cell paralysis. The so called “exhaustion” of anti-leukemic T cells is, in fact, 
tumor-driven, chronically silencing activated T cells which are unable to mediate anti- 
leukemia activity in the tumor environment. 
One objective of pembrolizumab therapy in AML is to rescue anti-leukemia T cells from blast- 
mediated chronic check-point inhibition by targeting PD-1 and allowing T cells to exercise 
anti-AML blast activity. Another objective is to decrease immune suppression mediated by 
regulatory T cells (Treg) which are increased in the frequency and activity in AML. [44] Treg, 
especially activated Treg present in patients with cancer, express PD-1 and it is likely that they 
are targeted by pembrolizumab via up-regulated antibody-mediated cellular cytotoxicity 
(ADCC). It is possible that this mechanism is responsible for, or contributes to, recovery of 
anti-leukemia T cell activity by removing Treg. As ADCC is largely mediated by Ab-armed 
activated NK cells, their functional recovery from check-point inhibition is an important 
consequence of pembrolizumab therapy. Exosomes produced by tumor cells or leukemic blasts 
are known to carry immunosuppressive cargo and to contribute to immune dysfunction of T 
cells and NK cells. We have recently observed that plasma-derived exosomes obtained from 
patients with AML carry PD-L1. We, therefore, expect that pembrolizumab would neutralize 
immunosuppressive exosomes. 
In this study, we will measure recovery in the frequency/absolute numbers of activated immune 
cells and anti-leukemic functions of T cells after pembrolizumab therapy. We will measure 
anti-AML reactivity of T cells using autologous AML blast-derived antigens for ex vivo 
activation of T cells. We will monitor changes in the frequency and absolute numbers of Treg 
in the patients’ circulation. In addition, we will study levels and cargo of exosomes in the 
plasma. The hypothesis is that these immune parameters will be altered following 
pembrolizumab therapy and that change in the immune cell numbers and functions will provide 
insights into cellular mechanisms responsible for potential clinical responses observed in the 
proposed study. 
Blood/tissue specimens will be saved at University of Pittsburgh Health Sciences Tissue Bank 
in the Department of Health Sciences Core Research where specimens will be coded using an 
Honest Broker. Correlative studies will be conducted in the laboratory of Dr. Theresa 
Whiteside at the University of Pittsburgh. Blood/tissue specimens will be labeled with study 
number not patient identifiers. Information linking these study numbers with the subject’s 
identity will be kept separate from the research records. Any breech in confidentiality will be 
reported to the IRB. 
3.2.3.2.1 Quantitative study of T-cell subsets 
Assay Description: 30ml in non-citrate tubes (heparinized) and 10ml in citrate tube(s) of 
peripheral blood will be obtained at the following time points: at diagnosis, prior to 
pembrolizumab initiation, prior to Cycles 2, 4, 8, 17 (± 1 treatment cycle) , and at disease 
progression or the end of 2 years of treatment, whichever comes first. We will perform 
immunofluorescence staining and multiparameter flow cytometry to evaluate expression of 
PD-L1 and PD-1 on blasts and effector cells and changes in the patients’ lymphocyte subsets 
and the expression of their surface receptors at these specific time points. The conjugated 
monoclonal antibodies CD 45, 3, 4, 8, 25, 39, 69, 56, FOXP3 and NKp46 will be used in 


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combinations to evaluate Total CD8+ Tcells and activated T-cells, total and activated CD4+ 
Tcells, total and activated NK cells and Treg. 
Assay Performance: The frequency of the aforementioned T-cell and NK cell subsets in healthy 
donors is well documented. On the other hand, the frequency of these T and NK cells subset 
in AML patients is incompletely documented. PBMCs from 15 age-matched healthy donors 
will be studied as control group. A sample that is positive for above markers will be used as 
the positive control for the staining as well. Isotype controls for all Abs will be used. Flow 
cytometry is an established methodology with well-defined accuracy and precision. 
Data interpretation and considerations: The proportions and absolute numbers of total and 
activated (CD69+/ CD25+) CD8+ T-cells, total and activated CD4+ Tcells, and CD3-CD56+ 
NK cells in AML patients at diagnosis and prior to pembrolizumab will be compared to values 
obtained with PBMC of healthy donors. These values in AML patients are expected to be lower 
than the established normal, suggesting the presence of T-cell suppression and/or apoptosis. 
Following pembrolizumab therapy, these values are expected to increase. Tregs 
(CD4+CD39+FOXP3+ and CD4+FOXP3+CD25+PD-1+) are expected to be elevated in 
frequency and absolute numbers in AML patients prior to pembrolizumab therapy. We expect 
Treg percentages/absolute numbers to decrease after pembrolizumab therapy based on the 
hypothesis that this Ab targets PD-1+ Treg and eliminates them. Expression of PD-1 is 
expected to decrease after therapy. This would suggest that pembrolizumab restores anti- 
leukemia immune responses not only by removing the checkpoint blockade and allowing for 
immune cell activation but also by removing Treg-mediated suppression. 
 
3.2.3.2.2 T-cell expression of IFN- γ and Granzyme B/Perforin in T-cells stimulated ex 
vivo with autologous AML blast-derived antigens 
Assay Description: Cryopreserved PBMCs will be thawed and washed. Autologous AML 
blasts will be separated from PBMCs at diagnosis, cryopreserved and stored. Just prior to the 
assay, AML blasts will be repeatedly frozen/thawed to solubilize the potentially relevant 
antigens. The protein content of the lysates will be determined. Lysates of autologous AML 
blasts will be used for in vitro stimulation of lymphocytes in PBMC. Antigen-presenting cells 
(APC) in PBMCs will be able to present antigens in the lysate to immune cells. Stimulation 
may be antigen-specific via the Tcell receptor (TCR) on cognate T cells or non-specific via 
TLRs or other receptors on immune cells responding to antigens in the lysate. IFN- γ 
expression by CD8+ T-cells and granzyme B (GrB) and perforin expression by CD8 T-cells 
and NK cells will be measured as previously described. [54] Briefly, lysates of autologous 
blasts will be added to PBMC at 3 different concentrations and incubated for 18 h. Cells 
harvested from these cultures will be incubated with mAbs specific for surface markers (CD3, 
CD4, CD8, CD56), fixed with 4% paraformaldehyde in phosphate buffered saline (PBS) for 
20 min at room temperature, washed once with PBS containing 0.5% bovine serum albumen 
(BSE) and 2 nM ethylene diamine triacetic acid, permeabilized with PBS containing 0.5% 
BSA and 0.1% saponin, washed and stained with pre-titrated anti-GrB-PE, anti-perforin-FITC, 
and IFN-γ-PE. Flow cytometry will be performed immediately on a Beckman Coulter equipped 
with Expo32 software. Percentages of IFN-γ-positive cells among CD8+ T cells and 
GrB/Perforin-positive CD8+ T cells and CD3-CD56+NK cells will be determined. 


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Assay Performance: This is a two-step assay selected for monitoring of immune cell (T and 
NK cell) responses to a mix of blast-derived antigens. [54] This is an autologous system, with 
PBMC serving as APC. The assay can be readily adapted to serial monitoring. PBMC and 
autologous lysates will be cryopreserved and thawed for culture. Serially-collected specimens 
of each patient (as described in Section 4.2.3.2.1) will be batched and tested in one assay to 
avoid inter-assay variability. Culture controls set in parallel with patients’ samples will be 
PBMCs of a normal donor (cryopreserved in bulk to supply the same control for all patients’ 
cultures) stimulated with anti-CD3/CD28 Abs. Also, PBMCs of each evaluated AML patient 
will be stimulated with anti-CD3/CD28 Abs to serve as control for the ability to respond to 
TCR-mediated signals. 18h activation was previously shown to be a sufficient time period for 
induction of intra-cytoplasmic cytokines or GrB/perforin expression. [54] Multicolor flow 
cytometry assessments after cell permeabilization and staining with labeled antibodies to T 
and NK cell surface markers and the relevant cytokines are routinely performed on an 
instrument which is calibrated daily. The SOP for the assay is on file. 
Data interpretation and considerations: This assay should be able to inform us about the ability 
of AML patients’ immune cells to respond by cytokine or GrB/perforin expression to external 
stimulatory signals. [55] We expect from 10 to 15% of CD8+T cells of a normal donor to 
respond to activation with anti-CD3/CD28 Abs by up-regulating expression of these mediators. 
We expect to see a much lower frequency of responsive T-cells in AML patients. Only a small 
percentage of immune cells in AML patients (2-4%) are expected to respond to AML blast- 
derived lysates. Cells of normal donors (used as controls) are likely to respond but this will 
reflect alloantigen- rather than AML antigen-driven response. In patients receiving 
pembrolizumab, we expect to see recovery of T- cell responses to anti-CD3/CD28 Abs and of 
T and NK cell responses to antigens in AML blast-derived lysates by up-regulated expression 
of either IFN-g or GrB/perforin or both. 
The proportions/ absolute numbers of CD8+ Tells and NK cells expressing IFN-γ as well as 
CD8+ T-cells and NK cells expressing GrB and Perforin will be evaluated at diagnosis and 
just prior to starting pembrolizumab therapy and will be compared to the proportions/absolute 
numbers of positive cells at pre-determined intervals after pembrolizumab treatment. The 
numbers of CD8+ T cells and NK cells expressing IFN- γ, GrB and/or perforins are expected 
to increase from values at diagnosis and those prior to pembrolizumab treatment. This increase 
would suggest recovery of normal immune responses to general stimulatory signals and to 
AML blast-derived signals, providing evidence for the effect of pembrolizumab on AML blast- 
reactive T-cells and NK cells through elimination of the checkpoint blockade and/or potentially 
also through ADCC directed at Treg. 
 
3.2.3.2.3 : Effects of pembrolizumab on functions and levels of exosomes 
 
Exosomes are small (30-150mm) vesicles secreted by all cell types and present in all body 
fluids. [56] While exosome secretion occurs under physiologic conditions, tumor cells are avid 
exosome producers. In AML, blast-derived exosomes carry an immunosuppressive cargo. 
Furthermore, plasma exosomes in patients with newly diagnosed with AML prior to any 
therapy had higher levels of exosomes (in µg protein/mL plasma) compared to normal donors 
[57]. Ex vivo, exosomes decrease NK-cell cytotoxicity and down-regulate NKG2D expression 
in normal NK cells. More recently, we have shown elevated levels of exosomes in AML 
patients that are in complete remission and that these exosomes contain PD1 and PD-L1. [58] 


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We hypothesize that the use of pembrolizumab will affect the immunosuppressive activity of 
exosomes. 
 
Assay Description: Exosomes will be isolated from the plasma of AML patients using 
differential centrifugation, ultrafiltration and size-exclusion chromatography on mini- 
Sepharose 2a columns. Using Western blotting, we will identify the exosomal cargo, including 
PD1, PD-L1, TGF-β1 and CD39 and CD73. To study immune suppression mediated by 
exosomes, AutoMACs-isolated normal NK or T cells will be co-incubated with exosomes 
isolated at the time of enrollment prior to pembrolizumab therapy. The levels of exosomes and 
the effects on the function of the immune cells will be monitored serially at diagnosis, prior to 
pembrolizumab initiation, at 1, 3, 6, 12, and 24 months post initiation of pembrolizumab . 
 
Data interpretation and considerations: The hypothesis is that suppression of normal NK or T 
cells by AML exosomes and concomitant activation of Treg reverse with the use of 
pembrolizumab. Silencing of the negative signals should diminish or ablate exosome-mediated 
immune suppression and restore immune cell functions. 
 
4.0 METHODOLOGY 
Entry Criteria 
4.1.1 Diagnosis/Condition for Entry into the Trial 
 
Subject eligible for entry into the trial must have a diagnosis of non-M3 AML and currently 
be in first CR/CRi (see Appendix I for response criteria). Patients should receive 2-4 cycles 
of consolidation, provided that the last dose of either induction chemotherapy or 
consolidation chemotherapy falls within 3 months prior to enrollment in this trial. A patient 
receiving less than 2 of consolidation therapy is eligible only if they are deemed intolerant to 
consolidation therapy by the treating physician. 
 
4.1.2 Subject Inclusion Criteria 
 
In order to be eligible for participation in this trial, the subject must: 
 
1. Be willing and able to provide written informed consent for the trial. 
 
2. Be  60 years of age on day of signing informed consent. 
3. Have a newly diagnosed AML, based on World Health Organization criteria [59], 
currently in 1st CR/CRi (see 12.3 for definition of CR/CRi) on a bone marrow biopsy 
performed within 4 weeks of study enrollment. 
 
4. Have received the last dose of induction or consolidation chemotherapy within 3 
months of enrollment. 
 
5. Have a performance status of <1 on the ECOG Performance Scale. 


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6. Demonstrate adequate organ function as defined in Table 1, with all screening labs 
performed within 10 days of treatment initiation. 
 
Table 1: Adequate Organ Function Laboratory Values 
 
System 
Laboratory Value 
Hematological 
Absolute neutrophil count (ANC) 
≥1,000 /mcL with no growth factor support in the previous 3 
weeks 
Platelets 
≥50,000 / mcL (transfusion independent) 
Hemoglobin 
≥9 g/dL or ≥5.6 mmol/L 
Renal 
Serum creatinine OR 
Measured or calculateda creatinine 
clearance 
(GFR can also be used in place of 
creatinine or CrCl) 
≤1.5 X upper limit of normal (ULN) OR 
≥60 mL/min for subject with creatinine levels > 1.5 X 
institutional ULN 
Hepatic 
Serum total bilirubin 
≤ 1.5 X ULN OR 
Direct bilirubin ≤ ULN for subjects with total bilirubin levels > 
1.5 ULN 
AST (SGOT) and ALT (SGPT) 
≤ 2.5 X ULN 
Coagulation 
International Normalized Ratio (INR) or 
Prothrombin Time (PT) 
Activated Partial Thromboplastin Time 
(aPTT) 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
aCreatinine clearance should be calculated per institutional standard. 
 
7. Transfusion independent (no red blood cell or platelet transfusions in the preceding 2 
weeks of screening). 
 
8. Female subject of childbearing potential require a negative pregnancy test 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. 
 
9. Female subjects of childbearing potential must be willing to use 2 methods of birth 
control or be surgically sterile, or abstain from heterosexual activity for the course of 
the study through 120 days after the last dose of study medication (Reference Section 
5.7.2). Subjects of childbearing potential are those who have not been surgically 
sterilized or have not been free from menses for > 1 year. 
 
10. Male subjects must agree to use an adequate method of contraception starting with the 
first dose of study therapy through 120 days after the last dose of study therapy. 
 
4.1.3 Subject Exclusion Criteria 
 
The subject must be excluded from participating in the trial if the subject: 
 
1. Has a diagnosis of Acute Promyelocytic Leukemia (APL) as defined by the World 
Health Organization. [59] 


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2. Eligible and willing to proceed with an allogeneic stem cell transplant with an 
acceptable stem cell donor 
 
3. Has favorable risk AML as defined by the presence of isolated t(8;21) or inv(16) or 
t(16;16)(p13.1;q22) on a standard karyotype or mutated NPM1 with concurrent wild- 
type FLT3 on molecular testing. 
 
4. Is currently participating in or has participated in a study of an investigational agent 
or using an investigational device within 4 weeks of the first dose of treatment. 
 
5. 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. 
 
6. Has had a prior monoclonal antibody within 4 weeks prior to study Day 1 or who has 
not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents 
administered more than 4 weeks earlier. 
 
7. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy 
within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at 
baseline) from adverse events due to a previously administered agent. 
 
- 
Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion 
and 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. 
 
8. Has a known additional malignancy that is progressing or requires active treatment. 
Exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the 
skin, or in situ cervical cancer that has undergone potentially curative therapy. 
 
9. Has known active central nervous system (CNS) involvement. Subjects with 
previously treated CNS disease may participate provided they are stable (without 
evidence of CNS leukemia at the time of screening and any neurologic symptoms 
have returned to baseline) and are not using steroids for at least 7 days prior to trial 
treatment. 
 
10. Has an active automimmune disease requiring systemic treatment within the past 3 
months or a documented history of clinically severe autoimmune disease, or a 
syndrome that requires systemic steroids or immunosuppressive agents. Subjects 
with vitiligo or resolved childhood asthma/atopy are an exception to this rule, and are 
eligible. Subjects that require intermittent use of bronchodilators or local steroid 
injections would not be excluded from the study. Subjects with hypothyroidism 
stable on hormone replacement or Sjogren’s syndrome will not be excluded from the 
study. 


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11. Has a history of (non-infectious) pneumonitis that required steroids or current 
pneumonitis. 
 
12. Has an uncontrolled, life-threatening active infection. 
 
13. 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. 
 
14. Has known psychiatric or substance abuse disorders that would interfere with 
cooperation with the requirements of the trial. 
 
15. Is pregnant or breastfeeding or expecting to conceive or father children within the 
projected duration of the trial, starting with the pre-screening or screening visit 
through 120 days after the last dose of trial treatment. 
 
16. Has received prior therapy with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, 
or anti-Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) antibody (including 
ipilimumab or any other antibody or drug specifically targeting T-cell co-stimulation 
or checkpoint pathways). 
 
17. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies). 
 
18. Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA 
[qualitative] is detected). 
 
19. Has received a live vaccine within 30 days prior to the first dose of trial treatment. 
 
Trial Treatments 
 
The treatment to be used in this trial is outlined below in Table 2.


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Table 2: Trial Treatment 
 
Drug 
Dose 
Dose 
Frequency 
Route of 
Administration 
Regimen/Treatment 
Period 
Use 
pembrolizumab 
200 mg 
Every 3 
weeks 
IV infusion 
Up to 2 years 
Experimental 
The pembrolizumab dosing interval may be increased due to toxicity as described in Section 
4.2.1.2. 
 
Trial treatment should begin on the day of treatment assignment, or as close as possible to the 
day at which treatment is assignment. Treatment must occur within 10 days of official 
enrollment, or all screening tests must be repeated. 
 
4.2.1 Dose Selection/Modification 
 
4.2.1.1 Dose Selection 
 
The rationale for selection of doses to be used in this trial is provided in Section 4.0 – 
Background and Rationale. 
 
Details on preparation and administration of Pembrolizumab are provided in the Pharmacy 
Manual. 
 
4.2.1.2 Dose Modification 
 
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. Adverse experiences will be graded and 
recorded throughout the study and during the follow-up period according to NCI CTCAE 
Version 4.0. Pembrolizumab must be withheld for drug-related toxicities and severe or life- 
threatening drug-related AEs as per Table 3 below. See Section 4.6.1 and Events of Clinical 
Interest Guidance Document for supportive care guidelines, including use of corticosteroids. 
 
Table 3 
 
Dose Modification Guidelines for Drug-Related Adverse Events 
 
 
 
Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting Treatment 
Discontinue Subject 
Diarrhea/Colitis 
2-3 
Toxicity resolves to Grade 0-1. 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
4 
Permanently discontinue 
Permanently discontinue 
AST, ALT, or 
Increased Bilirubin 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose. 


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Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting Treatment 
Discontinue Subject 
3-4 
Permanently discontinue 
Permanently discontinue 
Type 1 diabetes 
mellitus (if new 
onset) or 
Hyperglycemia 
T1DM or 
3-4 
Hold Pembrolizumab for new onset Type 1 
diabetes 
mellitus 
or 
Grade 
3-4 
hyperglycemia associated with evidence of 
beta cell failure. 
Resume Pembrolizumab when patients are clinically and 
metabolically stable. 
Hypophysitis 
2-3 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
4 
Permanently discontinue 
Permanently discontinue 
Hyperthyroidism 
3 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
4 
Permanently discontinue 
Permanently discontinue 
Hypothyroidism 
2-4 
Therapy with Pembrolizumab can be 
continued while treatment for the thyroid 
disorder is instituted 
Therapy with Pembrolizumab can be continued while treatment for 
the thyroid disorder is instituted. 
Infusion Reaction 
3-4 
Permanently discontinue 
Permanently discontinue 
Pneumonitis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
Renal Failure or 
Nephritis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
3-4 
Permanently discontinue 
Permanently discontinue 
All Other Drug- 
Related Toxicity1 
3 or Severe 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks. 
4 
Permanently discontinue 
Permanently discontinue 
Note: Permanently discontinue for any severe or Grade 3 drug-related AE that recurs or any life-threatening event. 
1 Patients with intolerable or persistent Grade 2 drug-related AE may hold study medication at physician discretion. Permanently discontinue study drug for 
persistent Grade 2 adverse reactions for which treatment with study drug has been held, that do not recover to Grade 0-1 within 12 weeks of the last dose. 
 
 
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 Investigator. The reason for 
interruption should be documented in the patient's study record. 
 
Subjects with a history of AML who undergo induction therapy may have intermittent 
thrombocytopenia or neutropenia. This may be due to relapse of AML but could also be due 
to viral infection, a medication effect, or an unexplained by transient etiology. 
Thrombocytopenia and neutropenia are not commonly (>10%) experienced adverse event with 
pembrolizumab in other clinical studies in solid tumors (Investigator’s Brochure). As such, 
pembrolizumab treatment should not be withheld for a platelet count of >30,000/mcL or an 
absolute neutrophil count of >500/mcL unless the investigator feels that disease assessment is 
warranted. However, if platelet count is <30,000/mcL or ANC is <500/mcL, pembrolizumab 
therapy should be held and the etiology of the thrombocytopenia evaluated. If platelets increase 
to >30,000/mcL and ANC to >500/mcL within 3 weeks, pembrolizumab may be restarted at 
the current dose. If a subject develops febrile or prolonged neutropenia which requires growth 


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factor support at the discretion of the investigator, pembrolizumab should be permanently 
discontinued. 
 
The dose may be held based on assessment of the patient at the time of the scheduled dose. If 
the dose is held, the patient will be reassessed weekly (or more frequently if clinically 
indicated) and dosing will be restarted at the discretion of the principal investigator. 
 
4.2.2 Timing of Dose Administration 
 
Trial treatment should be administered on Day 1 of each cycle after all procedures/assessments 
have been completed as detailed on the Trial Flow Chart (Section 5.0). Trial treatment may 
be administered within a window of +/-3 days from the scheduled Day 1 of each cycle. 
 
All trial treatments will be administered on an outpatient basis. 
 
Pembrolizumab 200 mg will be administered as a 30-minute IV infusion every 3 weeks. 
Sites should make every effort to target infusion timing to be as close to 30 minutes as 
possible. However, given the variability of infusion pumps from site to site, a window of -5 
minutes and +10 minutes is permitted (i.e., infusion time is 30 minutes: -5 min/+10 min). Vital 
signs should be monitored within 60 minutes prior to infusion and  if reaction occurs every 
15-30 minutes until symptoms resolve. 
 
The Pharmacy Manual contains specific instructions for the preparation of the Pembrolizumab 
infusion fluid and administration of infusion solution. 
 
4.2.3 Trial Blinding/Masking 
 
This is an open-label trial; therefore, the investigators, research staff, and subject will know 
the treatment administered. 
 
Randomization or Treatment Allocation 
 
This is an open-label, single arm, phase II trial in which all enrolled subjects will receive the 
study drug. 
 
Stratification 
 
As a single arm study, there is no need for stratification of patients between arms. 
 
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. Treating sub-investigators should discuss any questions 
regarding this with the Principal Investigator. The final decision on any supportive therapy or 
vaccination rests with the investigator and/or the subject's primary physician. 


Version 5, dated 06/03/2019 
26 
 
4.5.1 
Acceptable Concomitant Medications 
 
All treatments that the investigator considers necessary for a subject’s welfare may be 
administered at the discretion of the investigator in keeping with the community standards of 
medical care. All concomitant medication will be recorded on the case report form (CRF) 
including all prescription, over-the-counter (OTC), herbal supplements, and IV medications 
and fluids. If changes occur during the trial period, documentation of drug dosage, frequency, 
route, and date may also be included on the CRF. 
 
All concomitant medications received within 28 days before the first dose of trial treatment 
and 30 days after the last dose of trial treatment should be recorded. Concomitant medications 
administered up to 30 days after the last dose of trial treatment should be recorded for SAEs 
and ECIs as defined in Section 6.2.3. 
 
4.5.2 
Prohibited Concomitant Medications 
 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase (including retreatment for post-complete response relapse) of this trial: 
 
• Anti-cancer systemic chemotherapy or biological therapy 
• Immunotherapy not specified in this protocol 
• Chemotherapy not specified in this protocol 
• Investigational agents other than pembrolizumab 
• 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, chicken pox, yellow fever, rabies, BCG, and 
typhoid (oral) vaccine. Seasonal influenza vaccines for injection are generally killed 
virus vaccines and are allowed; however intranasal influenza vaccines (e.g. Flu-Mist®) 
are live attenuated vaccines, and are not allowed. 
 
• Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
event of clinical interest of suspected immunologic etiology. The use of physiologic 
doses of corticosteroids may be approved after consultation with the Sponsor. 
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. 
 
The Exclusion Criteria describes other medications which are prohibited in this trial. 
There are no prohibited therapies during the Post-Treatment Follow-up Phase. 


Version 5, dated 06/03/2019 
27 
 
Rescue Medications & Supportive Care 
 
4.6.1 Supportive Care Guidelines 
 
Subjects should receive appropriate supportive care measures as deemed necessary by the 
treating investigator. Suggested supportive care measures for the management of adverse 
events with potential immunologic etiology are outlined below and in greater detail in the ECI 
guidance document. Where appropriate, these guidelines include the use of oral or intravenous 
treatment with corticosteroids as well as additional anti-inflammatory agents if symptoms do 
not improve with administration of corticosteroids. Note that several courses of steroid 
tapering may be necessary as symptoms may worsen when the steroid dose is decreased. For 
each disorder, attempts should be made to rule out other causes such as metastatic disease or 
bacterial or viral infection, which might require additional supportive care. The treatment 
guidelines are intended to be applied when the investigator determines the events to be related 
to Pembrolizumab. 
 
Note: if after the evaluation the event is determined not to be related, the investigator is 
instructed to follow the ECI reporting guidance but does not need to follow the treatment 
guidance (as outlined in the ECI guidance document). Refer to Section 4.2.1 for dose 
modification. 
 
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or 
skin photography as part of evaluation of the event. Suggested conditional procedures, as 
appropriate, can be found in the ECI guidance document. 
 
• Pneumonitis: 
o For Grade 2 events, treat with systemic corticosteroids. When symptoms 
improve to Grade 1 or less, steroid taper should be started and continued over 
no less than 4 weeks. 
o For Grade 3-4 events, immediately treat with intravenous steroids. 
Administer additional anti-inflammatory measures, as needed. 
o Add prophylactic antibiotics for opportunistic infections in the case of 
prolonged steroid administration. 
 
 
• Diarrhea/Colitis: 
Subjects should be carefully monitored for signs and symptoms of enterocolitis (such 
as diarrhea, abdominal pain, blood or mucus in stool, with or without fever) and of 
bowel perforation (such as peritoneal signs and ileus). 
 
o All subjects who experience diarrhea/colitis should be advised to drink liberal 
quantities of clear fluids. If sufficient oral fluid intake is not feasible, fluid and 
electrolytes should be substituted via IV infusion. For Grade 2 or higher 
diarrhea, consider GI consultation and endoscopy to confirm or rule out colitis. 
o For Grade 2 diarrhea/colitis that persists greater than 3 days, administer oral 
corticosteroids. 


Version 5, dated 06/03/2019 
28 
 
o For Grade 3 or 4 diarrhea/colitis that persists > 1 week, treat with intravenous 
steroids followed by high dose oral steroids. 
o When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks. 
 
 
• Type 1 diabetes mellitus (if new onset, including diabetic ketoacidosis [DKA]) or 
≥ Grade 3 Hyperglycemia, if associated with ketosis (ketonuria) or metabolic 
acidosis (DKA) 
 
o For T1DM or Grade 3-4 Hyperglycemia 
▪ Insulin replacement therapy is recommended for Type I diabetes 
mellitus and for Grade 3-4 hyperglycemia associated with metabolic 
acidosis or ketonuria. 
▪ Evaluate patients with serum glucose and a metabolic panel, urine 
ketones, glycosylated hemoglobin, and C-peptide. 
 
• Hypophysitis: 
 
o For Grade 2 events, treat with corticosteroids. When symptoms improve to 
Grade 1 or less, steroid taper should be started and continued over no less than 
4 weeks. Replacement of appropriate hormones may be required as the steroid 
dose is tapered. 
o For Grade 3-4 events, treat with an initial dose of IV corticosteroids followed 
by oral corticosteroids. When symptoms improve to Grade 1 or less, steroid 
taper should be started and continued over no less than 4 weeks. Replacement 
of appropriate hormones may be required as the steroid dose is tapered. 
 
 
• Hyperthyroidism or Hypothyroidism: 
Thyroid disorders can occur at any time during treatment. Monitor patients for changes 
in thyroid function (at the start of treatment, periodically during treatment, and as 
indicated based on clinical evaluation) and for clinical signs and symptoms of thyroid 
disorders. 
 
o Grade 2 hyperthyroidism events (and Grade 3-4 hypothyroidism): 
▪ In hyperthyroidism, non-selective beta-blockers (e.g. propranolol) are 
suggested as initial therapy. 
▪ In hypothyroidism, thyroid hormone replacement therapy, with 
levothyroxine or liothyroinine, is indicated per standard of care. 
o Grade 3-4 hyperthyroidism 
▪ Treat with an initial dose of IV corticosteroid followed by oral 
corticosteroids. When symptoms improve to Grade 1 or less, steroid 
taper should be started and continued over no less than 4 weeks. 
Replacement of appropriate hormones may be required as the steroid 
dose is tapered. 


Version 5, dated 06/03/2019 
29 
 
 
 
• Hepatic: 
o For Grade 2 events, monitor liver function tests more frequently until returned 
to baseline values (consider weekly). 
▪ Treat with IV or oral corticosteroids 
o For Grade 3-4 events, treat with intravenous corticosteroids for 24 to 48 hours. 
o When symptoms improve to Grade 1 or less, a steroid taper should be started 
and continued over no less than 4 weeks. 
 
• Renal Failure or Nephritis: 
o For Grade 2 events, treat with corticosteroids. 
o For Grade 3-4 events, treat with systemic corticosteroids. 
o When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks. 
 
• Management of Infusion Reactions: Signs and symptoms usually develop during or 
shortly after drug infusion and generally resolve completely within 24 hours of 
completion of infusion. 
 
 
Table 4 below shows treatment guidelines for subjects who experience an infusion 
reaction associated with administration of Pembrolizumab. 
 
Table 4 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 
Subject may be premedicated 1.5h 
(± 30 minutes) prior to infusion of 
Pembrolizumab with: 
Diphenhydramine 50 mg po (or 
equivalent dose of antihistamine). 
Acetaminophen 500-1000 mg po 
(or equivalent dose of antipyretic). 


Version 5, dated 06/03/2019 
30 
 
NCI CTCAE Grade 
Treatment 
Premedication at subsequent 
dosing 
permanently discontinued from further trial 
treatment administration. 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly responsive 
to symptomatic medication and/or 
brief interruption of infusion); 
recurrence of symptoms following 
initial improvement; hospitalization 
indicated for other clinical sequelae 
(e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or ventilatory 
support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued from 
further trial treatment administration. 
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period of drug 
administration. 
 
 
Diet/Activity/Other Considerations 
 
4.7.1 Diet 
 
Subjects should maintain a normal diet unless modifications are required to manage an AE 
such as diarrhea, nausea or vomiting. 
 
4.7.2 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. Non-pregnant, non- 
breast-feeding women may be enrolled if they are willing to use 2 methods of birth control or 
are considered highly unlikely to conceive. Highly unlikely to conceive is defined as 1) 
surgically sterilized, or 2) postmenopausal (a woman who is ≥45 years of age and has not had 
menses for greater than 1 year will be considered postmenopausal), or 3) not heterosexually 
active for the duration of the study. The two birth control methods can be either two barrier 
methods or a barrier method plus a hormonal method to prevent pregnancy. Subjects should 
start using birth control from study Visit 1 throughout the study period up to 120 days after the 
last dose of study therapy. 
 
The following are considered adequate barrier methods of contraception: diaphragm, condom 
(by the partner), copper intrauterine device, sponge, or spermicide. Appropriate hormonal 
contraceptives will include any registered and marketed contraceptive agent that contains an 
estrogen and/or a progestational agent (including oral, subcutaneous, intrauterine, or 
intramuscular agents). 
 
Subjects should be informed that taking the study medication may involve unknown risks to 
the fetus (unborn baby) if pregnancy were to occur during the study. In order to participate in 
the study they must adhere to the contraception requirement (described above) for the duration 


Version 5, dated 06/03/2019 
31 
 
of the study and during the follow-up period defined in section 6.2.2 Reporting of Pregnancy 
and Lactation to the Investigator and to Merck. If there is any question that a subject will not 
reliably comply with the requirements for contraception, that subject should not be entered into 
the study. 
 
4.7.3 Use in Pregnancy 
 
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab, the 
subject will immediately be removed from the study. The site will contact the subject at least 
monthly and document the subject’s status until the pregnancy has been completed or 
terminated. The outcome of the pregnancy will be reported to the Investigator and to Merck 
without delay and within 24 hours 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 Investigator. 
If a male subject impregnates his female partner the study personnel at the site must be 
informed immediately and the pregnancy reported to the Investigator and to Merck and 
followed as described above . 
 
4.7.4 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. 
 
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 treating sub-investigator or the Principal Investigator if enrollment into the 
trial is inappropriate, the trial plan is violated, or for administrative and/or other safety reasons. 
Specific details regarding discontinuation or withdrawal are provided in Section 6.1.4 – Other 
Procedures. 
 
A subject must be discontinued from the trial for any of the following reasons: 
 
• The subject or legal representative (such as a parent or legal guardian) withdraws 
consent. 
 
• Confirmed pathologic disease progression 
• Unacceptable adverse experiences as described in Section 6.2.1.2 
• Intercurrent illness that prevents further administration of treatment 
• Investigator’s decision to withdraw the subject 
• The subject has a confirmed positive serum pregnancy test 


Version 5, dated 06/03/2019 
32 
 
• Noncompliance with trial treatment or procedure requirements 
• The subject is lost to follow-up 
• Completed 24 months of treatment with pembrolizumab and required follow-up 
• Administrative reasons 
The End of Treatment and Follow-up visit procedures are listed in Section 5 (Trial Flow Chart) 
and Section 6.1.5 (Visit Requirements). After the end of treatment, each subject will be 
followed for 30 days for adverse event monitoring (serious adverse events will be collected for 
90 days after the end of treatment as described in Section 6.2.3.1). Subjects who discontinue 
for reasons other than progressive disease will have post-treatment follow-up for disease status 
until disease progression, initiating a non-study cancer treatment, withdrawing consent or 
becoming lost to follow-up. After documented disease progression each subject will be 
followed by telephone for overall survival until death, withdrawal of consent, or the end of the 
study, whichever occurs first. 
 
Subject Replacement Strategy 
 
Participants who are not evaluable for efficacy because they have not received at least one dose 
of drug will not be included in analyses for either efficacy or toxicity and will be replaced. 
Any participant who receives at least one dose of pembrolizumab will be included in both 
efficacy and safety analyses, and will not be replaced. 
 
Clinical Criteria for Early Trial Termination 
 
Early trial termination will be the result of the criteria specified below: 
 
1. Quality or quantity of data recording is inaccurate or incomplete 
 
2. Poor adherence to protocol and regulatory requirements 
 
3. Incidence or severity of adverse drug reaction in this or other studies indicates a potential 
health hazard to subjects 
 
4. Plans to modify or discontinue the development of the study drug 
 
In the event of Merck decision to no longer supply study drug, ample notification will be 
provided so that appropriate adjustments to subject treatment can be made. 


Version 5, dated 6/3/19 
34 
 
 
 
5.0 TRIAL FLOW CHART 
Study Flow Chart 
 
Trial Period: 
Treatment Cyclesa 
End of 
Treatment 
Post-Treatment 
Treatment Cycle/Title: 
Main 
Study 
Screening 
1 
2 
3 
4 
To be repeated beyond 8 
cycles 
Discon 
Safety 
Follow-up 
Follow Up 
Visitsb 
Survival 
Follow- 
Up 
5 
6 
7 
8 
Scheduling Window (Days): 
-28 to -1 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
At time of 
Discon 
30 days 
post 
discon 
Every 12 
weeks post 
discon 
Every 
12 
weeks 
Pre-screening Consent 
Informed Consent 
X 
Inclusion/Exclusion Criteria 
X 
Subject Identification Card 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Demographics and Medical History 
X 
Prior and Concomitant Medication Review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Trial Treatment Administration 
X 
X 
X 
X 
X 
X 
X 
X 
Post-study anticancer therapy status 
X 
X 
Survival Status 
X 
Review Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Full Physical Examination 
X 
X 
X 
X 
X 
Directed Physical Examination 
X 
X 
X 
X 
X 
X 
Vital Signs and Weight 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ECOG Performance Status 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Test – Urine or Serum -HCG 
X 
Xc 
PT/INR and aPTT 
X 
CBC with Differential 
Xd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Comprehensive Serum Chemistry Panel 
Xd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urinalysis 
Xd 
X 
X 
X 
X 
X 
X 


Version 5, dated 6/3/19 
35 
 
 
 
 
Trial Period: 
Treatment Cyclesa 
End of 
Treatment 
Post-Treatment 
Treatment Cycle/Title: 
Main 
Study 
Screening 
1 
2 
3 
4 
To be repeated beyond 8 
cycles 
Discon 
Safety 
Follow-up 
Follow Up 
Visitsb 
Survival 
Follow- 
Up 
5 
6 
7 
8 
Scheduling Window (Days): 
-28 to -1 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
At time of 
Discon 
30 days 
post 
discon 
Every 12 
weeks post 
discon 
Every 
12 
weeks 
T3, FT4 and TSH 
Xd 
X 
X 
X 
X 
X 
X 
Chest radiograph 
X 
Bone marrow biopsy 
Xe 
Xf 
Xf 
Archival or Newly Obtained Tissue 
Collection 
Xg 
Correlative Studies Blood Collectionh 
X 
X 
X 
Xh 
X 
a: Treatment cycles occur every 3 weeks, but may be given +/- 3 days of the scheduled dose. See Section 6.1.5.2 
 
b: Follow-up CBC with differential should occur every 12 weeks +/- 7 days after discontinuation of therapy until disease progression, initiation of new anti- 
neoplastic therapy, death, end of study, re-treatment with pembrolizumab., or a total of 5 years from the subject’s enrollment. 
 
c: Pregnancy tests must occur within 72 hours of the first dose of pembrolizumab 
 
d: All screening laboratory assessment must occur within 10 days prior to the first treatment 
 
e: The screening bone marrow biopsy must be performed and read by a UPMC hematopathologist within 4 weeks prior to the 1st treatment cycle, and include flow 
cytometry and cytogenetic assessment. If possible, the screening bone marrow biopsy should be sent to the Fred Hutchingson Cancer Center for multiparameter 
flow cytometric minimal residual disease testing. 
 
f: Bone marrow biopsy for efficacy assessment should occur at one year (between treatment cycle 16-18), and at treatment discontinuation (due to completion of 
2 years, toxicity, or relapse) and include flow cytometry and cytogenetic assessment. 
 
g: Subject should be assessed for achieved marrow or peripheral leukemic blasts from diagnosis of AML at screening visit 
 
h: Correlative blood draws may be collected up to two (2) days prior to dosing. Blood collection for correlative studies should occur prior to cycle 1, 2, 4, 8, 17 
(+/-1 treatment cycle), and at disease progression or the end of 2 years of treatment, whichever comes first. 


Version 5, dated 06/03/2019 
36 
 
 
6.0 TRIAL PROCEDURES 
Trial Procedures 
The Trial Flow Chart - Section 5.0 summarizes the trial procedures to be performed at each 
visit. Individual trial procedures are described in detail below. It may be necessary to perform 
these procedures at unscheduled time points if deemed clinically necessary by the investigator. 
 
Furthermore, additional evaluations/testing may be deemed necessary by the Investigator for 
reasons related to subject safety. In some cases, such evaluation/testing may be potentially 
sensitive in nature (e.g., HIV, Hepatitis C, etc.), and thus local regulations may require that 
additional informed consent be obtained from the subject. In these cases, such 
evaluations/testing will be performed in accordance with those regulations. 
 
6.1.1 
Administrative Procedures 
 
6.1.1.1 Informed Consent 
 
Investigators must obtain documented consent from each potential subject prior to participating 
in a clinical trial. 
 
6.1.1.1.1 
General Informed Consent 
 
Consent must be documented by the subject’s dated signature on a consent form along with 
the dated signature of the person conducting the consent discussion. 
 
A copy of the signed and dated consent form should be given to the subject before participation 
in the trial. 
 
The initial informed consent form, any subsequent revised written informed consent form and 
any written information provided to the subject must receive the IRB/ERC’s 
approval/favorable opinion in advance of use. The subject should be informed in a timely 
manner if new information becomes available that may be relevant to the subject’s willingness 
to continue participation in the trial. The communication of this information will be provided 
and documented via a revised consent form or addendum to the original consent form that 
captures the subject’s dated. 
 
Specifics about a trial and the trial population will be added to the consent form template at 
the protocol level. 
 
The informed consent will adhere to local IRB/ERC requirements and applicable laws and 
regulations. 


Version 5, dated 06/03/2019 
37 
 
 
6.1.1.2 Inclusion/Exclusion Criteria 
 
All inclusion and exclusion criteria will be reviewed by the investigator or qualified designee 
to ensure that the subject qualifies for the trial trial as defined in Sections 4.1.2 and 4.1.3. 
 
6.1.1.3 Medical History 
 
A medical history will be obtained by the investigator or qualified designee. Medical history 
will include all active conditions. Any condition diagnosed within the prior 10 years that is 
considered to be clinically significant by the Investigator should be recorded. Details regarding 
the disease for which the subject has enrolled in this study will be recorded separately and not 
listed as medical history. 
 
6.1.1.4 Prior and Concomitant Medications Review 
 
6.1.1.4.1 
Prior Medications 
 
The investigator or qualified designee will review prior medication use, including any 
protocol-specified washout requirement, and record prior medication taken by the subject 
within 28 days before starting the trial. Treatment for the disease for which the subject has 
enrolled in this study will be recorded separately and not listed as a prior medication. 
 
6.1.1.4.2 
Concomitant Medications 
 
The investigator or qualified designee will record medication, if any, taken by the subject 
during the trial. All medications related to reportable SAEs and ECIs should be recorded as 
defined in Section 6.2. 
 
6.1.1.5 Disease Details and Treatments 
 
6.1.1.5.1 
Disease Details 
 
The investigator or qualified designee will obtain prior and current details regarding disease 
status. 
 
6.1.1.5.2 
Prior Treatment Details 
 
The investigator or qualified designee will review all prior cancer treatments including 
systemic treatments, radiation and surgeries. 
 
6.1.1.5.3 
Subsequent Anti-Cancer Therapy Status 
 
The investigator or qualified designee will review all new anti-neoplastic therapy initiated after 
the last dose of trial treatment. If a subject initiates a new anti-cancer therapy within 30 days 
after the last dose of trial treatment, the 30 day Safety Follow-up visit must occur before the 
first dose of the new therapy. Once new anti-cancer therapy has been initiated the subject will 
move into survival follow-up. 


Version 5, dated 06/03/2019 
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6.1.1.6 Trial Compliance (Medication/Diet/Activity/Other) 
 
During treatment, subjects must not use a prohibited concomitant medication, as detailed in 
4.5.2. These include other anti-cancer systemic chemotherapy or biologic therapy, other 
investigation agents, radiation therapy, live vaccines, or glucocorticoids except as required to 
modulate symptoms from an adverse event of suspected immunologic etiology, as determined 
by the study sub-investigators or physiologic doses of steroids that are approved by the 
Principal Investigator. Subjects requiring prohibited concomitant medications must withdraw 
from the study. No diet or activity modification is required when enrolling on this study. 
Patients must have a negative urine or serum pregnancy test within 72 hours of the first dose 
of pembrolizumab, and agree to appropriate contraception during the duration of the study for 
120 days after the last dose of medication, as described in Section 4.7.2. 
 
6.1.2 
Clinical Procedures/Assessments 
 
6.1.2.1 Adverse Event (AE) Monitoring 
 
The investigator or qualified designee will assess each subject to evaluate for potential new or 
worsening AEs as specified in the Trial Flow Chart and more frequently if clinically indicated. 
Adverse experiences will be graded and recorded throughout the study and during the follow- 
up period according to NCI CTCAE Version 4.0 (see Section 11.2). Toxicities will be 
characterized in terms regarding seriousness, causality, toxicity grading, and action taken with 
regard to trial treatment. 
 
For subjects receiving treatment with Pembrolizumab all AEs of unknown etiology associated 
with Pembrolizumab exposure should be evaluated to determine if it is possibly an event of 
clinical interest (ECI) of a potentially immunologic etiology (termed immune-related adverse 
events, or irAEs); see the separate ECI guidance document regarding the identification, 
evaluation and management of potential irAEs. 
 
Please refer to section 6.2 for detailed information regarding the assessment and recording of 
AEs. 
 
6.1.2.2 Full Physical Exam 
 
The investigator or qualified designee will perform a complete physical exam during the 
screening period. Clinically significant abnormal findings should be recorded as medical 
history. A full physical exam should be performed during screening, 
 
6.1.2.3 Directed Physical Exam 
 
For cycles that do not require a full physical exam per the Trial Flow Chart, the investigator or 
qualified designee will perform a directed physical exam as clinically indicated prior to trial 
treatment administration. 


Version 5, dated 06/03/2019 
39 
 
 
6.1.2.4 Vital Signs 
 
The investigator or qualified designee will take vital signs at screening, within 60 minutes 
prior to infusion and  if reaction occurs every 15-30 minutes until symptoms resolve and at 
treatment discontinuation as specified in the Trial Flow Chart (Section 6.0). Vital signs 
should include temperature, pulse, respiratory rate, weight and blood pressure. Height will be 
measured at screening only. 
 
6.1.2.5 Eastern Cooperative Oncology Group (ECOG) Performance Scale 
 
The investigator or qualified designee will assess ECOG status (see Section 11.1) at screening, 
prior to the administration of each dose of trial treatment and discontinuation of trial treatment 
as specified in the Trial Flow Chart. After Cycle 8, assessment of ECOG status will be 
performed every other cycle in conjunction with the directed or full physical exam. 
 
6.1.2.6 Assessment of Disease 
 
The subject will have a bone marrow biopsy and aspirate with flow cytometric studies and 
cytogenetics performed and officially reviewed by a UPMC hematopathologist within 4 weeks 
prior to the first treatment as part of the screening period. Subsequent disease assessments are 
performed by bone marrow biopsy and aspirate with flow cytometric studies and cytogenetics 
after 1 year (+/- 4 weeks) and after 2 years (+/- 4 weeks) or at disease relapse or treatment 
discontinuation. 
 
6.1.2.7 Tumor Tissue Collection and Correlative Studies Blood Sampling 
 
As part of the functional correlative studies, it is recommended that patients enrolled on the 
study have cyropreserved autologous AML blasts within the UPMC Tissue Bank. Correlative 
studies blood sampling includes 30ml of peripheral blood in non-citrate tubes (heparinized) 
and 10ml in citrate tube(s), collected prior to cycle 1, 2, 4, 8, 17, and 34. Correlative studies 
are described in full detail in Section 3.2.3.2. 
 
6.1.3 
Laboratory Procedures/Assessments 
 
Details regarding specific laboratory procedures/assessments to be performed in this trial are 
provided below. Laboratory Safety Evaluations (Hematology, Chemistry and Urinalysis) 
 
Laboratory tests for hematology, chemistry, urinalysis, and others are specified in Table 9. 


 
 
Table 9: Laboratory Tests 
 
Hematology 
Chemistry 
Urinalysis 
Other 
Hematocrit 
Albumin 
Blood 
Serum β-human chorionic gonadotropin† 
Hemoglobin 
Alkaline phosphatase 
Glucose 
(β-hCG)† 
Platelet count 
Alanine aminotransferase (ALT) 
Protein 
PT (INR) 
WBC (total and differential) 
Aspartate aminotransferase (AST) 
Specific gravity 
aPTT 
Red Blood Cell Count 
Lactate dehydrogenase (LDH) 
Microscopic exam (If abnormal) 
Total thriiodothyronine (T3) 
Absolute Neutrophil Count 
Bicarbonate 
results are noted 
Free tyroxine (T4) 
Uric Acid 
Urine pregnancy test † 
Thyroid stimulating hormone (TSH) 
Calcium 
Chloride 
Glucose 
Blood for correlative studies 
Phosphorus 
Potassium 
Sodium 
Magnesium 
Total Bilirubin 
Direct Bilirubin (If total bilirubin is 
elevated above the upper limit of 
normal) 
Total protein 
Blood Urea Nitrogen 
Creatinine 
† Perform on women of childbearing potential only. If urine pregnancy results cannot be confirmed as negative, a serum pregnancy test will be required. 
 
 
 
 
 
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Laboratory tests for screening or entry into the Second Course Phase should be performed 
within 10 days prior to the first dose of treatment. After Cycle 1, pre-dose laboratory 
procedures can be conducted up to 72 hours prior to dosing. Results must be reviewed by the 
investigator or qualified designee and found to be acceptable prior to each dose of trial 
treatment. 
 
6.1.4 
Other Procedures 
 
6.1.4.1 Withdrawal/Discontinuation 
 
When a subject discontinues/withdraws prior to trial completion, all applicable activities 
scheduled for the final trial visit should be performed at the time of discontinuation. Any 
adverse events which are present at the time of discontinuation/withdrawal should be followed 
in accordance with the safety requirements outlined in Section 7.2 - Assessing and Recording 
Adverse Events. After discontinuing treatment following assessment of CR, these subjects 
should return to the site for a Safety Follow-up Visit (described in Section 6.1.5.3.1) and then 
proceed to the Follow-Up Period of the study (described in Section 6.1.5.4). 
 
6.1.4.2 Blinding/Unblinding 
 
N/A 
 
6.1.5 
Visit Requirements 
 
Visit requirements are outlined in Section 5.0 Trial Flow Chart. Specific procedure-related 
details are provided above in Section 6.1 - Trial Procedures. 
 
6.1.5.1 Screening 
 
6.1.5.1.1 
Screening Period 
 
Potential subjects who enter the screening period must undergo a full medical history, complete 
physical exam, chest radiograph, laboratory assessment as detailed in Section 6.0, a bone 
marrow biopsy, and meet full inclusion/exclusion criteria. All screening assessments must be 
completed within 4 weeks of obtaining full informed consent for the study. A negative serum 
pregnancy test must be documented within 72 hours of the first treatment. Full laboratory 
assessment must be completed no more than 10 days before the first treatment. 
 
6.1.5.2 Treatment Period 
 
Subjects enrolled on the study should receive treatment as close as possible to the data when 
enrollment occurred, and must start treatment within 10 days of official enrollment or full 
screening assessment must be repeated. Those who enter the treatment period are expected to 
receive treatment with pembrolizumab every 3 weeks + 3 days in the absence of adverse events 
requiring treatment delays. Treatment delays and dose modifications are discussed in full detail 
in Section 4.2. Physical exam, laboratory assessment, efficacy assessments, and correlative 
blood sampling is required during treatment as detailed in Section 6.0. 


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6.1.5.3 Post-Treatment Visits 
 
6.1.5.3.1 
Safety Follow-Up Visit 
 
The mandatory Safety Follow-Up Visit should be conducted approximately 30 days after the 
last dose of trial treatment or before the initiation of a new anti-cancer treatment, whichever 
comes first, as described in Section 6.0. All AEs that occur prior to the Safety Follow-Up Visit 
should be recorded. Subjects with an AE of Grade > 1 will be followed until the resolution of 
the AE to Grade 0-1 or until the beginning of a new anti-neoplastic therapy, whichever occurs 
first. SAEs that occur within 90 days of the end of treatment or before initiation of a new anti- 
cancer treatment should also be followed and recorded. 
 
6.1.5.4 Follow-up Visits 
 
Subjects who discontinue trial treatment for a reason other than disease progression will move 
into the Follow-Up Phase and should be assessed every 12 weeks (84 ± 7 days) by complete 
blood count to monitor disease status. Every effort should be made to collect information 
regarding disease status until the start of new anti-neoplastic therapy, disease progression, 
death, or end of the study or up to 5 years from enrollment. Information regarding post-study 
anti-neoplastic treatment will be collected if new treatment is initiated. 
 
6.1.5.4.1 Survival Follow-up 
 
Once a subject experiences confirmed disease progression or starts a new anti-cancer therapy, 
the subject moves into the survival follow-up phase and should be contacted by telephone 
every 12 weeks to assess for survival status until death, withdrawal of consent, or the end of 
the study, whichever occurs first. 
 
Assessing and Recording Adverse Events 
 
An adverse event is defined as any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and which does not necessarily 
have to have a causal relationship with this treatment. An adverse event can therefore be any 
unfavorable and unintended sign (including an abnormal laboratory finding, for example), 
symptom, or disease temporally associated with the use of a medicinal product or protocol- 
specified procedure, whether or not considered related to the medicinal product or protocol- 
specified procedure. Any worsening (i.e., any clinically significant adverse change in 
frequency and/or intensity) of a preexisting condition that is temporally associated with the use 
of the investigational product, is also an adverse event. 
 
Changes resulting from normal growth and development that do not vary significantly in 
frequency or severity from expected levels are not to be considered adverse events. Examples 
of this may include, but are not limited to, teething, typical crying in infants and children and 
onset of menses or menopause occurring at a physiologically appropriate time. 


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Adverse events may occur during the course of the use of the investigational product in clinical 
trials or within the follow-up period specified by the protocol, or prescribed in clinical practice, 
from overdose (whether accidental or intentional), from abuse and from withdrawal. 
 
Adverse events may also occur in screened subjects during any pre-allocation baseline period 
as a result of a protocol-specified intervention, including washout or discontinuation of usual 
therapy, diet, placebo treatment or a procedure. 
 
All adverse events will be recorded from the time the consent form is signed through 30 days 
following cessation of treatment and at each examination on the Adverse Event case report 
forms/worksheets. The reporting timeframe for adverse events meeting any serious criteria is 
described in section 6.2.3.1. 
 
Adverse events will not be collected for subjects during the pre-screening period (for 
determination of archival tissue status) as long as that subject has not undergone any protocol- 
specified procedure or intervention. If the subject requires a blood draw, fresh tumor biopsy 
etc., the subject is first required to provide consent to the main study and AEs will be captured 
according to guidelines for standard AE reporting. 
 
6.2.1 
Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Investigator and to Merck 
 
For purposes of this trial, an overdose will be defined as any dose exceeding the prescribed 
dose for pembrolizumab by 20% over the prescribed dose. No specific information is available 
on the treatment of overdose of pembrolizumab. In the event of overdose, pembrolizumab 
should be discontinued and the subject should be observed closely for signs of toxicity. 
Appropriate supportive treatment should be provided if clinically indicated. 
 
If an adverse event(s) is associated with (“results from”) the overdose of the investigational 
product, the adverse event(s) is reported as a serious adverse event, even if no other seriousness 
criteria are met. 
 
If a dose of the investigational product meeting the protocol definition of overdose is taken 
without any associated clinical symptoms or abnormal laboratory results, the overdose is 
reported as a non-serious Event of Clinical Interest (ECI), using the terminology “accidental 
or intentional overdose without adverse effect.” 
 
All reports of overdose with and without an adverse event must be reported within 24 hours to 
the Investigator and within 2 working days hours to Merck Global Safety. (Attn: Worldwide 
Product Safety; FAX 215 993-1220) 
 
6.2.2 
Reporting of Pregnancy and Lactation to the Investigator and to Merck 
 
Although pregnancy and lactation are not considered adverse events, 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 or within 120 days of completing the trial completing the trial, or 30 days following 


Version 5, dated 06/03/2019 
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cessation of treatment if the subject initiates new anticancer therapy, whichever is earlier. All 
subjects and female partners of male subjects who become pregnant must be followed to the 
completion/termination of the pregnancy. Pregnancy outcomes of spontaneous abortion, 
missed abortion, benign hydatidiform mole, blighted ovum, fetal death, intrauterine death, 
miscarriage and stillbirth must be reported as serious events (Important Medical Events). If 
the pregnancy continues to term, the outcome (health of infant) must also be reported. 
 
Such events must be reported within 24 hours to the Investigator and within 2 working days to 
Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220) 
 
6.2.3 
Immediate Reporting of Adverse Events to the Investigator and to Merck 
 
6.2.3.1 Serious Adverse Events 
 
A serious adverse event is any adverse event occurring at any dose or during any use of the 
investigational 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 another important medical event 
Progression of the cancer under study is not considered an adverse event unless it results in 
hospitalization or death. 
 
Any serious adverse event, or follow up to a serious adverse event, including death due to any 
cause other than progression of the cancer under study that occurs to any subject from the time 
the consent is signed through 90 days following cessation of treatment, or the initiation of new 
anti-cancer therapy, whichever is earlier, whether or not related to the investigational product, 
must be reported within 24 hours to the Investigator and within 2 working days to Merck 
Global Safety. 
 
Non-serious Events of Clinical Interest will be forwarded to Merck Global Safety and will be 
handled in the same manner as SAEs. 
 
Additionally, any serious adverse event, considered by an investigator who is a qualified 
physician to be related to the investigational 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 Investigator 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 


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All subjects with serious adverse events must be followed up for outcome. 
 
6.2.3.2 Events of Clinical Interest 
 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest 
(ECI) and must be recorded as such on the Adverse Event case report forms/worksheets and 
reported within 24 hours to the Investigator 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: 
 
1. an overdose of the investigational product, as defined in Section 6.2.1 - Definition of an 
Overdose for This Protocol and Reporting of Overdose to the Investigator, that is not associated 
with clinical symptoms or abnormal laboratory results. 
 
2. an elevated AST or ALT lab value that is greater than or equal to 3X the upper limit of 
normal and an elevated total bilirubin lab value that is greater than or equal to 2X the upper 
limit of normal and, at the same time, an alkaline phosphatase lab value that is less than 2X the 
upper limit of normal, as determined by way of protocol-specified laboratory testing or 
unscheduled laboratory testing.* 
 
*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). 
 
1. 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”). 
 
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 Investigator 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. 


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6.2.4 
Evaluating Adverse Events 
 
An investigator who is a qualified physician will evaluate all adverse events according to the 
NCI Common Terminology for Adverse Events (CTCAE), version 4.0. Any adverse event 
which changes CTCAE grade over the course of a given episode will have each change of 
grade recorded on the adverse event case report forms/worksheets. 
 
All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 


 
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Table 10: Evaluating Adverse Events 
 
An investigator who is a qualified physician, will evaluate all adverse events as to: 
 
V4.0 
CTCAE 
Grading 
Grade 1 
Mild; asymptomatic or mid symptoms; clinical or diagnostic observations only; intervention not indicated. 
Grade 2 
Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental ADL. 
Grade 3 
Severe or medically significant but not immediately life-threatening; hospitalization or prolongation or hospitalization indicated; 
disabling; limiting self-care ADL. 
Grade 4 
Life threatening consequences; urgent intervention indicated. 
Grade 5 
Death related to AE 
Seriousness 
A serious adverse event is any adverse event occurring at any dose or during any use of investigational product that: 
†Results in death; or 
†Is life threatening; or places the subject, in the view of the investigator, at immediate risk of death from the event as it occurred (Note: This does not include an 
adverse event that, had it occurred in a more severe form, might have caused death.); or 
†Results in a persistent or significant disability/incapacity (substantial disruption of one’s ability to conduct normal life functions); or 
†Results in or prolongs an existing inpatient hospitalization (hospitalization is defined as an inpatient admission, regardless of length of stay, even if the 
hospitalization is a precautionary measure for continued observation. (Note: Hospitalization [including hospitalization for an elective procedure] for a preexisting 
condition which has not worsened does not constitute a serious adverse event.); or 
†Is a congenital anomaly/birth defect (in offspring of subject taking the product regardless of time to diagnosis);or 
Is a new cancer; (that is not a condition of the study) or 
Is an overdose (whether accidental or intentional). Any adverse event associated with an overdose is considered a serious adverse event. An overdose that is not 
associated with an adverse event is considered a non-serious event of clinical interest and must be reported within 24 hours. 
Other important medical events that may not result in death, not be life threatening, or not require hospitalization may be considered a serious adverse event when, 
based upon appropriate medical judgment, the event may jeopardize the subject and may require medical or surgical intervention to prevent one of the outcomes 
listed previously (designated above by a †). 
Duration 
Record the start and stop dates of the adverse event. If less than 1 day, indicate the appropriate length of time and units 
Action taken 
Did the adverse event cause the investigational product to be discontinued? 
Relationship to 
test drug 
Did the investigational product cause the adverse event? The determination of the likelihood that the investigational product caused the adverse event will be 
provided by an investigator who is a qualified physician. The investigator’s signed/dated initials on the source document or worksheet that supports the causality 
noted on the AE form, ensures that a medically qualified assessment of causality was done. This initialed document must be retained for the required regulatory time 
frame. The criteria below are intended as reference guidelines to assist the investigator in assessing the likelihood of a relationship between the test drug and the 
adverse event based upon the available information. 
The following components are to be used to assess the relationship between the investigational product and the AE; the greater the correlation with the 
components and their respective elements (in number and/or intensity), the more likely the investigational product caused the adverse event (AE): 
Exposure 
Is there evidence that the subject was actually exposed to the investigational product such as: reliable history, acceptable compliance assessment 
(pill count, diary, etc.), expected pharmacologic effect, or measurement of drug/metabolite in bodily specimen? 
Time Course 
Did the AE follow in a reasonable temporal sequence from administration of the investigational product? 
Is the time of onset of the AE compatible with a drug-induced effect (applies to trials with investigational medicinal product)? 
Likely Cause 
Is the AE not reasonably explained by another etiology such as underlying disease, other drug(s)/vaccine(s), or other host or environmental 
factors 


 
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Relationship 
The following components are to be used to assess the relationship between the test drug and the AE: (continued) 
to 
investigational 
product 
(continued) 
Dechallenge 
Was the investigational product discontinued or dose/exposure/frequency reduced? 
If yes, did the AE resolve or improve? 
If yes, this is a positive dechallenge. If no, this is a negative dechallenge. 
(Note: This criterion is not applicable if: (1) the AE resulted in death or permanent disability; (2) the AE resolved/improved despite continuation 
of the investigational product; or (3) the trial is a single-dose drug trial); or (4) investigational product(s) is/are only used one time.) 
Rechallenge 
Was the subject re-exposed to the investigational product in this study? 
If yes, did the AE recur or worsen? 
If yes, this is a positive rechallenge. If no, this is a negative rechallenge. 
(Note: This criterion is not applicable if: (1) the initial AE resulted in death or permanent disability, or (2) the trial is a single-dose drug trial); or 
(3) investigational product(s) is/are used only one time). 
NOTE: IF A RECHALLENGE IS PLANNED FOR AN ADVERSE EVENT WHICH WAS SERIOUS AND WHICH MAY HAVE BEEN 
CAUSED BY THE MERCK PRODUCT, OR IF REEXPOSURE TO THE INVESTIGATIONAL PRODUCT POSES ADDITIONAL 
POTENTIAL SIGNIFICANT RISK TO THE SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE 
U.S. CLINICAL MONITOR AS PER DOSE MODIFICATION GUIDELINES IN THE PROTOCOL. 
Consistency 
with Trial 
Treatment 
Profile 
Is the clinical/pathological presentation of the AE consistent with previous knowledge regarding the investigational product or drug class 
pharmacology or toxicology? 
The assessment of relationship will be reported on the case report forms /worksheets by an investigator who is a qualified physician according to his/her best clinical judgment, including 
consideration of the above elements. 
Record one of the following 
Use the following scale of criteria as guidance (not all criteria must be present to be indicative of a investigational product relationship). 
Yes, there is a reasonable 
possibility of Merck product 
relationship. 
There is evidence of exposure to the investigational product. The temporal sequence of the AE onset relative to the administration of the 
investigational product is reasonable. The AE is more likely explained by the investigational product than by another cause. 
No, there is not a reasonable 
possibility Merck product 
relationship 
Subject did not receive the investigational product OR temporal sequence of the AE onset relative to administration of the investigational product 
is not reasonable OR there is another obvious cause of the AE. (Also entered for a subject with overdose without an associated AE.) 


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6.2.5 
Sponsor Responsibility for Reporting Adverse Events 
 
All Adverse Events will be reported to regulatory authorities, IRB/IECs and investigators in 
accordance with all applicable global laws and regulations. 
 
The principal investigator / sponsor must promptly review all information relevant to the safety of 
the drug obtained or otherwise received from foreign or domestic sources, including information 
derived from any clinical or epidemiological investigations, animal or in vitro studies, reports in 
the scientific literature, and unpublished scientific papers, as well as reports from foreign 
regulatory authorities and reports of foreign commercial marketing experience for drugs that are 
not marketed in the United States. The study principal investigator / sponsor must notify all 
participating investigators of potential serious risks, from clinical trials or any other source, as 
soon as possible. 
 
In addition to completing appropriate patient demographic and suspect medication information, 
the report should include as applicable the following information that is available at the time of 
report within the Event Description of the MedWatch 3500 form: 
 
• CTCAE term(s) and grade(s) 
• current status of study drug 
• all interventions to address the AE (testing and result, treatment and response) 
• hospitalization and/or discharge dates 
• event relationship to study drug 
Follow-up reports: 
Additional information may be added to a previously submitted report by adding to the original 
MedWatch 3500 report and submitting it as follow-up or creating supplemental summary 
information and submitting it as follow-up with the original MedWatch 3500 form. 
 
7.0 STATISTICAL ANALYSIS PLAN 
Analysis Samples 
For both the primary safety and efficacy endpoints, the analysis sample will be eligible patients 
who have taken at least one dose of pembrolizumab. Patients who are eligible but withdraw prior 
to taking the first dose will not be included in these analyses and will be replaced, so that, barring 
early stopping, the analysis sample will be 40 patients who have taken at least one dose of drug. 
 
Statistical Analysis Plan Summary 
 
7.2.1 
Primary Efficacy Objective: To evaluate the time to relapse (TTR) in patients > 60 years 
with AML in complete remission undergoing post-remission therapy with pembrolizumab. The 
time to relapse function will be estimated by the product-limit (Kaplan-Meier) method, with an 
appropriate 80% confidence interval. Death is considered a censoring event in determining TTR. 


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The median TTR will also be estimated, along with an appropriate confidence interval. 
Assuming an exponential time to failure distribution, 26% two-year TTR under the standard 
induction therapy is associated with a median of 12.3 months. The null hypothesis that the 
treatment with pembrolizumab offers no increase in TTR will be tested by determining if 12.3 
months is within an 80% confidence interval around the median, a one-sided α=0.10 test. The 
sensitivity of the treatment of death as a censoring event will be assessed by repeating the above 
analysis on relapse-free survival, where death and relapse are both considered events. Patients 
who drop out of the study will be treated as censored at the last observation time. 
 
Potential prognostic factors for TTR in this population will also be explored. These include the use 
of consolidation therapy (0 vs 1-4), cytogenetic risk category (high-risk, intermediate risk, or low 
risk), FLT3 status (FLT3-ITD mutation present or absent), NPM1 status (NPM1 mutation present 
or absent), age >70 years, minimal residual disease, and ECOG performance status. The survival 
distributions for TTR will be computed using the Kaplan-Meier method and the log-rank test used 
to test for statistical  differences  in  the  distributions  for  the  aforementioned  exposure  
groups. Multivariate analysis using Cox regression will then be used to adjust for all significant 
covariates. Patients who drop out of the study will be treated as censored at the last observation 
time. Patients with missing covariate data will be excluded from this exploratory analysis. 
 
7.2.2 
Primary Safety Objective: To evaluate the safety and tolerability of pembrolizumab in 
patients > 60 years with AML. The NCI CTCAE type and grade of adverse events and their 
association with treatment will be tabulated. Section 8.3 contains a stopping rule for excess 
toxicity. 
 
7.2.3 
Secondary Efficacy Objective: To evaluate overall survival with post-remission 
pembrolizumab treatment in patients > 60 years with AML. The analysis plan is similar to that 
of TTR. Assuming an 8% five-year survival rate with induction therapy alone, median overall 
survival is 17.2 months. 
 
7.2.4 
Secondary Biomarker Objectives 
 
7.2.4.1 Second Biomarker Objective 
 
To evaluate the effect of pembrolizumab on AML blast-reactive T-cells by quantification of 
activated T and NK cells, which are predicted to increase, and Tregs, which are predicted to 
decrease. The changes in these markers from baseline after treatment will be assessed by paired 
comparison t-test or Wilcoxon rank sum test, as appropriate. All point estimates will be 
accompanied by appropriate 95% confidence intervals. In all secondary biomarker analyses, 
observations with missing data will be excluded. 
 
7.2.4.2 Secondary Biomarker Objective 
 
To evaluate the effect of pembrolizumab on AML blast-reactive T-cells through functional 
analysis, through assessment of cytokine and Granzyme B/perforin expression in response to blast 
antigens. The analysis plan is similar to 7.2.4.1. 


Version 5, dated 06/03/2019 
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Probability of Stopping Early 
0.0 0.2 0.4 0.6 0.8 1.0 
10 
20 
30 
40 
Mean Number of Participants 
 
7.2.4.3 Secondary Biomarker Objective: To evaluate the effect of pembrolizumab on the 
immunosuppressive activity of exosomes, measured by their effects on NK-cell activity and T-cell 
expansion. The analysis plan is similar to 7.2.4.1. 
 
Stopping Rule for Excess Toxicity 
 
The table displays the stopping rule for excessive toxicity. Excessive toxicity is defined as any 
drug-related toxicity that results in withholding or discontinuation of pembrolizumab. 
Additionally, any unexpected grade 3-4 AEs will be defined as excessive toxicity.” 
 
 
 
The   trial 
is suspended for toxicity if 
the 
number of toxicities is 
greater 
than or equal to the 
number 
in the second column. For 
instance, 
if  5  out  of  the  first  15 
patients 
experience 
severe 
toxicity, 
the trial is suspended. 
 
Justification of Design 
0.2 0.3 0.4 0.5 0.6 0.7 0.8 
True Probability of Toxicity 
The plot presents the power of the hypothesis test of the 
primary efficacy endpoint against the median TTR after 
pembrolizumab treatment. It is seen that 80% power is 
achieved (at α=0.1 in a one-sided test) if the true median 
TTR is 19.5 months or greater. The stopping rule is based 
on a beta-binomial probability model that stops the trial if 
PP(P(Toxicity)>0.2)>0.8, where PP is the posterior 
probability function for P(Toxicity). The posterior model 
includes a binomial data model and a Beta(2,8) prior for the 
P(Toxicity). The plot displays the operating characteristics 
of the rule as a function of the true (unobserved) probability 
of toxicity. It is seen that, for instance, if the true probability 
 
 
 
 
 
 
 
 
 
 
 
 
 
12 
16 
20 
24 
 
TTR (months) 
of toxicity is 0.4, the probability the trial will stop early is 0.5, and the expected number of patients 
accrued is 28. 
Power 
0 
0.0 
0.4 
0.8 
# Patients #Toxicities 
5 
3 
10 
4 
15 
5 
20 
7 
25 
8 
30 
9 
35 
10 


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8.0 LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL SUPPLIES 
Investigational Product 
The investigator shall take responsibility for and shall take all steps to maintain appropriate records 
and ensure appropriate supply, storage, handling, distribution and usage of investigational product 
in accordance with the protocol and any applicable laws and regulations. 
 
Clinical Supplies will be provided by Merck as summarized in Table 11. 
 
Table 11 Product Descriptions 
 
Product Name & Potency 
Dosage Form 
pembrolizumab 50 mg 
Lyophilized Powder for Injection 
pembrolizumab 100 mg/ 4mL 
Solution for Injection 
 
Packaging and Labeling Information 
 
Clinical supplies will be affixed with a clinical label in accordance with regulatory requirements. 
 
Clinical Supplies Disclosure 
 
This trial is open-label; therefore, the subject, the trial site personnel, the Investigator and/or 
designee are not blinded to treatment. Drug identity (name, strength) is included in the label text; 
random code/disclosure envelopes or lists are not provided. 
 
Storage and Handling Requirements 
 
Clinical supplies must be stored in a secure, limited-access location under the storage conditions 
specified on the label. 
 
Receipt and dispensing of trial medication must be recorded by an authorized person at the trial 
site. 
 
Clinical supplies may not be used for any purpose other than that stated in the protocol. 
 
Returns and Reconciliation 
 
The investigator is responsible for keeping accurate records of the clinical supplies received from 
Merck or designee, the amount dispensed to and returned by the subjects and the amount remaining 
at the conclusion of the trial. 
 
Upon completion or termination of the study, all unused and/or partially used investigational 
product will be destroyed at the site per institutional policy. It is the Investigator’s responsibility 
to a r r a n g e f o r disposal of all empty containers, provided that procedures for proper disposal 


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have been established according to applicable federal, state, local and institutional guidelines and 
procedures, and provided that appropriate records of disposal are kept. 
 
9.0 ADMINISTRATIVE AND REGULATORY DETAILS 
Confidentiality 
All records related to this research study will be stored in a locked environment. Only the 
researchers affiliated with the research study and their staff will have access to the research records. 
All study data reviewed and discussed will be kept confidential. Any breach in subject 
confidentiality will be reported to the IRB in the form of an Unanticipated Problem submission 
per reporting guidelines. 
 
Compliance with Law, Audit and Debarment 
 
The Sponsor-Investigator will maintain records in accordance with Good Clinical Practice 
guidelines. 
 
Compliance with Trial Registration and Results Posting Requirements 
 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and the Food 
and Drug Administration Amendments Act (FDAAA), the Sponsor of the trial is solely responsible 
for determining whether the trial and its results are subject to the requirements for submission to 
the Clinical Trials Data Bank, http://www.clinicaltrials.gov. Information posted will allow 
subjects to identify potentially appropriate trials for their disease conditions and pursue 
participation by calling a central contact number for further information on appropriate trial 
locations and trial site contact information. 
 
Quality Management System 
 
Independent monitoring of the clinical study for protocol and GCP compliance can be conducted 
upon PI request by qualified staff of the Education and Compliance Office – Human Subject 
Research, Research Conduct and Compliance Office, University of Pittsburgh. 
 
Data Management 
 
Investigator/Sub-investigators, regulatory, site management, clinical research coordinators, 
clinical research associates, data managers, and clinic staff meet regularly in disease center Data 
Safety Monitoring Boards (DSMB) to review and discuss study data to include, but not limited to, 
the following: 
 
• 
serious adverse events 
• 
subject safety issues 
• 
recruitment issues 
• 
accrual 
• 
protocol deviations 
• 
unanticipated problems 


Version 5, dated 06/03/2019 
54 
 
 
• 
breaches of confidentiality 
 
All toxicities encountered during the study will be evaluated on an ongoing basis according to the 
NCI Common Toxicity Criteria version 4.0. All study treatment associated adverse events that are 
serious, at least possibly related and unexpected will be reported to the IRB per reporting 
guidelines. Any modifications necessary to ensure subject safety and decisions to continue, or 
close the trial to accrual are also discussed during these meetings. If any literature becomes 
available which changes the risk/benefit ratio or suggests that conducting the trial is no longer 
ethical, the IRB will be notified in the form of an Unanticipated Problem submission and the study 
may be terminated. 
 
For all research protocols, there will be a commitment to comply with the IRB’s policies for 
reporting unanticipated problems involving risk to subjects or others (including adverse events). 
DSMC progress reports, to include a summary of all serious adverse events and modifications, and 
approval will be submitted to the IRB at the time of renewal. 
 
Protocols with subjects in long-term (survival) follow-up or protocols in data analysis only, will 
be reviewed semi-annually. 
 
The summaries of these meetings are forwarded to the UPCI DSMC which meets monthly 
following a designated format. Both the UPCI DSMC as well as the individual disease center 
DSMB have the authority to suspend accrual or further investigate treatment on any trial based on 
information discussed at these meetings. 


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10.0 LIST OF REFERENCES 
 
1. 
Disis ML. Immune regulation of cancer. J Clin Oncol 2010; 28(29):4531-8. 
 
2. 
Dong H, Strome SE, Salomao DR, Tamura H, Hirano F, Flies DB, et al. Tumor-associated 
B7-H1 promotes T-cell apoptosis: a potential mechanism of immune evasion. Nat Med 
2002;8(8):793-800. 
 
3. 
Sharpe AH, Freeman GJ. The B7-CD28 superfamily. Nature 2002;2:116-26. 
4. 
Brown JA, Dorfman DM, Ma F-R, Sullivan EL, Munoz O, Wood CR, et al. Blockade of 
programmed death-1 ligands on dendritic cells enhances T cell activation and cytokine 
production. J Immunol 2003;170:1257-66. 
 
5. 
Francisco LM, Sage PT, Sharpe AH. The PD-1 pathway in tolerance and autoimmunity. 
Immunol Rev 2010;236:219-42. 
 
6. 
Thompson RH, Dong H, Lohse CM, Leibovich BC, Blute ML, Cheville JC, et al. PD-1 
expressed by tumor-infiltrating immune cells and is associated with poor outcome for patients 
with renal cell carcinoma. Clin Caner Res 2007;13(6):1757-61. 
 
7. 
Talmadge JE, Donkor M, Scholar E. Inflammatory cell infiltration of tumors: Jekyll or Hyde. 
Cancer Metastasis Rev 2007;26:373-400. 
 
8. 
Usubütün A, Ayhan A, Uygur MC, zen H, klu C, acan S. Prognostic factors in renal cell 
carcinoma. J Exp Clin Cancer Res 1998;17(1):77-81. 
 
9. 
Al-Shibli KI, Donnem T, Al-Saad S, Persson M, Bremnes RM, Busund L-T. Prognostic effect 
of epithelial and stromal symphocyte infiltration in non-small cell lung cancer. Clin Cancer 
Res 2008;14(16):5220-7. 
 
10. Deschoolmeester V, Baay M, Van Marck E, Weyler J, Vermeulen p, Lardon F, et al. Tumor 
infiltrating lymphocytes: an intriguing player in the survival of colorectal cancer patients. 
BMC Immunol 2010;11:19. 
 
11. Diez M, Pollán M, Enriquez JM, Dominguez P, Santana A, Tobaruela E, et al. Histopathologic 
prognostic score in colorectal adenocarcinomas. Anticancer Res 1998;18:689-94. 
 
12. Galon J, Costes A, Sanchez-Cabo F, Kirilovsky A, Mlecnik B, Lagorce-Pagès C, et al. Type, 
density, and location of immune cells within human colorectal tumors predict clinical 
outcome. Science 2006;313:1960-4. 
 
13. Hiraoka N. Tumor-infiltrating lymphocytes and hepatocellular carcinoma: molecular biology. 
Int J Clin Oncol 2010;15:544-51. 


Version 5, dated 06/03/2019 
56 
 
 
14. Nobili C, Degrate L, Caprotti R, Franciosi C, Leone BE, Trezzi R, et al. Prolonged survival 
of a patient affected by pancreatic adenocarcinoma with massive lymphocyte and dendritic 
cell infiltration after interleukin-2 immunotherapy. Report of a case. Tumori 2008;94:426-30. 
 
15. Hodi FS, Dranoff G. The biologic importance of tumor-infiltrating lymphocytes. J Cutan 
Pathol 2010;37(Suppl 1):48-53. 
 
16. Kloor M. Lymphocyte infiltration and prognosis in colorectal cancer. Lancet 
2009;10(840):841. 
 
17. Hillen F, Baeten CIM, van de Winkel A, Creytens D, van der Schaft DWJ, Winnepenninckx 
V, et al. Leukocyte infiltration and tumor cell plasticity are parameters of aggressiveness in 
primary cutaneous melanoma. Cancer Immunol Immunother 2008;57:97-106. 
 
18. Lee HE, Chae SW, Lee YJ, Kim MA, Lee HS, Lee BL, et al. Prognostic implications of type 
and density of tumour-infiltrating lymphocytes in gastric cancer. Br J Cancer 
2008;99(10):1704-11. 
 
19. Leffers N, Gooden MJM, de Jong RA, Hoogeboom B-N, ten Hoor KA, Hollema H, et al. 
Prognostic significance of tumor-infiltrating T-lymphocytes in primary and metastatic lesions 
of advanced stage ovarian cancer. Cancer Immunol Immunother 2009;58:449-59. 
 
20. Nishimura H, Honjo T, Minato N. Facilitation of β selection and modification of positive 
selection in the thymus of PD-1-deficient mice. J Exp Med 2000;191(5):891-7. 
 
21. Liotta F, Gacci M, Frosali F, Querci V, Vittori G, Lapini A, et al. Frequency of regulatory T 
cells in peripheral blood and in tumour-infiltrating lymphocytes correlates with poor 
prognosis in renal cell carcinoma. BJU Intern 2010;107:1500-6. 
 
22. Robert, C., Ribas, A., Wolchok, J. D., Hodi, F. S., Hamid, O., Kefford, R., Daud, A. Anti- 
programmed-death-receptor-1 treatment with pembrolizumab in ipilimumab-refractory 
advanced melanoma: a randomised dose-comparison cohort of a phase 1 trial. Lancet 
2014;384:1109-17. 
 
23. Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA: a cancer journal for clinicians 
2014;64:9-29. 
 
24. Lowenberg B, Downing JR, Burnett A. Acute myeloid leukemia. The New England journal 
of medicine 1999;341:1051-62. 
 
25. Tallman MS, Gilliland DG, Rowe JM. Drug therapy for acute myeloid leukemia. Blood 
2005;106:1154-63. 
 
26. Burnett A, Wetzler M, Lowenberg B. Therapeutic advances in acute myeloid leukemia. 
Journal of clinical oncology : official journal of the American Society of Clinical Oncology 
2011;29:487-94. 


Version 5, dated 06/03/2019 
57 
 
 
27. Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, 
Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER 
Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, 
http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, 
posted to the SEER web site, April 2014. 
 
28. Juliusson G, Antunovic P, Derolf A, Lehmann S, Mollgard L, Stockelberg D, et al. Age and 
acute myeloid leukemia: real world data on decision to treat and outcomes from the Swedish 
Acute Leukemia Registry. Blood 2009;113:4179-87. 
 
29. Kantarjian H, O'Brien S, Cortes J, Giles F, Faderl S, Jabbour E, et al. Results of intensive 
chemotherapy in 998 patients age 65 years or older with acute myeloid leukemia or high-risk 
myelodysplastic 
syndrome: 
predictive 
prognostic 
models 
for 
outcome. 
Cancer 
2006;106:1090-8. 
 
30. Stone RM, Berg DT, George SL, Dodge RK, Paciucci PA, Schulman PP, et al. Postremission 
therapy in older patients with de novo acute myeloid leukemia: a randomized trial comparing 
mitoxantrone and intermediate-dose cytarabine with standard-dose cytarabine. Blood 
2001;98:548-53. 
 
31. Lowenberg B, Beck J, Graux C, van Putten W, Schouten HC, Verdonck LF, et al. 
Gemtuzumab ozogamicin as postremission treatment in AML at 60 years of age or more: 
results of a multicenter phase 3 study. Blood 2010;115:2586-91. 
 
32. 
Freeman SD, Virgo P, Couzens S, Grimwade D, Russell N, Hills RK, et al. Prognostic 
relevance of treatment response measured by flow cytometric residual disease detection in 
older patients with acute myeloid leukemia. Journal of clinical oncology : official journal of 
the American Society of Clinical Oncology 2013;31:4123-31. 
 
33. 
McSweeney PA, Niederwieser D, Shizuru JA, et al. Hematopoietic cell transplantation in 
older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with 
graft-versus-tumor effects. Blood. Jun 1 2001;97(11):3390-3400. 
 
34. 
Gooley TA, Chien JW, Pergam SA, et al. Reduced mortality after allogeneic hematopoietic- 
cell transplantation. N Engl J Med. Nov 25;363(22):2091-2101. 
 
35. 
Sorror ML, Sandmaier BM, Storer BE, et al. Long-term outcomes among older patients 
following nonmyeloablative conditioning and allogeneic hematopoietic cell transplantation 
for advanced hematologic malignancies. JAMA. Nov 2;306(17):1874-1883. 
 
36. 
Estey E, de Lima M, Tibes R, Pierce S, Kantarjian H, Champlin R, et al. Prospective 
feasibility analysis of reduced-intensity conditioning (RIC) regimens for hematopoietic stem 
cell transplantation (HSCT) in elderly patients with acute myeloid leukemia (AML) and 
high-risk myelodysplastic syndrome (MDS). Blood 2007;109:1395-400. 
 
37. 
Pasquini MC ZX. Current use and outcome of hematopoietic stem cell transplantation: 
CIBMTR Summary Slides 2014. Available at: http://www.cibmtr.org. 


Version 5, dated 06/03/2019 
58 
 
 
38. 
Kolb HJ, Schattenberg A, Goldman JM, Hertenstein B, Jacobsen N, Arcese W, et al. Graft- 
versus-leukemia effect of donor lymphocyte transfusions in marrow grafted patients. Blood 
1995;86:2041-50. 
 
39. 
Collins RH, Jr., Shpilberg O, Drobyski WR, Porter DL, Giralt S, Champlin R, et al. Donor 
leukocyte infusions in 140 patients with relapsed malignancy after allogeneic bone marrow 
transplantation. Journal of clinical oncology : official journal of the American Society of 
Clinical Oncology 1997;15:433-44. 
 
40. 
Schmid C, Labopin M, Nagler A, Bornhauser M, Finke J, Fassas A, et al. Donor lymphocyte 
infusion in the treatment of first hematological relapse after allogeneic stem-cell 
transplantation in adults with acute myeloid leukemia: a retrospective risk factors analysis 
and comparison with other strategies by the EBMT Acute Leukemia Working Party. Journal 
of clinical oncology : official journal of the American Society of Clinical Oncology 
2007;25:4938-45. 
 
41. 
Buggins AG, Milojkovic D, Arno MJ, Lea NC, Mufti GJ, Thomas NS, et al. 
Microenvironment produced by acute myeloid leukemia cells prevents T cell activation and 
proliferation by inhibition of NF-kappaB, c-Myc, and pRb pathways. Journal of immunology 
2001;167:6021-30. 
 
42. 
Mussai F, De Santo C, Abu-Dayyeh I, Booth S, Quek L, McEwen-Smith RM, et al. Acute 
myeloid leukemia creates an arginase-dependent immunosuppressive microenvironment. 
Blood 2013;122:749-58. 
 
43. 
Ustun C, Miller JS, Munn DH, Weisdorf DJ, Blazar BR. Regulatory T cells in acute 
myelogenous leukemia: is it time for immunomodulation? Blood 2011;118:5084-95. 
 
44. 
Szczepanski MJ, Szajnik M, Czystowska M, Mandapathil M, Strauss L, Welsh A, et al. 
Increased frequency and suppression by regulatory T cells in patients with acute 
myelogenous leukemia. Clinical cancer research : an official journal of the American 
Association for Cancer Research 2009;15:3325-32. 
 
45. Shenghui Z, Yixiang H, Jianbo W, Kang Y, Laixi B, Yan Z, et al. Elevated frequencies of 
CD4(+) CD25(+) CD127lo regulatory T cells is associated to poor prognosis in patients 
with acute myeloid leukemia. International journal of cancer Journal international du 
cancer 2011;129:1373-81. 
46. 
Wang X, Zheng J, Liu J, Yao J, He Y, Li X, et al. Increased population of 
CD4(+)CD25(high), regulatory T cells with their higher apoptotic and proliferating status in 
peripheral blood of acute myeloid leukemia patients. European journal of haematology 
2005;75:468-76. 
 
47. 
Lichtenegger FS, Lorenz R, Gellhaus K, Hiddemann W, Beck B, Subklewe M. Impaired NK 
cells and increased T regulatory cell numbers during cytotoxic maintenance therapy in AML. 
Leukemia research 2014;38:964-9. 


Version 5, dated 06/03/2019 
59 
 
 
48. 
Kanakry CG, Hess AD, Gocke CD, Thoburn C, Kos F, Meyer C, et al. Early lymphocyte 
recovery after intensive timed sequential chemotherapy for acute myelogenous leukemia: 
peripheral oligoclonal expansion of regulatory T cells. Blood 2011;117:608-17. 
 
49. 
Zhou Q, Munger ME, Highfill SL, Tolar J, Weigel BJ, Riddle M, et al. Program death-1 
signaling and regulatory T cells collaborate to resist the function of adoptively transferred 
cytotoxic T lymphocytes in advanced acute myeloid leukemia. Blood 2010;116:2484-93. 
 
50. 
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. 
 
51. Yang H, Bueso-Ramos C, DiNardo C, Estecio MR, Davanlou M, Geng QR, et al. Expression 
of PD-L1, PD-L2, PD-1 and CTLA4 in myelodysplastic syndromes is enhanced by treatment 
with hypomethylating agents. Leukemia 2014;28:1280-8. 
 
52. Kronig H, Kremmler L, Haller B, Englert C, Peschel C, Andreesen R, et al. Interferon-induced 
programmed death-ligand 1 (PD-L1/B7-H1) expression increases on human acute myeloid 
leukemia blast cells during treatment. European journal of haematology 2014;92:195-203. 
 
53. Norde WJ, Maas F, Hobo W, Korman A, Quigley M, Kester MG, et al. PD-1/PD-L1 
interactions contribute to functional T-cell impairment in patients who relapse with cancer 
after allogeneic stem cell transplantation. Cancer Res 2011;71:5111-22. 
 
54. Strauss L, Bergmann C, Whiteside TL. Human circulating CD4+CD25highFoxp3+ regulatory 
T cells kill autologous CD8+ but not CD4+ responder cells by Fas-mediated apoptosis. 
Journal of immunology 2009;182:1469-80. 
 
55. Czystowska M, Strauss L, Bergmann C, Szajnik M, Rabinowich H, Whiteside TL. Reciprocal 
granzyme/perforin-mediated death of human regulatory and responder T cells is regulated by 
interleukin-2 (IL-2). Journal of molecular medicine 2010;88:577-88. 
 
56. Boyiadzis M, Whiteside TL. Information transfer by exosomes: A new frontier in hematologic 
malignancies. Blood Reviews. 
 
57. Szczepanski MJ, Szajnik M, Welsh A, Whiteside TL, Boyiadzis M. Blast-derived 
microvesicles in sera of acute myeloid leukemia patients suppresses NK cell function via 
membrane-associated TGF-β12011. 
 
58. Hong CS, Muller L, Whiteside TL, Boyiadzis M. Plasma exosomes as markers of therapeutic 
response in patients with acute myeloid leukemia. Frontiers in Immunology, 10;5:160, 2014. 
 
59. Vardiman JW, Thiele J, Arber DA, Brunning RD, Borowitz MJ, Porwit A, et al. The 2008 
revision of the World Health Organization (WHO) classification of myeloid neoplasms and 
acute leukemia: rationale and important changes. Blood 2009;114:937-51. 


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11.0 APPENDICES 
 
ECOG Performance Status 
 
Grade 
Description 
0 
Normal activity. Fully active, able to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous 
activity, but ambulatory and able to carry out work of a light or 
sedentary nature (e.g., light housework, office work). 
2 
In bed <50% of the time. Ambulatory and capable of all self-care, but 
unable to carry out any work activities. Up and about more than 50% 
of waking hours. 
3 
In bed >50% of the time. Capable of only limited self-care, confined 
to bed or chair more than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-care. 
Totally confined to bed or chair. 
5 
Dead. 
* As published in Am. J. Clin. Oncol.: Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., 
McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative Oncology 
Group. Am J Clin Oncol 5:649-655, 1982. The Eastern Cooperative Oncology Group, Robert Comis 
M.D., Group Chair. 
 
Common Terminology Criteria for Adverse Events V4.0 (CTCAE) 
 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 will be utilized for adverse event reporting. 
(http://ctep.cancer.gov/reporting/ctc.html) 
 
12.3 Response Criteria for Acute Leukemia 
 
Morphologic leukemia-free state 
Bone marrow < 5% blasts in an aspirate with spicules 
No blasts with Auer rods or persistence of extramedullary disease 
 
Complete remission 
Patient achieves a morphologic leukemia-free state and 
Absolute neutrophil count > 1000/mcL 
Platelets ≥100,000/mcL 
No residual evidence of extramedullary disease 
Morphologic CR - patient independent of transfusions 
Cytogenetic CR - cytogenetics normal (in those with previously abnormal cytogenetics) 
Molecular CR - molecular studies negative 


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Complete remission with incomplete count recovery 
Patient fulfill all of the criteria for CR except for residual neutropenia (< 1,000/mcL) or 
thrombocytopenia (< 100,000/mcL). 
 
Partial remission 
Decrease of at least 50% in the percentage of blasts to 5 to 25% in the bone marrow 
Patients failing to achieve a complete response are considered treatment failures 
 
Relapse 
Relapse following complete response is defined as reappearance of leukemic blasts in the 
peripheral blood or the finding of more than 5% blasts in the bone marrow, not attributable to 
another cause (eg, bone marrow regeneration after consolidation therapy) 
 
 
Cheson BD, Bennett JM, Kopecky KJ et al. J Clin Oncol 2003;21 (24):4642-4649