Conditions: Acute Myeloid Leukemia
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 67
Healthy volunteers: no

Brief summary:
This is a multicenter, nonrandomized, open-label phase 2 study (with a safety run-in phase) of azacitidine (AZA) 75 mg/m2 given IV or SQ on days 1-7 every 28 days in combination with pembrolizumab 200 mg given IV every 3 weeks (starting on day 8 of cycle 1). The dose/schedule of AZA selected for this study is FDA approved for patients with MDS/AML.

Detailed description:
Acute myeloid leukemia (AML) remains a therapeutic challenge. Although 60-80% of newly diagnosed patients with AML respond to induction chemotherapy, the relapse rate remains high (40%-50%) even after allogeneic stem cell transplant (alloHSCT). Data suggests that epigenetic therapy with azacitidine combined with blockade of PD-1/PD-L1 pathway is a rational therapeutic approach both in newly diagnosed older patients and those with relapsed and refractory AML. Furthermore, recent data suggest that the addition of PD-1 blockade (nivolumab) to azacitidine in patients with AML who have previously failed hypomethylating agents may induce responses in up to 20% patients

We plan to examine two AML patient cohorts:

Cohort 1: relapsed/refractory AML. Cohort 2: newly diagnosed AML in older patients (≥65 years) not candidates for induction chemotherapy. Azacitidine and pembrolizumab have distinct mechanisms of action with no common overlapping toxicities; however, as azacitidine and pembrolizumab have not been tested previously in combination in AML patients, we plan to start enrollment with Cohort 1 (a safety run-in phase) and include only relapsed/refractory AML patients excluding those relapsing after allogeneic hematopoietic stem cell transplant (alloHSCT). The primary objective of the run in safety phase would be to determine the safe and tolerable dose/schedule of azacitidine and pembrolizumab in patients with AML. We will perform safety run in phase only in Cohort 1 as Cohort 2 patients would be expected to have a same or better tolerability given that they are not heavily pretreated

Arms:
arm 1: The treatment of relapsed and refractory AML patients. arm 2: The treatment of newly diagnosed AML patients (≥ 65 years) who are not candidates for intensive induction chemotherapy.

Interventions: intervention 1: pembrolizumab intervention 2: Azacitadine
Intervention descriptions: intervention 1: Intravenous pembrolizumab intervention 2: Intravenous or subcutaneous

Protocol document:
Prot_SAP_000.pdf: 
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Protocol Amendment #8 (October 14, 2020) 
J1651: A Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years) AML Patients 
Amendment #8 Incorporates: 
X Administrative Protocol Revisions: 
 Telemedicine options have been added to the protocol in the study calendar 
section (Section 6.1, page 56) 
 
X Investigator’s Brochure: 
 Pembrolizumab IB edition 19 
 The updated IB did not result in any changes to the study ICF. 
 
 
 
NCT02845297


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Protocol Amendment #7 (January 14, 2020) 
J1651: A Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years) AML Patients 
Amendment #7 Incorporates: 
X Administrative Protocol Revisions: 
 List of JH Co-Investigators updated 
 Statement added to Section 5.1.1 reflecting study enrollment closure on 
1/8/2020.  The relapsed/refractory cohort has been completed, and new 
enrollment to the newly diagnosed AML cohort has been closed based on 
FDA guidance on the risk benefit analysis.  
 Unit for albumin changed from mg/dL to g/dL in Section 5.1.2 Table 1 
 
X Changes to the Informed Consent Form: 
 Information added to section 2 to notify patients of enrollment closure and 
updated risk benefit analysis information from the FDA 
 (Note: Risk language was previously updated with ICF template version 
8-15-19 in accordance with Pembrolizumab IB v17 and aggregate safety 
report for Pembrolizumab Primary Adrenal Insufficiency. JHMIRB 
approved on 9-4-19.) 
 
 


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Protocol Amendment #6 (July 18, 2018) 
J1651: A Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years) AML Patients 
Amendment #6 Incorporates: 
X Changes to the Protocol: 
 Correction of the spelling of pembrolizumab throughout the protocol 
 An echocardiogram exception for screening has been added to section 
7.1.5.1.1 and Section 6.1, footnote k.  If an echocardiogram was conducted 
within 3 months prior to the screening date and the patient has not received 
any chemotherapy in the time between and has not experienced any cardiac 
symptoms or events (heart attack, chest pain, arrhythmia, etc), then the 
screening echocardiogram does not need to be repeated, unless it is 
clinically indicated per investigator’s discretion. 
 Vital signs will no longer be obtained post pembrolizumab infusion.  This 
revision has been made to Section 6.1, footnote g. 
 For pembrolizumab related toxicities, additional information about 
resumption of dosing has been added to Table 4 in Section 5.2.1.4. 
 A window of 4 days has been added to the 30 day follow up visit in 
Section 6.1 so that the patients can be seen on their physicians’ clinic 
days. 
 The D-Dimer laboratory test has been removed from section 7.1.5.1.1. 
X Changes to the Informed Consent Form to update the risk language as per 
new Pembrolizumab IBv16 and Merck recommendations, and include: 
 
 The risk language in section 4 has been updated.   
o Statement added to indicate number of patients treated with 
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o Statement under pembrolizumab risks was revised to note that 
immune-mediated adverse reactions may be fatal and may occur 
after discontinuation of pembrolizumab.  
o Solid organ transplant risk information has been added. 
o A new paragraph was included to note that “arthritis” was added 
after the Rare side effects section as an adverse reaction from the 
post-marketing environment. 
 
 


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Protocol Amendment #5 (January 23, 2018) 
J1651: A Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years) AML Patients 
Amendment #5 Incorporates: 
 Administrative changes to the protocol 
o Correcting name spelling of non-JHU co-investigator Robert K. 
Stuart, MD, Medical University of South Carolina, Hollings 
Cancer Center 
 
 Changes to do the dose modification table for pembrolizumab-related 
immune adverse events in Section 5.2.1.4 according to Merck 
recommendations (letter dated 11/28/2017). 
 
 Correction to the study calendar Section 6.1. to be consistent with 
footnotes and the intended collection schedule 
 
 
 
 
 
 
 
 
 
 
 


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PROTOCOL AMENDMENT #4 (10/24/2017) 
J1651: Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years AML Patients) 
AMENDMENT #4 INCORPORATES: 
X Administrative Changes to the Protocol 
 Non-JHU co-investigator change from Juan Varela, MD, PhD to Robert 
Stewart, MD 
 Clarification of cohort #2 exclusion criteria in Section 5.1.3 
X Changes to the Informed Consent Form to update the risk language as per new 
Pembrolizumab IBv15 and Merck recommendations, and include: 
 Addition of allogeneic stem cell transplant risk language 
 Administrative changes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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PROTOCOL AMENDMENT #3 (08/17/2017) 
J1651: Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years) AML Patients 
This protocol is amended to update definition of disease response based on 
revisions included in AML European Leukemia Net criteria 2017 and provide 
clarification on the assessment of disease progression in accordance with AML 
ELN 2017, and expectations for response and follow up in AML patients 
undergoing low dose chemotherapy in combination with immunotherapy. The 
informed consent form is revised to update risk language for pembrolizumab 
according to a new version of the MK-3475 Risk Wording document issued on 
06.09.2017 by Merck and Co. 
AMENDMENT #3 INCORPORATES: 
X Administrative, Editorial Changes to the Protocol 
 Section 11.3 and 12 (Reference #63) revised to include online reference to 
revised AML criteria in 2017. 
 Section 5.2.1.3 - corrected grammatical error, and section 5.2.1.4 –removed 
reference to Appendix, section 11.4 as it was incorrect. 
X Scientific Changes to the Protocol 
 Section 5.2.1.5.3- Added requirement that dose reductions/delays during 
cycle 1, 2 or subsequent cycles should be discussed with the Protocol Chair 
before being made.  
 Section 7.1.2.6 – Response criteria were updated to reflect changes 
incorporated in new AML ELN criteria 2017. In particular, new categories for 
response assessment including complete remission without minimal residual 
disease (CRMRD-), morphologic leukemia-free state (MLFS), stable disease 
and molecular relapse were added. Also, definitions for response assessment 
(CR, CRi, PR, CD) were updated according to AML ELN 2017. In particular, 
progressive disease criteria were updated, with detailed clarification provided 
for follow up and subsequent treatment, as well as when patient should be 
removed from study for progressive disease before completion of 6 cycles of 
therapy.  
 In accordance with updated response criteria (Section 7.1.2.6), changes to the 
section 1.0, section 2.1, section 3.3 (3. and 4.), section 4.2.3.1.2, 5.2.1.5.4, 
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 category of response; and minor changes to the section 1.0 (Duration of 
participation), section 2.1, section 5.2.1.3 to be consistent throughout the 
protocol, we changed wording to the bone marrow assessment. 
X Eligibility Changes 
 Inclusion criterion (Section 5.1.2, Cohort #1 and #2, criterion 6.) changed to 
ECOG PS < 2 (previously ≤ 2) 
X Changes to the ICF to update the risk language for pembrolizumab according 
to a new version of the MK-3475 Risk Wording document issued on 06.09.2017 
by Merck and Co. High level summary of changes:  
1. General 
a. Wording of Rarely this condition can lead to death has been changed to 
Sometimes this condition can lead to death 
b. Changed the wording of some terms to align better with the other terms with 
regards to grammar and/or addition of symptoms upon Medical Director review. 
c. Removed KEYTRUDA® from document 
2. What side effects could the study drug(s) cause?  
a. Section streamlined to remove specific reference to the approved indications 
by name as well as specific clinical trial exposure numbers, etc. as information 
changes continually. 
b. Added pembrolizumab information from patient medication guides (USPI 
medication guide and/or SmPC patient leaflet) to explain how pembrolizumab 
works and how it may cause side effects. 
c. Used the format of 4 categories (Very Common, Common, Uncommon, and 
Rare) which simplifies and eliminates need for repetition of terms by overall and 
serious frequencies, etc. vs percentages. 
i. Removed duplicate terms, ie, that were in the previous version’s Common and 
Serious side effect percentage categories 
d. Removed reference to “immune-mediated” serious events <1%, as not helpful 
or informative for patient and has created numerous site/IRB/EC and Health 
Authority questions. 
e. Added simplified language for 4 new terms: thyroiditis, myasthenic syndrome, 
sarcoidosis, and encephalitis. 
3. Hematologic Malignancy trials language 
a. Changed paragraph order and text for readability 
 
 
 
 
 
 
 
 
 


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PROTOCOL AMENDMENT #2 (03/07/2017) 
J1651: Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years) AML Patients 
AMENDMENT #2 INCORPORATES: 
X Administrative Changes to the Protocol 
 Clarified which type of tubes can be used for the specimen collection in 
the Section 6.1, 7.1.3.1.3.5., and 11.4. 
 Provided additional clarification in the text for the Table 6.1 Study Flow 
Chart that the bone marrow should be obtained at the treatment 
discontinuation as well as PB and BM research specimens collected. 
 Clarified that correlative studies will be done in collaboration with UNC 
(a participating site for this study), Section 7.1.3.1.3. 
X Changes to the Informed Consent Form to update the risk language as per new 
Pembrolizumab IBv13 (02/17/2017) and Merck recommendations, and include: 
 Administrative changes 
 Update on the risks:  
i. 
Additional language added to Severe Skin Reactions (first 
bullet) to reflect symptoms associated with Stevens-Johnson 
Syndrome and Toxic Epidermal Necrolysis. 
ii. 
Diabetes language updated to ensure subjects know that they 
will likely need regular insulin 
iii. 
New side effect language added for myocarditis (last bullet) 
iv. 
New text for the potential side effect, myasthenic syndrome, 
has been added. 
 
  
 
 
 
 
 


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PROTOCOL AMENDMENT #1 (12/28/2016) 
J1651: Phase 2 Study of Azacitidine in Combination with Pembrolizumab in 
Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients and in Newly 
Diagnosed Older (≥65 Years) AML Patients 
 
AMENDMENT #1 INCORPORATES: 
X Administrative Changes 
X Scientific Changes 
X Eligibility Changes 
A summary of revisions is provided as follows: 
1. Corrected language in Section 2.1 (page 8) to specify that patients will be 
assessed during cycle 1-3 for DLT to be consistent with the rest of the 
protocol. 
2. Section 4.2.1. updated clinical results on use of anti-PD1 and azacitidine 
in AML. 
3. Revised eligibility criteria (Section 5.2.1. Subject Inclusion Criteria) for 
Cohort #1 (4.), for Cohort #2 (4.) to allow prior treatment with 
hypomethylating agents. 
4. Revised eligibility criteria (Section 5.2.2 Subject Exclusion Criteria) for 
Cohort #2 – Removed exclusion criteria (1.) to allow prior treatment with 
hypomethylating agents. 
5. Revised Section 5.2.1.5 to be consistent with Section 5.2.1.4. specifying 
when delay in treatment between cycles will be allowed. 
6. Revised Section 5.2.1.5.1 to better define circumstances when azacitidine 
treatment can be interrupted and restarted within a cycle. 
7. Revised Section 6.1. Table footnote “a” to reflect changes listed under 5-
6 of this amendment. 
8. Revised Section 5.6.2 for hydroxyurea dosing during study. 
 
 
                                              


 
 
 


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TITLE:  
Phase 2 Study of Azacitidine in Combination with 
Pembrolizumab in Relapsed/Refractory Acute Myeloid 
Leukemia (AML) Patients and in Newly Diagnosed Older 
(≥65 Years) AML Patients 
 
Principal Investigator:  
Ivana Gojo, MD 
(Study Chair) 
Sidney Kimmel Comprehensive Cancer Center (SKCCC) at 
Johns Hopkins 
1650 Orleans Street, CRB1, Room 346 
 
 
 
 
Baltimore, MD 21287  
 
 
 
 
 
Phone: 410-502-8775; Fax: 410-614-1005 
 
 
 
 
E-mail: igojo1@jhmi.edu 
 
Co-investigators(s):   
Leo Luznik, MD 
 
 
 
 
B. Doug Smith, MD  
 
 
 
 
 
 
                        Mark Levis, MD, PhD 
 
 
 
 
Margaret Showel, MD 
 
 
 
 
Amy Dezern, MD 
 
 
 
 
Gabriele Prince, MD 
 
 
 
 
Lukasz Gondek, MD, PhD 
 
 
 
 
Gabriel Ghiaur, MD, PhD 
 
 
 
 
Jonathan Webster, MD 
 
 
 
 
William Dalton, MD, PhD 
 
Non-JHU Co-investigator(s):  
 
Joshua Zeidner, MD, University of North Carolina Lineberger Comprehensive Cancer Center 
Robert K. Stuart, MD, Medical University of South Carolina, Hollings Cancer Center 
 
Study coordinator:  
Colin Huck 
 
 
 
 
550 N Broadway, Ste 801 
 
 
 
 
Baltimore MD 21287 
 
 
 
 
Phone: 410-614-3725 
 
 
 
 
Email: chuck1@jhmi.edu and onc-coordcnt@jhmi.edu 
 
Research Nurse: 
 
Jillian Morrow 
 
 
 
 
1650 Orleans St. CRB1 2M05 
 
 
 
 
Baltimore MD 21287 
 
 
 
 
Phone: 410-502-5396 
 
 
 
 
Email: jmorro16@jhmi.edu and onc-coordcnt@jhmi.edu 
 
Statistician:  
 
Amanda Blackford, MS 
 
 
 
 
 
 
 
 
Ravi Vardahan, PhD 
 
IND NUMBER: 
 
12983 


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TABLE OF CONTENTS 
1.0 
TRIAL SUMMARY.................................................................................................... 7 
2.0 
TRIAL DESIGN.......................................................................................................... 8 
2.1 
Trial Design ............................................................................................................. 8 
2.2 
Trial Diagram ........................................................................................................ 10 
3.0 
OBJECTIVE(S) & HYPOTHESIS(ES) .................................................................. 10 
3.1 
Primary Objective(s) & Hypothesis(es) (safety run in-phase) .......................... 10 
3.2 
Primary Objective(s) & Hypothesis(es) (Phase 2) ............................................. 10 
3.3 
Secondary Objective(s) & Hypothesis(es)........................................................... 11 
3.4 
Exploratory Objective .......................................................................................... 12 
4.0 
BACKGROUND & RATIONALE .......................................................................... 12 
4.1 
Background ........................................................................................................... 12 
4.1.1 Pharmaceutical and Therapeutic Background .................................................... 12 
4.2 
Rationale ................................................................................................................ 15 
4.2.1 Rationale for the Trial and Selected Subject Population .................................... 15 
4.2.2 Rationale for Dose Selection/Regimen/Modification ......................................... 17 
4.2.3 Rationale for Endpoints ...................................................................................... 18 
5.0 
METHODOLOGY ................................................................................................... 20 
5.1 
Entry Criteria ........................................................................................................ 20 
5.1.1 Diagnosis/Condition for Entry into the Trial ...................................................... 20 
5.1.2 Subject Inclusion Criteria.................................................................................... 20 
5.1.3 Subject Exclusion Criteria .................................................................................. 23 


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5.2 
Trial Treatments ................................................................................................... 27 
5.2.1 Dose Selection/Modification .............................................................................. 28 
5.2.2 Timing of Dose Administration .......................................................................... 37 
5.2.3 Trial Blinding/Masking ....................................................................................... 38 
5.3 
Randomization or Treatment Allocation ............................................................ 38 
5.4 
Stratification .......................................................................................................... 38 
5.5 
Drug Information .................................................................................................. 38 
5.5.1 Pembrolizumab .................................................... Error! Bookmark not defined. 
5.5.2 Azacitidine .......................................................................................................... 40 
5.6 
Concomitant Medications/Vaccinations (allowed & prohibited) ..................... 42 
5.6.1 Acceptable Concomitant Medications ................................................................ 42 
5.6.2 Prohibited Concomitant Medications.................................................................. 42 
5.7 
Rescue Medications & Supportive Care ............................................................. 43 
5.7.1 Antiemetics ......................................................................................................... 43 
5.7.2 Antimicrobial Prophylaxis .................................................................................. 43 
5.7.3 Colony Stimulating Factors ................................................................................ 43 
5.7.4 Prevention and Management of Tumor Lysis Syndrome ................................... 43 
5.7.5 Supportive Care Guidelines for Pembrolizumab ................................................ 44 
5.8 
Diet/Activity/Other Considerations ..................................................................... 47 
5.8.1 Diet ...................................................................................................................... 47 
5.8.2 Contraception ...................................................................................................... 48 
5.8.3 Use in Pregnancy ................................................................................................ 49 
5.8.4 Use in Nursing Women ....................................................................................... 50 
5.9 
Subject Withdrawal/Discontinuation Criteria ................................................... 50 


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5.9.1 Discontinuation of Study Therapy after CR ....................................................... 51 
5.10 
Subject Replacement Strategy ............................................................................. 51 
5.11 
Clinical Criteria for Early Trial Termination ................................................... 52 
6.0 
TRIAL FLOW CHART ........................................................................................... 53 
6.1 
Study Flow Chart .................................................................................................. 53 
7.0 
TRIAL PROCEDURES ........................................................................................... 57 
7.1 
Trial Procedures ................................................................................................... 57 
7.1.1 Administrative Procedures .................................................................................. 57 
7.1.2 Clinical Procedures/Assessments ........................................................................ 60 
7.1.3 Laboratory Procedures/Assessments ................................................................ 644 
7.1.4 Other Procedures ............................................................................................... 688 
7.1.5 Visit Requirements ............................................................................................ 699 
7.2 
Assessing and Recording Adverse Events ........................................................ 722 
7.2.1 Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Sponsor and to Merck ....................................................................................... 733 
7.2.2 Reporting of Pregnancy and Lactation to the Sponsor and to Merck ............... 744 
7.2.3 Immediate Reporting of Adverse Events to the Sponsor and to Merck............ 744 
7.2.4 Evaluating Adverse Events ............................................................................... 799 
7.2.5 Sponsor Responsibility for Reporting Adverse Events .................................... 822 
7.2.6 Reporting Protocol Deviation ........................................................................... 822 
8.0 
STATISTICAL ANALYSIS PLAN ...................................................................... 833 
8.1 
Statistical Analysis Plan Summary ................................................................... 833 
8.2 
Statistical Analysis Plan ..................................................................................... 833 
8.2.1 Safety Run-In .................................................................................................... 833 


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8.2.2 Sample Size ....................................................................................................... 844 
8.2.3 Analysis of Primary Endpoint ........................................................................... 877 
8.2.4 Analysis of Secondary Endpoints ..................................................................... 877 
8.2.5 Analysis of Correlative Endpoints .................................................................... 888 
9.0 
LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL 
SUPPLIES ............................................................................................................... 888 
9.1 
Investigational Product ...................................................................................... 888 
9.2 
Packaging and Labeling Information ............................................................... 888 
9.3 
Clinical Supplies Disclosure ............................................................................... 899 
9.4 
Storage and Handling Requirements ................................................................ 899 
9.5 
Returns and Reconciliation ................................................................................ 899 
10.0 
ADMINISTRATIVE AND REGULATORY DETAILS ..................................... 899 
10.1 
Confidentiality ..................................................................................................... 899 
10.2 
Compliance with Financial Disclosure Requirements ..................................... 899 
10.3 
Compliance with Law, Audit and Debarment ................................................... 90 
10.4 
Compliance with Trial Registration and Results Posting Requirements ...... 911 
10.5 
Quality Management System ............................................................................. 911 
10.6 
Data Management ............................................................................................... 922 
10.7 
Record Retention ................................................................................................ 922 
11.0 
APPENDICES ......................................................................................................... 933 
11.1 
ECOG Performance Status ................................................................................ 933 
11.2 
Common Terminology Criteria for Adverse Events V4.0 (CTCAE) ............. 933 
11.3 
Response Evaluation Criteria in Acute Myeloid Leukemia ............................ 933 
11.4    Operating Procedures for Specimen Collection ................................................ 944 


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11.5   Multicenter Guidelines ......................................................................................... 988 
12.0  List of References ....................................................................................................... 100 
 


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1.0 TRIAL SUMMARY 
Abbreviated Title 
Azacitidine and Pembrolizumab for the treatment of relapsed/refractory 
AML patients and newly diagnosed older (≥ 65 years) AML patients who 
are not candidates for intensive induction chemotherapy 
Trial Phase 
Phase II 
Clinical Indication 
Safety Run In Phase (only Cohort 1): The treatment of relapsed and 
refractory AML patients with no prior history of allogeneic hematopoietic 
stem cell transplant (HSCT). 
Phase 2: 
Cohort 1:   The treatment of relapsed and refractory AML patients. 
Cohort 2:  The treatment of newly diagnosed AML patients (≥ 65 years) 
who are not candidates for intensive induction chemotherapy.   
Trial Type 
Interventional 
Type of control 
No control arm 
Route of administration 
Intravenous pembrolizumab; intravenous or subcutaneous azacitidine 
Trial Blinding 
Open Label 
Treatment Groups  
Cohort 1: Relapsed/refractory AML patients 
Cohort 2: Newly diagnosed older patients (≥65 years) who are not 
candidates for intensive induction chemotherapy 
Number of trial subjects 
Cohort 1: 10-40 
Cohort 2: 10-40 
Estimated enrollment period 
24 months 
Estimated duration of trial 
48 months 
Duration of Participation
Each subject will participate in the trial from the time the subject signs the 
Informed Consent Form through the final protocol-specified contact. Each 
treatment cycle will last 28 days. Bone marrow will be examined after 2 
and 6 cycles and every 3-6 months thereafter. Patients who achieved 
complete remission (CR/CRi) or patients without remission but benefiting 
from therapy (partial remission [PR], morphologic leukemia-free state 
[MLFS], hematologic improvement [HI], stable disease [SD]) can 
continue on study receiving both azacitidine and pembrolizumab as long 
as they have ongoing clinical benefit without evidence of significant 
toxicity or disease progression and up to 2 years. 
Estimated average length of 
treatment per patient 
Up to 2 years or as long as subjects have ongoing clinical benefit without 
evidence of disease progression or significant toxicity. 
 
 
 
 


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2.0 TRIAL DESIGN 
2.1 
Trial Design 
This is a multicenter, nonrandomized, open-label phase 2 study (with a safety run-in phase) of 
azacitidine (AZA) 75 mg/m2 given IV or SQ on days 1-7 every 28 days in combination with 
pembrolizumab 200 mg given IV every 3 weeks (starting on day 8 of cycle 1). The 
dose/schedule of AZA selected for this study is FDA approved for patients with MDS/AML. 
The rationale for pembrolizumab dose/schedule- Section 4.2.2. 
We plan to examine two AML patient cohorts:  
Cohort 1: relapsed/refractory AML.  
Cohort 2: newly diagnosed AML in older patients (≥65 years) not candidates for induction 
chemotherapy.  
Each cohort will be enrolled separately with distinct null hypotheses and statistical plans.  
Azacitidine and pembrolizumab have distinct mechanisms of action with no common 
overlapping toxicities; however, as azacitidine and pembrolizumab have not been tested 
previously in combination in AML patients, we plan to start enrollment with Cohort 1 (a 
safety run-in phase) and include only relapsed/refractory AML patients excluding those 
relapsing after allogeneic hematopoietic stem cell transplant (alloHSCT).  
Cohort 1 (a safety run-in phase, 3 + 3 design): The first three patients will be enrolled and 
receive planned azacitidine and pembrolizumab in cycle 1 (Section 2.2). If 0 or 1 patient of the 
first three patients have a DLT (dose limiting toxicity) in cycle 1, we will enroll additional 3 
patients to better assess for toxicities. If less than 2 among first 6 patients experiences DLT in 
the cycle 1-3, we will open enrollment in Cohort 1 for all relapsed/refractory patients including 
those with prior history of alloHSCT and will also start to enroll patients in Cohort 2. We plan 
to monitor for DLTs up to the end of cycle 3 as some of immunological side effects associated 
with pembrolizumab may occur with the delay. 
If ≥2 of the first 3 patients or ≥2 of 6 patients have DLTs during cycle 1, we will perform safety 
(detailed toxicity) review to assess for disease versus treatment-related toxicities. Given that 
pembrolizumab is given only once in cycle 1 (day 8), we will first dose de-escalate azacitidine 
to 75 mg/m2 x 5 days. However, if the safety data analysis suggests that the toxicities are more 
likely pembrolizumab related, an alternative approach we may take is to exclude 
pembrolizumab in cycle 1 and start pembrolizumab dosing in cycle 2 when AML is better 
controlled but maintain azacitidine dose/schedule. If ≤1 of the 6 patients experience DLTs 
during cycle 1 but ≥ 2 of 6 patients experience DLTs during cycle 2 and cycle 3 or  cycle 1, 2 
and 3, we will first dose de-escalate pembrolizumab to 200 mg given every 4 weeks starting 
on Day 1 of Cycle 2 and maintain azacitidine dose/schedule. When each dose de-escalation 
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escalation, please see Section 2.2 Trial Diagram.  
Only after safe dose/schedule is defined (≤ 1 of 6 patients having DLT in cycle 1-3) we will 
start enrollment in the phase 2 cohorts. A full safety assessment of the combination of AZA 
and pembrolizumab will be performed in all patients after 1, 2, and 3 cycles and in subsequent 
cycles according to the NCI Common Terminology Criteria for Adverse Events (CTCAE), 
version 4.0. For efficacy analysis, those patients who were treated at dose/schedule selected 
for Phase 2 will be included. 
Bone marrow biopsy/aspirate will be performed after 2 and 6 cycles of therapy, and every 3-6 
months thereafter as described in Section 6.0 Trial Flow Chart. Treatment with 
azacitidine/pembrolizumab will continue until confirmed disease progression, unacceptable 
toxicity, or if patient is withdrawn from study for other reasons (Section 5.9). Patients having 
a clinical benefit from this treatment combination including CR/CRi but also those who 
achieve response less than CR/CRi (ie., PR/MLFS/HI/SD) will be able to continue on treatment 
on clinical study (AZA and pembrolizumab) until they meet criteria specified in section 5.9. 
After the end of treatment, each subject will be followed for 30 days for AEs monitoring 
(serious adverse events will be collected for 90 days after the end of treatment as described in 
Section 7.2.3.3.2.). Subjects who discontinue treatment for reasons other than disease 
progression will have post-treatment follow up for disease status until disease progression, 
initiating non-study cancer treatment, withdrawing consent or becoming lost for follow up. All 
subjects will be followed for overall survival until death, withdrawal of consent or the end of 
the study, whichever comes first.  
The primary objective of the run in safety phase would be to determine the safe and tolerable 
dose/schedule of azacitidine and pembrolizumab in patients with AML. We will perform safety 
run in phase only in Cohort 1 as Cohort 2 patients would be expected to have a same or better 
tolerability given that they are not heavily pretreated. Patients who relapse post alloHSCT will 
be enrolled on the study only if they are at least 3 month after alloHSCT and off all immune 
suppression for at least 3 weeks and have no evidence of active graft versus host disease 
(GVHD). These patients are expected to tolerate treatment as well as all other 
relapsed/refractory patients but will be monitored for any GVHD exacerbation in the course of 
treatment. The primary objective of this Phase 2 study would be to estimate the CR/CRi rates 
in two separate cohorts of patients: Cohort 1: relapsed or refractory AML patients. Cohort 2: 
Newly diagnosed older AML patients (≥65 years) who are not candidates for intensive 
induction chemotherapy. Secondary objectives of the trial are to determine safety, tolerability, 
and analysis of various efficacy parameters such as overall response rate, disease-free survival, 
progression-free survival, time to progression, overall survival, and exploration of association 
between potential biomarkers and clinical activity. These analyses will be performed 
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2.2 
Trial Diagram 
 
3.0 OBJECTIVE(S) & HYPOTHESIS(ES) 
3.1 
Primary Objective(s) & Hypothesis(es) (safety run in-phase) 
(1) Objective: Determine the safe and tolerable dose of AZA followed by pembrolizumab in 
relapsed and refractory AML patients. 
Hypothesis:  AZA followed by pembrolizumab will be safe and tolerable in relapsed and 
refractory AML. 
3.2 
Primary Objective(s) & Hypothesis(es) (Phase 2) 
(1) Objective (Cohort 1): Estimate the complete remission (CR/CRi) rate of AZA followed 
by pembrolizumab in relapsed and refractory AML patients. 
Hypothesis:  AZA followed by pembrolizumab will be effective (CR/CRi) in relapsed and 
refractory AML. 
(2) Objective (Cohort 2):  Estimate the complete remission (CR/CRi) rate of AZA followed 
by pembrolizumab in older (≥65 years) newly diagnosed AML patients not candidates for 
intensive induction chemotherapy. 


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Hypothesis: AZA followed by pembrolizumab will be effective (CR/CRi) in older (≥65 
years) newly diagnosed AML patients not candidates for intensive induction 
chemotherapy. 
3.3 
Secondary Objective(s) & Hypothesis(es) 
(1) Objective (Cohort 1):  Characterize the toxicity of AZA followed by pembrolizumab in 
relapsed and refractory AML. 
Hypothesis:  AZA followed by pembrolizumab will be safe and tolerable when 
administered to relapsed and refractory AML patients. 
(2) Objective (Cohort 2):  Characterize the toxicity of AZA followed by pembrolizumab in 
older (≥65 years) newly diagnosed AML patients not candidates for intensive induction 
chemotherapy. 
Hypothesis: AZA followed by pembrolizumab will be safe and tolerable when 
administered to older (≥65 years) newly diagnosed AML patients not candidates for 
intensive induction chemotherapy. 
(3) Objective (Cohort 1): Assess the overall response rates [ie.CR/CRi/partial response 
(PR)/morphologic leukemia-free state (MLFS)/hematologic improvement (HI)] of AZA 
followed by pembrolizumab in relapsed/refractory AML patients.  
Hypothesis: AZA followed by pembrolizumab will lead to a promising overall response 
rate in relapsed and refractory AML patients. 
(4) Objective (Cohort 2): Assess the overall response rates [ie.CR/CRi/partial response 
(PR)/ morphologic leukemia-free state (MLFS)/hematologic improvement (HI)] of AZA 
followed by pembrolizumab in newly diagnosed AML patients not candidates for 
intensive induction chemotherapy.  
Hypothesis: AZA followed by pembrolizumab will lead to a promising overall response 
rate in older (≥65 years) newly diagnosed AML patients not candidates for intensive 
induction chemotherapy. 
(5) Objective (Cohort 1 and Cohort 2): Estimate disease-free survival (DFS) and overall 
survival (OS) of patients who achieve a CR/CRi for each cohort separately: 
relapsed/refractory (Cohort 1) and newly diagnosed older AML patients (Cohort 2). 
Hypothesis: Patients who achieve a CR/CRi will have durable responses. 
(6)  Objective (Cohort 1 and Cohort 2): Estimate progression-free survival (PFS), time to 
progression (TTP), and OS for all patients. These survival parameters will be estimated 
separately for each Cohort. 


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Hypothesis: AZA followed by pembrolizumab will lead to a promising PFS, TTP and OS 
in both relapsed/refractory and older newly diagnosed AML patients not candidates for 
intensive induction chemotherapy. 
3.4 
Exploratory Objective 
(1) 
Objective: Explore association between potential biomarkers and clinical activity of the 
combination of AZA and pembrolizumab in patients with relapsed and refractory AML 
and in older (≥65 years) newly diagnosed AML patients not candidates for intensive 
induction chemotherapy. 
4.0 BACKGROUND & RATIONALE 
4.1 
Background 
4.1.1 Pharmaceutical and Therapeutic Background 
4.1.1.1 Pembrolizumab 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades1.  Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in 
various malignancies2–6.  In particular, the presence of CD8+ T-cells and the ratio of CD8+ 
effector T-cells / FoxP3+ regulatory T-cells seems to correlate with improved prognosis and 
long-term survival in many solid tumors. 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress 
immune control.  The normal function of PD-1, expressed on the cell surface of activated T-
cells under healthy conditions, is to down-modulate unwanted or excessive immune responses, 
including autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig superfamily 
member related to CD28 and CTLA-4 which has been shown to negatively regulate antigen 
receptor signaling upon engagement of its ligands (PD-L1 and/or PD-L2)7,8.  The structure of 
murine PD-1 has been resolved9.  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 cascade7,10–12.  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 proteins13,14.  PD-1 was shown to be expressed on activated lymphocytes including 
peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer cells15,16.  Expression 
has also been shown during thymic development on CD4-CD8- (double negative) T-cells as 


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well as subsets of macrophages and dendritic cells17.  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 tumors13,18,19. 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 tissues13.  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)20.  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. 
4.1.1.1.1 Pembrolizumab Preclinical and Clinical Trial Data 
Refer to the Investigator’s Brochure for additional Preclinical and Clinical data. 
4.1.1.1.1.1 Preclinical Findings 
In preclinical studies, T-lymphocyte responses in cells from healthy human subjects, patients 
with cancer, as well as in primates were strongly enhanced by pembrolizumab. The EC50 (i.e., 
concentration in which 50% of the maximum effect is seen) in human donor blood cells 
exposed to pembrolizumab has been reported to be between ~0.1 and 0.3 nM based on T-cell 
activation assays, and levels of cytokines, including but not limited to interleukin-2 (IL-2), 
tumor necrosis factor alpha (TNF-α) and interferon gamma (IFN-γ) were changed by this 
antibody. Of note, pembrolizumab does not impact immune responses unless antigen is 
present.  In syngeneic murine tumor models, an anti-murine PD-1 analog significantly 
inhibited tumor growth, and was synergistic with chemotherapy agents resulting in increased 
complete tumor regression rates. 
Safety pharmacology/toxicology studies of pembrolizumab were conducted in cynomolgus 
monkeys and included both a 1-month and 6-month repeat dosing period study. The maximum 
dose administered in each was 200mg/kg, administered weekly in the 1-month study and every 
other week in the 6-month study.  The antibody was well tolerated in both studies, with an 
increased incidence of inguinal swelling and increased splenic weights at the 200mg/kg dose 
the only notable findings in the 1-month study, neither of which was considered adverse. Anti-
pembroliuzmab antibodies were detected in both studies, but not at the 200mg/kg dose. 


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Further, based on the level of target engagement, the antibodies do not seem to impact 
pembrolizumab pharmacodynamics. The no observable adverse effect level (NOAEL) based 
on both studies is ≥200mg/kg/dose. See the most recent pembrolizumab Investigator’s 
Brochure for additional details. 
4.1.1.1.1.2 Clinical Findings  
As of the April 2015 Investigator’s Brochure (IB: data cut-off of October 2013), 1,000 patients 
across 7 studies have been treated with pembrolizumab at various dose-schedules, including 
10 mg/kg administered IV over 30 minutes every 2 weeks. The drug has been well tolerated to 
date, with no serious infusion reactions and no DLT reported. The most commonly reported 
treatment emergent adverse events (TEAEs) experienced are fatigue (43.8%), nausea (26.7%), 
cough (25.3%), pruritus (24.6%), diarrhea (22.3%) and rash (21.5%).  
An immune-related adverse event (irAE) is defined as a clinically significant AE of any organ 
that is associated with study drug exposure, is of unknown etiology, and is consistent with an 
immune-related mechanism. The most commonly reported irAEs across the dose-schedules in 
pembrolizumab studies are rash (3.2%), pruritus (2.9%), vitiligo (2.9%), hypothyroidism 
(2.7%), arthralgia (2.2%), diarrhea (2.2%) and pneumonitis (1.9%). The organ most frequently 
affected by irAEs with pembrolizumab is the skin. Less frequently affected tissues include 
thyroid gland, colon, lung, kidney, and liver.  
There have been no serious infusion reactions reported with pembrolizumab. Less than 1% of 
patients (one report) have had confirmed positive treatment emergent anti-drug antibodies and 
no clear impact on exposure to pembrolizumab has been observed. 
4.1.1.2 Azacitidine 
Azacitidine (AZA), a hypomethylating agent, is widely used in the treatment of high-risk 
myelodysplastic syndrome (MDS) and AML in older patients. In the phase III study, AZA 
improved survival over conventional care regimens not only in high-risk MDS patients but 
also AML patients having 20-30% blasts (24.5 vs 16 months)21,22. Besides a CR/CRi rate of 
18%, an additional 20-30% of AML patients benefited from AZA treatment in terms of 
transfusion-independence22. Subsequent, mainly retrospective studies have shown that AZA is 
effective in AML patients irrespective of blast percentage, with overall response rate (ORR) 
and CR/CRi rate of 40-50% (10%-31%) in newly diagnosed and 35-55% (0%-27%) in 
relapsed/refractory (including post alloHSCT) AML patients23–27.  
4.1.1.2.1 AZA: Indication and Usage 
Subcutaneous or intravenous azacitidine (75 mg/m2 for 7 days every 28 days) is approved for 
treatment of patients with all subtypes of MDS (AML up to 30% blasts) including chronic 
myelomonocytic leukemia (CMMoL).  The pivotal study leading to approval of the agent in 
MDS showed a median OS of 25 months vs the control arm showing 15 months in a 
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4.1.1.2.3 Adverse Events 
For the SC or IV formulation, the most common adverse reactions (>30%) as detailed in the 
package insert for the agent are; nausea, anemia, thrombocytopenia, vomiting, pyrexia, 
leukopenia, diarrhea, injection site erythema, constipation, neutropenia, ecchymosis and 
injection site reactions.  
4.2 
Rationale 
4.2.1 Rationale for the Trial and Selected Subject Population 
Acute Myeloid Leukemia 
Acute myeloid leukemia (AML) remains a therapeutic challenge. Although 60-80% of newly 
diagnosed patients with AML respond to induction chemotherapy, the relapse rate remains 
high (40%-50%) even after allogeneic stem cell transplant (alloHSCT)29–31. In particular, two 
groups of AML patients have an immediate and unmet need for novel and improved therapies: 
1) Relapsed/refractory AML. Different salvage regimens yield 20-30% response rate with a 
very few long-term survivors32,33. The outcomes are even worse for those patients relapsing 
after alloHSCT who also have a heightened risk of toxicity from aggressive chemotherapy 30,31; 
2) Newly diagnosed AML in older patients. The long-term survival of this patient population, 
which represents the majority of patients with AML, has been consistently <10%29,34. 
Furthermore, even when an older patient is a candidate for intensive induction chemotherapy, 
the AML is frequently chemoresistant and often progresses to the relapsed/refractory state. 
Novel paradigms of treatment are desperately needed to target AML, such as exploiting the 
immune system to exert an anti-leukemia effect35. The efficacy of alloHSCT and 
immunotherapy with donor lymphocyte infusion (DLI) underscores the fact that AML is 
sensitive to immunotherapeutic approaches36,37 and there is also evidence for autologous anti-
leukemia reactivity38,39. Thus, strategies to unleash endogenous anti-leukemia immunity 
applied in the context of a regimen that is tolerable and effective, are needed to effectively 
combat AML in these two populations.  
Azacitidine (AZA) effect on immune system 
There is growing evidence that AZA may induce immune reaction alterations ranging from 
increased expression of cancer testis antigens (CTA) and MHC class I co-stimulatory 
molecules to upregulation of co-inhibitory ligands such as PD-L1 on tumor cells, including 
myeloid malignancies40–43. Given intriguing responses to PD-1 blockade in patients with 
NSCLC pretreated with AZA/vorinostat, further in vitro studies were undertaken by the Baylin 
group44. Using the genome wide expression and DNA methylation analyses of solid tumor cell 
lines, they found that AZA upregulates genes and pathways related to both innate and adaptive 
immunity, including immune evasion41,42. Upregulation of PD-L1 was noted, suggesting that 
AZA may prime NSCLC cells to PD-1/PD-L1 blockade, and thus subverting this axis with 
antibody inhibition may be a useful therapeutic strategy42. The importance of epigenetic 
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methylation at the promoter/enhancer region can influence the transcription of PD-1 and 
several key cytokines (IL-2, IFN-у) after TCR stimulation, thus controlling T cell responses 
and differentiation. In particular, upregulation of PD-1 on exhausted effector memory T cells 
is noted in chronic viral infections and is associated with maintained demethylation of the PD-
1 locus45,46. By contrast, IL-2 promoter methylation is increased in T cells from patients with 
HIV suggesting a crucial link between changes in DNA methylation and downregulation of 
IL-2 expression47. Interestingly IL-2 co-administration with blockade of PD-1 synergistically 
enhanced virus-specific T cell responses48. Thus, we hypothesize that epigenetic re- 
programing of IL-2 and PD-1 promoter by AZA will result in increased IL-2 production 
and consequent activation of PD-1-expressing T cells that will be further augmented by 
subsequent blockade of PD-1/PD-L1, thus unleashing anti-leukemia immunity and 
enhancing efficacy of this approach in AML patients. 
PD-1 and AML 
Preclinical studies using murine models of AML have shown that signaling through the PD-
1/PD-L1 axis impairs anti-leukemic immunity. Firstly, long-lived murine leukemia cells 
(minimal residual disease) have upregulated PD-L1 that mediate resistance to cytotoxic 
lymphocyte (CTL)-mediated killing; upregulation of PD-L1 has also been observed on murine 
leukemia cells (C1498) in vivo49,50. Secondly, progressive tumor burden increases expression 
of the co-inhibitory molecule PD-1 on T cells51. Consequently, the in vivo blockade of this 
pathway improved outcomes in murine models of AML49–51. Across different human studies, 
the frequency of PD-L1-expressing AMLs varies from 18% to more than 50%. Furthermore, 
PD-L1 expression on AML cells increases after ex vivo stimulation by IFN-γ52–55. Higher PD-
L1 expression on AML cells also is observed after chemotherapy or at relapse52–54, providing 
a unique opportunity to augment the efficacy of chemotherapy by inhibiting immune inhibitory 
pathways after chemotherapy administration.  
PD-1 Post-alloHSCT 
In clinically relevant murine models of alloHSCT, the recipient antigen expression by non- 
hematopoietic cells promotes T cell exhaustion and abrogates the graft vs leukemia (GVL) 
reactivity through upregulation of PD-1 on donor T cells56,57. Donor T cell dysfunction could 
partially be restored by blockade of PD-L1 and delayed blockade of PD-L1 after transplant 
improved the beneficial GVL effect without inducing graft vs host disease (GVHD)56–58. In 
patients relapsing after alloHSCT, PD-L1 was found to be upregulated on leukemic 
progenitors59. Furthermore, high PD-1 expression was noted on allo-reactive minor 
histocompatibility antigen (MiHA)-specific effector memory CD8+ T cells (TEMs). Ex vivo 
treatment with monoclonal antibodies (mAbs) against PD-1 or PD-L1 restored the proliferation 
and IFN-γ production of MiHA-specific TEMs, more potently in relapsed patients than in those 
in remission59. Similarly, silencing of PD-L1 and PD-L2 on MiHA-loaded dendritic cells 
augmented the expansion of functional MiHA-specific TEMs from leukemia patients early after 
DLI and later during relapse60. Safety of immune checkpoint blockade after alloHSCT has 
been demonstrated for ipilimumab, a mAb targeting CTLA-461. Thus, it is reasonable to 
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and consequently augment a GVL effect in patients who relapse post-alloHSCT as long as it 
is administered to patients having no evidence of active GVHD and not requiring ongoing 
immune suppression.  
All together, these data suggest that epigenetic therapy with azacitidine combined with 
blockade of PD-1/PD-L1 pathway is a rational therapeutic approach both in newly diagnosed 
older patients and those with relapsed and refractory AML. Furthermore, recent data suggest 
that the addition of PD-1 blockade (nivolumab) to azacitidine in patients with AML who have 
previously failed hypomethylating agents may induce responses in up to 20% patients (Daver 
N; ASH abstract #763, ASH 2016), which is comparable to the responses obtained with 
intensive salvage therapies (for which many of AML patients may not be eligible due to age 
and co-morbidities). 
4.2.2 Rationale for Dose Selection/Regimen/Modification  
An open-label Phase I trial (Protocol 001/NCT01295827) was conducted to evaluate the safety 
and clinical activity of single agent MK-3475.  The dose escalation portion of this trial 
evaluated three dose levels, 1 mg/kg, 3 mg/kg, and 10 mg/kg, administered every 2 weeks 
(Q2W) in subjects with advanced solid tumors.  All three dose levels were well tolerated and 
no dose-limiting toxicities were observed.  This first in human study of MK-3475 showed 
evidence of target engagement and objective evidence of tumor size reduction at all dose levels 
(1 mg/kg, 3 mg/kg and 10 mg/kg Q2W).  No MTD has been identified to date.  10.0 mg/kg 
Q2W, the highest dose tested in PN001, is the dose and schedule utilized in a Phase IB trial 
(Protocol 013/ NCT01953692) in patients with hematologic malignancies (including MDS) to 
test for initial tumor activity.  Recent data from other clinical studies within the MK-3475 
program has shown that a lower dose of MK-3475 and a less frequent schedule may be 
sufficient for target engagement and clinical activity. 
 
PK data analysis of MK-3475 administered Q2W and Q3W showed slow systemic clearance, 
limited volume of distribution, and a long half-life (refer to IB).  Pharmacodynamic data (IL-
2 release assay) suggested that peripheral target engagement is durable (>21 days).  This early 
PK and pharmacodynamic data provides scientific rationale for testing a Q2W and Q3W 
dosing schedule.   
 
A population pharmacokinetic analysis has been performed using serum concentration time 
data from 476 patients. Within the resulting population PK model, clearance and volume 
parameters of MK-3475 were found to be dependent on body weight. The relationship between 
clearance and body weight, with an allometric exponent of 0.59, is within the range observed 
for other antibodies and would support both body weight normalized dosing or a fixed dose 
across all body weights.  MK-3475 has been found to have a wide therapeutic range based on 
the melanoma indication.  The differences in exposure for a 200 mg fixed dose regimen relative 
to a 2 mg/kg Q3W body weight based regimen are anticipated to remain well within the 
established exposure margins of 0.5 – 5.0 for MK-3475 in the melanoma indication. The 
exposure margins are based on the notion of similar efficacy and safety in melanoma at 10 
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exposure). The population PK evaluation revealed that there was no significant impact of 
tumor burden on exposure. In addition, exposure was similar between the NSCLC and 
melanoma indications. Therefore, there are no anticipated changes in exposure between 
different indication settings. 
 
The rationale for further exploration of 2 mg/kg and comparable doses of pembrolizumab in 
solid tumors is based on: 1) similar efficacy and safety of pembrolizumab when dosed at either 
2 mg/kg or 10 mg/kg Q3W in melanoma patients, 2) the flat exposure-response relationships 
of pembrolizumab for both efficacy and safety in the dose ranges of 2 mg/kg Q3W to 10 mg/kg 
Q3W, 3) the lack of effect of tumor burden or indication on distribution behavior of 
pembrolizumab (as assessed by the population PK model) and 4) the assumption that the 
dynamics of pembrolizumab target engagement will not vary meaningfully with tumor type. 
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. 
Thus, based on these pharmacokinetic data, the dose/schedule of pembrolizumab selected for 
this study is a flat dose of Pembrolizumab 200 mg every 3 weeks starting with Day 8 of Cycle 
1. Azacitidine will be used at the dose/schedule FDA approved for MDS/AML (≤30% blasts) 
and used in the clinic in AML patients. Recent study demonstrated that azacitidine induces 
demethylation of PD-1 locus in T cell in vivo in MDS/AML patients which correlated with 
poorer overall response rate, suggesting that this may represent potential resistance mechanism 
to the activity of AZA in this patient population and calling for an intervention such as 
pembrolizumab administration to inhibit PD-1/PD-L1 pathway62. Furthermore, in some 
patients the PD-1 locus in T cells becomes re-methylated close to the beginning of the next 
cycle; thus, administration of pembrolizumab on every 3 week schedule appears to be the most 
rationale approach to promote synergism of these two agents with no overlapping toxicities.  
4.2.3 Rationale for Endpoints 
4.2.3.1 Efficacy Endpoints 
4.2.3.1.1 Primary Endpoint 
The rate of CR+CRi (separately for each Cohort) as defined by the International European 
LeukemiaNet Guidelines in AML63. 


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4.2.3.1.2 Secondary Endpoints 
 Characterize the toxicity of AZA followed by pembrolizumab in each Cohort 
(summary statistics). The toxicity will be classified and graded according to National 
Cancer Institute’s (NCI) Common Terminology Criteria for Adverse Events (CTCAE, 
version 4.0) 
 The overall response rate CR+CRi+partial response (PR)+ morphologic leukemia-free 
state (MLFS)+hematologic improvement (HI) (separately for each Cohort) as defined 
by the International European LeukemiaNet Guidelines in AML63 and IWG Modified 
Response Criteria (2006) for MDS (for definition of HI)64. 
 Disease-free survival and overall survival of patients who achieve a CR/CRi for each 
Cohort separately. DFS will be defined as the time from CR/CRi to either relapse, death 
or last follow-up date (censored).  OS will be defined as the time from study initiation 
to either death or last follow-up date (censored). 
 Estimate progression free survival, time to progression, and overall survival for all 
patients (separately for each Cohort). PFS will be defined as the time from study 
initiation to progression or death or last follow-up date (censored). 
4.2.3.2 Biomarker Research 
We will be conducting an extensive set of correlative studies to evaluate the effect of 
azacitidine (epigenetic priming) and pembrolizumab on the leukemia cells and host immune 
responses. The overarching goals of our correlative studies are to i) identify and characterize 
mechanisms involved in T cell dysfunction in patients with AML; ii) identify potential 
predictive biomarker candidates to allow for better selection of AML patients who may benefit 
from AZA/pembrolizumab therapy; and iii) identify new pathways that could be targeted to 
enhance the efficacy of combined epigenetic/immunomodulation strategy in patients with 
AML. To accomplish these goals, we will perform multi-color flow cytometric analyses of 
immune markers pre- and post-treatment on both leukemia and immune cells (T cells, NK 
cells, MDSCs), T cell methylation analysis (DNA methylation of the IL-2 and PD-1 promoter), 
high-throughput DNA sequencing of rearranged TCRβ CDR3 regions from T cell genomic 
DNA, cytokine measurements, and immunohistochemistry on the bone marrow biopsies. In 
addition, we may perform exploratory gene expression analysis of immune biomarkers in the 
bone marrow aspirates and whole or targeted exome sequencing of the leukemia cells. 
We hypothesize that treatment with azacitidine will increase expression of co-signaling 
molecules on both leukemia cells and T cells, making them susceptible to subsequent 
therapeutic modulation of PD-1/PD-L1 pathway with pembrolizumab. In particular, we expect 
that epigenetic re-programing of IL-2 and PD-1 promoter by azacitidine will result in increased 
IL-2 production and consequent activation of PD-1-expressing T cells that will be further 
augmented by subsequent blockade of PD-1/PD-L1 pathway, thus unleashing anti-leukemia 
immunity and enhancing efficacy of this approach in AML patients. We also hypothesize that 


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a primary action of azacitidine/pembrolizumab will be to modulate the TCR diversity resulting 
in the emergence of unique TCR clonotypes that may be relevant in the anti-leukemia response. 
All patients will have pre- and post-treatment bone marrow aspirates (tumor tissues) as well as 
serial blood samples submitted for correlative studies to determine the dynamic nature of 
changes in leukemia cells/T cells. 
5.0 METHODOLOGY 
5.1 
Entry Criteria 
5.1.1 Diagnosis/Condition for Entry into the Trial 
1. Relapsed and refractory acute myeloid leukemia (Cohort 1) – This cohort has enrolled 
the expected 40 patients and is now completed. 
2. Newly diagnosed acute myeloid leukemia in older patients (≥65 years) not candidates 
for intensive induction chemotherapy (Cohort 2) – This cohort is closed to new accrual 
as of 1/8/2020 based on risk benefit analysis information received from the FDA on 
1/3/2020.   
5.1.2 Subject Inclusion Criteria 
In order to be eligible for participation in this trial, the subject must: 
Cohort #1 
1. Have histologically or cytologically confirmed relapsed or refractory AML (i.e. ≥5% 
blasts by manual differential on bone marrow aspirate/biopsy/flow cytometry), 
excluding acute promyelocytic leukemia (APL; FAB M3; t(15;17)). 
2. Be willing and able to provide written informed consent/assent for the trial. 
3. Be  18 years of age on day of signing informed consent. 
4. Not be appropriate candidate for intensive salvage chemotherapy due to co-morbidities 
or other disease- or treatment-related factors.  
NOTE: Subjects who received prior treatment with hypomethylating agents either for 
Myelodysplastic Syndrome (MDS), Myeloproliferative Neoplasm (MPN), or AML will be 
eligible.   
NOTE: Subjects who had prior allogeneic stem cell transplant (alloHSCT) will be eligible 
as long as they have been at least 3 months after allogeneic HSCT and are off of all immune 
suppression for at least 3 weeks (>21 days) and have no evidence of active graft versus 


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host disease (GVHD). Subjects with prior alloHSCT will NOT be eligible for 
enrollment during the safety run in phase. 
5. Demonstrate adequate organ function as defined in Table 1, all screening labs should 
be performed within 14 days of treatment initiation. 
6. ECOG performance status < 2. 
7. A projected life expectancy of at least 12 weeks. 
8. Female subject of childbearing potential should have a negative urine or serum 
pregnancy within 72 hours prior to receiving the first dose of study medication.  If the 
urine test is positive or cannot be confirmed as negative, a serum pregnancy test will 
be required.   
9. Female subjects of childbearing potential (Section 5.8.2) must be willing to use an 
adequate method of contraception as outlined in Section 5.8.2 – Contraception, for the 
course of the study through 120 days after the last dose of study medication.  
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception 
for the subject. 
10. Male subjects of childbearing potential (Section 5.8.2) must agree to use an adequate 
method of contraception as outlined in Section 5.8.2- Contraception, starting with the 
first dose of study therapy through 120 days after the last dose of study therapy. 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception 
for the subject. 
11. As determined by the enrolling physician or protocol designee, ability of the patient to 
understand and comply with study procedures for the entire length of the study. 
Cohort #2 
1. Have histologically and cytologically confirmed newly diagnosed AML (i.e. ≥ 20% 
blasts by manual differential on bone marrow aspirate/biopsy and/or in peripheral 
blood), excluding acute promyelocytic leukemia (APL; FAB M3, t (15;17)). 
2. Be willing and able to provide written informed consent/assent for the trial. 
3. Be ≥65 years of age on day of signing informed consent. 
4. Have received NO prior treatment for AML with the exception of 
hydroxyurea/leukapheresis.  


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NOTE: Subjects may have been treated for pre-existent myeloid disorder such as 
Myelodysplastic 
Syndrome 
or 
Myeloproliferative 
Neoplasm 
including  
hypomethylating agents. 
5. Demonstrate adequate organ function as defined in Table 1, all screening labs should 
be performed within 14 days of treatment initiation. 
6. ECOG performance status < 2. 
7. A projected life expectancy of at least 12 weeks. 
8. Female subject of childbearing potential should have a negative urine or serum 
pregnancy within 72 hours prior to receiving the first dose of study medication.  If 
the urine test is positive or cannot be confirmed as negative, a serum pregnancy test 
will be required.   
9. Female subjects of childbearing potential (Section 5.8.2) must be willing to use an 
adequate method of contraception as outlined in Section 5.8.2 – Contraception, for 
the course of the study through 120 days after the last dose of study medication. 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception 
for the subject. 
10. Male subjects of childbearing potential (Section 5.8.2) must agree to use an adequate 
method of contraception as outlined in Section 5.8.2- Contraception, starting with the 
first dose of study therapy through 120 days after the last dose of study therapy. 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception 
for the subject. 
11. As determined by the enrolling physician or protocol designee, ability of the patient 
to understand and comply with study procedures for the entire length of the study. 
Table 1. Adequate Organ Function Laboratory Values 
System 
Laboratory Value 
Hematological
 
White blood cell (WBC) count 
<30,000 /mcL  
NOTE: Hydroxyurea/leukapheresis use is allowed to meet this 
criterion. 
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*  


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*unless considered due to leukemic organ involvement, Gilbert’s 
or hemolysis, OR 
 
Direct bilirubin ≤ ULN for subjects with total bilirubin levels > 
1.5 ULN  
AST (SGOT) and ALT (SGPT) 
≤ 3 X ULN   
Albumin 
>2.5 g/dL 
Coagulation 
International Normalized Ratio (INR) or 
Prothrombin Time (PT) 
 
Activated Partial Thromboplastin Time 
(aPTT) 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
aCreatinine clearance should be calculated per institutional standard. 
 
5.1.3 Subject Exclusion Criteria 
The subject must be excluded from participating in the trial if the subject: 
Cohort #1 
1. Is currently participating and receiving study therapy or has participated in a study of 
an investigational agent and received study therapy or used an investigational device 
within 4 weeks of the first dose of treatment.  
NOTE: Subjects who were treated on a clinical study of allogeneic stem cell transplant 
(alloHSCT) will be eligible if they are at least 3 months after allogeneic HCT and are at 
least 3 weeks (>21 days) off of all immune suppression and have no evidence of active 
GVHD (physiologic corticosteroid replacement therapy for adrenal or pituitary 
insufficiency is allowed). Subjects with prior alloHSCT will not be eligible for 
enrollment during the safety run in phase. 
2. Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any 
other form of immunosuppressive therapy within 7 days prior to the first dose of trial 
treatment. 
 
3. Has a known history of active TB   (Bacillus Tuberculosis) 
 
4. Hypersensitivity to pembrolizumab or any of its excipients. 
5. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study 
Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due 
to agents administered more than 4 weeks earlier. 
6. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy 
within 2 weeks or growth factors within 1 week prior to study Day 1 or who has not 


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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 
may qualify for the study. 
- 
Note:  If subject received major surgery, they must have recovered adequately 
from the toxicity and/or complications from the intervention prior to starting 
therapy.   
7. Has a known additional malignancy that is progressing or requires active treatment.  
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the 
skin that has undergone potentially curative therapy or in situ cervical cancer. 
8. Has known active central nervous system (CNS) leukemia. Subjects with previously 
treated CNS leukemia may participate provided that they have documented clearance 
of CNS leukemia and are not actively treated with intrathecal chemotherapy.  
9. Has active autoimmune disease that has required systemic treatment in the past 2 years 
(i.e. with use of disease modifying agents, corticosteroids or immunosuppressive 
drugs). Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid 
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form 
of systemic treatment. Subjects that require intermittent use of bronchodilators or local 
steroid injections will not be excluded from the study. 
10. Has known history of non-infectious pneumonitis that required steroids or current  
pneumonitis. 
11. Has an active uncontrolled infection requiring systemic therapy (viral, bacterial or 
fungal). Patients with infection under active treatment and controlled with antibiotics 
are eligible. 
12. Has a white blood cell count > 30 x 109/L.  
NOTE: Leukapheresis and Hydroxyurea is permitted to meet this criterion and should be 
stopped ≥12 hours before starting treatment on the study. 
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. 


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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, or anti-PD-L2 agent. 
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 of planned start of study therapy. 
Note:  Seasonal influenza vaccines for injection are generally inactivated flu vaccines 
and are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live 
attenuated vaccines, and are not allowed. 
Cohort #2 
1. Is currently participating and receiving study therapy or has participated in a study of 
an investigational agent and received study therapy or used an investigational device 
within 4 weeks of the first dose of treatment for pre-existent myeloid disorder such as 
MDS or MPN.  
2. Is eligible for treatment with a standard cytarabine and anthracycline or similar 
intensive induction chemotherapy, or is willing to receive intensive induction therapy. 
If subject is not considered eligible for treatment with standard or similar intensive 
induction chemotherapy due to comorbidities or other factors, or is unwilling to receive 
intensive induction therapy will be allowed to participate in this study.  
3. 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. 
 
4. Has a known history of active TB   (Bacillus Tuberculosis) 
 
5. Hypersensitivity to pembrolizumab or any of its excipients. 
6. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study 
Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due 
to agents administered more than 4 weeks earlier. 
7. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy 
within 2 weeks or growth factors within 1 week prior to study Day 1 or who has not 


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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 
may qualify for the study. 
- 
Note:  If subject received major surgery, they must have recovered adequately 
from the toxicity and/or complications from the intervention prior to starting 
therapy.   
8. Has a known additional malignancy that is progressing or requires active treatment.  
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the 
skin that has undergone potentially curative therapy or in situ cervical cancer. 
9. Has known active central nervous system (CNS) leukemia. Subjects with previously 
treated CNS leukemia may participate provided that they have documented clearance 
of CNS leukemia and are not actively treated with intrathecal chemotherapy.  
10. Has active autoimmune disease that has required systemic treatment in the past 2 years 
(i.e. with use of disease modifying agents, corticosteroids or immunosuppressive 
drugs). Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid 
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form 
of systemic treatment. Subjects that require intermittent use of bronchodilators or local 
steroid injections will not be excluded from the study. 
11. Has known history of non-infectious pneumonitis that required steroids or current 
pneumonitis . 
12. Has an active uncontrolled infection requiring systemic therapy (viral, bacterial or 
fungal). Patients with infection under active treatment and controlled with antibiotics 
are eligible. 
13. Has a white blood cell count > 30 x 109/L.  
NOTE: Leukapheresis and hydroxyurea is permitted to meet this criterion and should 
be stopped ≥12 hours before starting treatment on the study. 
14. 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.   
15. Has known psychiatric or substance abuse disorders that would interfere with 
cooperation with the requirements of the trial. 


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16. 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. 
17. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent. 
18. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies). 
19. Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA 
[qualitative] is detected). 
20. Has received a live vaccine within 30 days of planned start of study therapy. 
Note:  Seasonal influenza vaccines for injection are generally inactivated flu vaccines 
and are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live 
attenuated vaccines, and are not allowed. 
 
5.2 
Trial Treatments 
The treatment to be used in this trial is outlined below in Table 1 
Table 1.  Trial Treatment 
Drug 
Dose/ 
Potency 
Dose 
Frequency 
Route of 
Administration 
Regimen/Treatment 
Period 
Use 
 
Azacitidine 
75 mg/m2 
Daily x 7 
days 
Subcutaneous 
(SQ) or IV 
infusion 
Day 1 to 7 of each 28 
day cycle 
Standard 
Pembrolizumab 
200 mg  
Q 3W 
IV infusion 
*# Starting on Day 8 
of Cycle 1  
Experimental 
 
*Pembrolizumab administration will start on Day 8 of Cycle 1. 
 
# On days when both agents are administered, azacitidine should be administered before the 
pembrolizumab. An anti-emetic, preferably a serotonin antagonist, should be administered 
prior to azacitidine; the individual anti-emetic selected is at the discretion of the investigator.
 
Trial treatment should begin as close as possible to the date on which treatment is 
allocated/assigned. 


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5.2.1 Dose Selection/Modification 
5.2.1.1 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 (MK-3475) are provided in the 
Pharmacy Manual.   
Azacitidine will be administered at the dose and schedule approved by the FDA for treatment 
of MDS/AML. The azacitidine IV/SQ will be administered before the dose of pembrolizumab 
on days that both agents are administered. 
5.2.1.2 Dose Modification (Escalation/Titration/Other)  
 Dose modifications will be made based on Common Terminology Criteria for Adverse 
Events (CTCAE) grading (version 4.0) 
 Patients may remain on study and therapy even if one of the agents are discontinued 
due to toxicity. No more than two dose reductions of any agent is allowed. 
5.2.1.3 Dose Limiting Criteria 
 Dose limiting toxicities during safety run in phase will be determined during Cycle 1, 
Cycle 2, and Cycle 3 of study treatment. Adverse events that occur after the first three 
cycles will also be evaluated by investigator and may be considered as dose limiting.  
 Subjects with AML have frequently ≥ grade 3 cytopenias; thus, will be un-evaluable 
for hematologic DLT with the exception listed below. 
 For hematologic toxicity, the only adverse event that will be considered dose limiting 
is: 
o grade ≥ 4 neutropenia and thrombocytopenia with a hypocellular bone marrow 
and no evidence of residual leukemia lasting for 42 days  
NOTE: only patients evaluable for hematologic toxicity as defined in Section 
5.2.1.5.2.1, 5.2.1.5.2.3 and Section 5.2.1.5.3 may need to have a bone marrow 
assessment after cycle 1 if no count recovery to baseline. Otherwise, all patients 
will have bone marrow after cycle 2); 
 For non-hematologic toxicities, the only adverse events that will be considered dose-
limiting are: 


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o Any grade 4 toxicity considered at least possibly related to study drugs 
excluding asymptomatic electrolyte aberrations that can be corrected to ≤ grade 
2 and excluding specific toxicities that are frequent in AML population such as 
fever, infections, fatigue, bleeding, bone pain. 
o Any grade 3 toxicity considered at least possibly related to study drugs that does 
not resolve to ≤ grade 2 within 48 hours with the exception of Grade 3 anorexia, 
nausea, vomiting, diarrhea, or mucositis if it resolves to ≤ grade 2 within 72 
hours of maximal supportive care; asymptomatic electrolyte abnormalities that 
can be corrected to ≤ grade 2 and excluding specific toxicities that are frequent 
in AML population such as fever, infections, fatigue, bleeding, bone pain. 
Grade 3 neurotoxicity and nephrotoxicity of any duration will be considered 
dose-limiting if at least possibly drug-related. 
Table 3. Safety Run In Phase- Dose De-escalation Rules 
Number of patients with DLT 
during run in phase 
(Planned 6 patients) 
Decision rule 
0 or 1 out of 3 in Cycle 1 
Enter 3 more patients 
≥2 of 3 in Cycle 1 
OR 
≥2 of 6 in Cycle 1 
Patients will be assessed for safety. Based on the 
complete assessment of AEs, the dose reduction 
as proposed in the Section 2.1 and 2.2. 
≥2 of 6 in Cycle 2 or/and 
Cycle 3 
OR 
≥2 of 6 in Cycle 1+2+3 
Patients will be assessed for safety. Based on the 
complete assessment of AEs, the dose reduction 
as proposed in the Section 2.1 and 2.2. 
≤ 1 of 6 in Cycle 1 + 2 + 3 
Open Phase II Cohort 1 and Cohort 2. 
 
5.2.1.4 Immune Adverse Events Associated with Pembrolizumab 
Adverse events (both non-serious and serious) associated with pembrolizumab exposure 
may represent an immunologic etiology.  These adverse events may occur shortly after the 
first dose or several months after the last dose of treatment. Pembrolizumab must be 
withheld for drug-related toxicities and severe or life-threatening AEs as per Table 4 
below. See Section 5.7.5 for supportive care guidelines, including use of corticosteroids. 
Table 4. Dose Modification and Toxicity Management Guidelines for Immune-related 
AEs Associated with Pembrolizumab 
General instructions: 
1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 weeks. 


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2.
For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to 
Grade 1 or 0 and corticosteroid has been tapered. For Grade 3 (excluding alopecia, fatigue) toxicities which are eligible 
for re-dosing: Increase dose interval to every 4 weeks, and to every 6 weeks with second occurrence.  Pembrolizumab 
should be permanently discontinued if AE does not resolve within 12 weeks of last dose or corticosteroids cannot be 
reduced to ≤10 mg prednisone or equivalent per day within 12 weeks.  
3. For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other 
immunosuppressive treatment should be initiated if irAEs cannot be controlled by corticosteroids. 
 
Immune-related 
AEs 
Toxicity grade or 
conditions 
(CTCAEv4.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies  
Monitor and follow-
up  
Pneumonitis  
Grade 2 
Withhold  
 Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
 
Monitor 
participants for 
signs and 
symptoms of 
pneumonitis 
 
Evaluate 
participants with 
suspected 
pneumonitis with 
radiographic 
imaging and 
initiate 
corticosteroid 
treatment 
 
Add prophylactic 
antibiotics for 
opportunistic 
infections 
Grade 3 or 4, or 
recurrent Grade 2 
Permanently 
discontinue 
Diarrhea / Colitis  
Grade 2 or 3 
Withhold 
 Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
 
Monitor 
participants for 
signs and 
symptoms of 
enterocolitis (ie, 
diarrhea, 
abdominal pain, 
blood or mucus 
in stool with or 
without fever) 
and of bowel 
perforation 
(ie, peritoneal 
signs and ileus). 
 
Participants with 
≥ Grade 2 
diarrhea 
suspecting colitis 
should consider 
GI consultation 
and performing 
endoscopy to rule 
out colitis.  
Grade 4 
Permanently 
discontinue 


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 
Participants with 
diarrhea/colitis 
should be 
advised to drink 
liberal quantities 
of clear fluids.  If 
sufficient oral 
fluid intake is not 
feasible, fluid 
and electrolytes 
should be 
substituted via IV 
infusion. 
AST / ALT 
elevation or 
Increased bilirubin 
Grade 2 
Withhold 
 Administer corticosteroids (initial 
dose of 0.5- 1 mg/kg prednisone or 
equivalent) followed by taper 
 
Monitor with 
liver function 
tests (consider 
weekly or more 
frequently until 
liver enzyme 
value returned to 
baseline or is 
stable 
Grade 3 or 4  
Permanently 
discontinue 
 Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
Type 1 diabetes 
mellitus (T1DM) or 
Hyperglycemia 
 
Newly onset 
T1DM or  
Grade 3 or 4 
hyperglycemia 
associated with 
evidence of -cell 
failure 
Withhold 
 Initiate insulin replacement 
therapy for participants with 
T1DM  
 Administer anti-hyperglycemic in 
participants with hyperglycemia  
 
 
Monitor 
participants for 
hyperglycemia or 
other signs and 
symptoms of 
diabetes. 
Hypophysitis 
Grade 2 
Withhold 
 Administer corticosteroids and 
initiate hormonal replacements as 
clinically indicated.   
 
 
Monitor for signs 
and symptoms of 
hypophysitis 
(including 
hypopituitarism 
and adrenal 
insufficiency) 
Grade 3 or 4  
Withhold or 
permanently 
discontinue1  
Hyperthyroidism  
Grade 2 
Continue  
 Treat with non-selective beta-
blockers (eg, propranolol) or 
thionamides as appropriate  
 
Monitor for signs 
and symptoms of 
thyroid 
disorders.  
 
Grade 3 or 4  
Withhold or  
permanently 
discontinue1 
Hypothyroidism 
Grade 2-4 
Continue  
 Initiate thyroid replacement 
hormones (eg, levothyroxine or 
liothyroinine) per standard of care 
 
Monitor for signs 
and symptoms of 
thyroid 
disorders.  
 
Nephritis and Renal 
dysfunction 
Grade 2 
Withhold  
 Administer corticosteroids 
(prednisone 1-2 mg/kg or 
equivalent) followed by taper. 
 
Monitor changes 
of renal function 
 
Grade 3 or 4  
Permanently 
discontinue 


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Myocarditis 
Grade 1 or 2 
Withhold 
 Based on severity of AE 
administer corticosteroids 
 
Ensure adequate 
evaluation to 
confirm etiology 
and/or exclude 
other causes 
 
Grade 3 or 4 
Permanently 
discontinue 
All other immune-
related AEs 
Intolerable/ 
persistent Grade 2 
Withhold 
 Based on type and severity of AE 
administer corticosteroids  
 
Ensure adequate 
evaluation to 
confirm etiology 
and/or exclude 
other causes 
 
Grade 3 
Withhold or 
discontinue based 
on the type of 
event.  Events that 
require 
discontinuation 
include and not 
limited to:  
Gullain-Barre 
Syndrome, 
encephalitis 
Grade 4 or 
recurrent Grade 3  
Permanently 
discontinue 
1. Withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating physician.   
NOTE:  
For participants with Grade 3 or 4 immune-related endocrinopathy where withhold of pembrolizumab is required, 
pembrolizumab may be resumed when AE resolves to ≤ Grade 2 and is controlled with hormonal replacement therapy or 
achieved metabolic control (in case of T1DM).   
 
 
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 4 weeks of the 
scheduled interruption, unless otherwise discussed with the Sponsor. The reason for 
interruption should be documented in the patient's study record. 
5.2.1.5 General dose modifications 
Every effort should be made to administer the study drug treatment according to the planned 
dose and schedule. 
In the event of significant toxicity, pembrolizumab dosing should be interrupted, delayed 
and/or reduced as outlined above in the Table 4. In the event of multiple toxicities, dose 
modification should be based on the worst toxicity observed.  
Dose modifications may occur in three ways: 
•Within a cycle: Dosing interruption until adequate recovery followed by dose reduction (if 
required) during a given treatment cycle. 


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Azacitidine dosing interruption is not allowed within a cycle unless there is an unexpected and 
unacceptable toxicity or as defined in Section 5.2.1.5.1. 
•Between cycles: The next treatment cycle may be delayed if toxicity from the preceding cycle 
persists or if specific non-treatment related circumstances arise as defined in Section 5.2.1.4 
(other non-treatment related medical/surgical events or logistical reasons). 
•In the next cycle: Dose reduction may be required based on toxicities experienced in the 
previous cycle. 
5.2.1.5.1 Dose interruptions/modification for non-hematologic toxicities 
Complications of myelosuppression include infections and bleeding, these may be exacerbated 
with the use of azacitidine and pembrolizumab treatment. Azacitidine and pembrolizumab 
treatment may be delayed at the discretion of the investigator, if the subject experiences 
myelosuppression-associated complications, such as those described below: 
● Febrile neutropenia (temperature ≥ 38.5°C and absolute neutrophil count < 1,000/μL) 
● Active uncontrolled viral, bacterial or fungal infection (i.e., requiring intravenous anti-
infectives or extensive supportive care) 
● Hemorrhage (gastrointestinal, genito-urinary, pulmonary with platelets < 25,000/μL or any 
central nervous system hemorrhage) 
Treatment may be resumed once the above conditions have improved or have been stabilized 
with adequate treatment (anti-infective therapy, transfusions). 
Azacitidine dose reductions are not recommended other than specified below. If a dose 
reduction is believed to be necessary for different reasons, a discussion with the Sponsor is 
required. 
Azacitidine dose interruption is not recommended within a cycle unless an unacceptable or 
unexpected study drug combination related toxicity occurs. Azacitidine and pembrolizumab 
may have some overlapping toxicities. Dose modifications/interruptions recommendations for 
non-hematologic toxicities: 
 For any grade 3 or higher diarrhea/colitis, hold azacitidine and pembrolizumab. If not 
immune-related colitis, and if symptoms resolve within 5 days with maximum therapy 
to ≤ grade 1, may restart azacitidine and pembrolizumab as per schedule. The 
azacitidine doses can be resumed in the same cycle if no more than a 5 day gap 
occurred and/or the patient is still likely to have clinical benefit. Pembrolizumab dose 
will be omitted if delayed for more than 7 days. If not immune-related colitis and but 
if it requires more than 5 days for toxicities to resolve to ≤ grade 1 then dose reduce 
azacitidine to 75 mg/m2 x 5 day in the next cycle and pembrolizumab to every 4 weeks. 
For recurrent grade 3 colitis, azacitidine dose can be reduced to 75 mg/m2 x 5 days (if 


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receiving 75 mg/m2 x 7 days) or to 50 mg/m2 x 5 days (if receiving 75 mg/m2 x 5 
days). Even if not considered immune-related colitis, unless there is an objective 
reason (i.e., C diff infection, viral infection) for recurrent grade 3 colitis, the 
pembrolizumab will be discontinued for second occurrence of grade 3 colitis. If there 
is an objective reason, pembrolizumab may be reduced to every 6 weeks (if given 
every 4 weeks) or to every 4 weeks (if given every 3 weeks). 
 For grade 2 diarrhea/colitis that persists more than 3 days hold azacitidine. 
Pembrolizumab should be held immediately for grade 2 diarrhea/colitis.  If not 
immune-related colitis, and if symptoms resolve within 7 days with maximum therapy 
to ≤ grade 1, may restart azacitidine and pembrolizumab as per schedule. The 
azacitidine doses can be resumed in the same cycle if no more than a 5 day gap 
occurred and/or the patient is still likely to have clinical benefit. Pembrolizumab dose 
will be omitted if delayed for more than 7 days. If not immune related colitis but if it 
requires more than 7 days for toxicities to resolve to ≤ grade 1 then dose reduce 
azacitidine to 75 mg/m2 x 5 days in the next cycle, and reduce pembrolizumab to every 
4 weeks. For any recurrent grade 2 diarrhea/colitis lasting more than 7 days, the dose 
of azacitidine should be reduced to 75 mg/m2 x 5 days (if pt is on azacitidine 75 mg/m2 
x 7 days) or to 50 mg/m2 x 5 days (if pt is on azacitidine 75 mg/m2 x 5 days). If not 
immune related recurrent grade 2 diarrhea/colitis but if it requires more than 7 days 
for toxicities to resolve to ≤ grade 1, dose-reduce pembrolizumab to every 4 weeks (if 
on every 3 weeks schedule) or every 6 weeks (if on every 4 weeks schedule). 
 If unexplained reductions in serum bicarbonate levels to < 20 mEq/L occur, azacitidine 
dosage should be reduced by 50% on the next course (50 mg/m2 x 5 days). Similarly, 
if unexplained elevations of BUN or serum creatinine occur, the next cycle should be 
delayed until values return to normal or baseline and the dose of the azacitidine should 
be reduced by 50% on the next treatment course. 
Azacitidine administration should not be interrupted if pembrolizumab dosing is interrupted 
for toxicity except as defined above or at the discretion of the investigator for any clinical 
toxicities where ongoing administration of azacitidine is felt to be unsafe (grade 3 or 4 
pembrolizumab-related toxicities). The azacitidine doses can be resumed in the same cycle if 
no more than a 5 day gap occurred, the patient is still likely to have clinical benefit, and the 
investigator feels that it is safe to restart azacitidine therapy. No dose reduction of azacitidine 
will be required. 
Patients experiencing Grade 3 or 4 toxicities potentially attributable to pembrolizumab should 
have their pembrolizumab treatment interrupted regardless of when it occurs in the cycle until 
the toxicity resolves or returns to baseline.  
Cycle duration maybe extended beyond 28 days to allow resolution of toxicities related to 
study treatments (see Table 4). In general, the next cycle of treatment should be restarted when 
drug-related toxicities resolve to ≤ 1; even if pembrolizumab cannot be administered (ongoing 
steroid taper), azacitidine should be restarted. The pembrolizumab can be restarted on any day 


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of the cycle when the criteria are met for its administration (steroids tapered to the required 
level) and according to the dose reduction recommendations.  
If for unforeseen circumstances (for reasons other than toxicity, eg, emergency surgery, 
unrelated medical events, or logistical reasons not related to study therapy such as patient 
vacation, and/or holidays) the patient misses a doses of azacitidine within a cycle, the doses 
can be resumed in the same cycle if no more than a 5 day gap occurred and the patient is still 
likely to have clinical benefit. The dose of pembrolizumab within 7 days of surgery will be 
omitted. 
If a treatment delay continues beyond Day 28 of the current cycle, then the day when 
azacitidine treatment is restarted will be counted as Day 1 of the next cycle. 
5.2.1.5.2 Definitions of hematologic toxicity 
5.2.1.5.2.1 For patients with ANC ≥ 500/μL at baseline: 
Persistent neutropenia (ANC < 500/μL) for greater than 42 days without evidence of leukemia 
in peripheral blood or on bone marrow examination. 
5.2.1.5.2.2 For patients with baseline ANC < 500/μL: 
Patients with baseline neutropenia (ANC < 500/μL) which is persistent for greater than 42 days 
without evidence of leukemia in peripheral blood or on bone marrow examination. All patients 
will be evaluated for time course and severity of neutropenia to determine whether any trend 
can be identified related to study drug administration. Patients with baseline neutropenia (ANC 
< 500/μL) can proceed to cycle 2 with persistent neutropenia (ANC < 500/μL) without having 
repeat bone marrow assessment. However, bone marrow assessment is required after cycle 2. 
5.2.1.5.2.3 For patients with non-transfused platelet count of ≥ 20,000/μL at baseline: 
Persistent thrombocytopenia (platelet count of < 20,000/μL or necessitating platelet transfusion 
for more than 42 days) without evidence of leukemia in peripheral blood or on bone marrow 
evaluation. 
5.2.1.5.2.4 For patients with baseline thrombocytopenia (platelet count < 20,000/μL or 
platelet transfusion dependent)  
Patients with baseline thrombocytopenia (platelet count < 20,000/μL) which is persistent for 
greater than 42 days without evidence of leukemia in peripheral blood or on bone marrow 
examination. The time course and severity of thrombocytopenia will be evaluated on all 
patients to determine whether any trends can be identified related to study drug administration. 
Patients with baseline thrombocytopenia (platelet count < 20,000/μL) can proceed to cycle 2 
with persistent thrombocytopenia (platelet count < 20,000/μL) without having repeat bone 
marrow assessment. However, bone marrow assessment is required after cycle 2. 
 


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5.2.1.5.3 Dose delays/modifications for hematologic toxicity 
There will not be any dose delays for hematological toxicities given that these patients have 
acute myeloid leukemia. Delays in dosing would not be helpful in the context of active 
leukemia. We do not expect that acute leukemia will be cured with only one or two cycles of 
this therapy and this underscores the importance of staying on schedule. If a patient is evaluable 
for drug induced neutropenia or thrombocytopenia as discussed in section 5.2.1.5.2 and 
develops critical neutropenia or thrombocytopenia (as defined in sections 5.2.1.5.2.1- 
5.2.1.5.2.4) lasting more than 42 days, azacitidine and pembrolizumab will be held for up to 
28 days, only if bone marrow or peripheral blood does not show evidence of active leukemia. 
[Exception are patients with baseline neutropenia (< 500/μL) and thrombocytopenia (< 
20,000/μL who can proceed to cycle 2 with persistently low count without need for bone 
marrow assessment]. If this happens, dose reduction to the next dose level AZA 75 mg/m2 x 5 
days (or AZA 50 mg/m2 x 5 days if pt receiving AZA 75 mg/m2 x 5 days), will be required in 
the next cycle. Subsequent cycles of azacitidine will be administered only once the ANC is ≥ 
500/μL (cycle 2 and 3) and platelets ≥20,000/μL (cycle 2 and 3) in the absence of residual 
leukemia in the bone marrow. In patients with baseline neutropenia (< 500/μL) and 
thrombocytopenia (< 20,000/μL, and bone marrow assessment after cycle 2 shows no evidence 
of leukemia, cycle 3 may proceed after ANC > 500/μL and platelets >20,000/μL. After the first 
3 cycles of therapy, subsequent cycles of azacitidine will be administered only if ANC is ≥ 
1,000/μL and platelets ≥30,000/μL in the absence of residual leukemia in the bone marrow. 
Also, if there is increasing blasts in peripheral blood or the investigator has a suspicion that 
there is progressive disease, then a bone marrow biopsy can be performed at any time. Any 
dose reductions/delays during cycle 1, 2 or subsequent cycles should be discussed with the 
Protocol Chair before being made. 
First occurrence: If the counts do not return to baseline prior to the next cycle, a bone marrow 
aspirate/biopsy should be performed and patients evaluated to determine if they have evidence 
of persistent disease or bone marrow suppression. Patients may resume next cycle when counts 
have recovered or if there is evidence of persistent leukemia. 
5.2.1.5.4 Dose Reductions for Azacitidine and Pembrolizumab 
Following dosing interruption or cycle delay due to toxicity, the azacitidine and/or 
pembrolizumab dose may need to be reduced when treatment is resumed. 
Dose reduction of azacitidine and/or pembrolizumab-if necessary, 2 dose levels will be allowed 
depending on the type and severity of toxicity encountered. 
Table 5.  Dose Modifications for Azacitidine and Pembrolizumab 
Dose modification 
Azacitidine 
Pembrolizumab 
1st dose reduction 
75 mg/m2 x 5 days 
200 mg every 4 weeks
2nd dose reduction 
50 mg/m2 x 5 days 
200 mg every 6 weeks
 


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Patients requiring more than 2 dose reductions of azacitidine should permanently discontinue 
both azacitidine and pembrolizumab, unless patient has achieved response (CR, PR, MLFS, 
HI, SD) in which case patients may be allowed to continue pembrolizumab only as long as 
they have ongoing clinical benefit without evidence of significant toxicity or disease 
progression and up to 2 years.  
All dose modifications/adjustments must be clearly documented in the patient's notes and CRF. 
Once dose has been reduced, all subsequent cycles should be administered at that dose level, 
unless further dose reduction is required. Dose re-escalation is not allowed. 
Once the azacitidine dose has been reduced for a given patient, subsequent cycles should be 
administered at that dose level. If a patient undergoes two cycles at a reduced dose without 
recurrent hematologic toxicity, dose re-escalation to the next higher dose level is allowed if the 
dose was initially reduced for hematologic toxicity. Azacitidine dose re-escalation must be 
discussed and agreed with the Sponsor. If hematologic toxicity recurs, the patient will have the 
prior dose reduction re-instituted and will not be eligible for a second round of dose re-
escalation.  
5.2.2 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 6.0).  Trial treatment may 
be administered up to 3 days before or after the scheduled Day 1 of each cycle due to 
administrative reasons. 
All trial treatments will be administered on an outpatient basis unless the patient is already 
hospitalized or requires monitoring during initial therapy for AML as per standard of care. 
Pembrolizumab 200 mg will be administered as a 30 minute IV infusion every 3 weeks 
(treatment cycle intervals may be increased due to toxicity as described in Section 5.2.1.4 and 
5.2.1.5).  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). 
The Pharmacy Manual contains specific instructions for the preparation of the pembrolizumab 
infusion fluid and administration of infusion solution. 
Azacitidine 75 mg/m2 will be administered subcutaneously or as an IV infusion (10-40 
minutes) on scheduled days 1-7 as per the Trial Flow Chart (treatment duration and/or dose 
may be decreased due to toxicity as described in Section 5.2.1.5).   
On the days of therapy with both pembrolizumab and azacitidine, the azacitidine should be 
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5.2.3 Trial Blinding/Masking 
This is an open-label trial; therefore, the Sponsor, investigator and subject will know the 
treatment administered. 
5.3 
Randomization or Treatment Allocation 
Patients will be allocated to two different Cohorts, Cohort 1- relapsed/refractory AML and 
Cohort 2- newly diagnosed AML in patients ≥65 years old and not considered candidates for 
intensive induction chemotherapy. Each Cohort has a specific Inclusion/ Exclusion criteria and 
statistics/monitoring rules. 
5.4 
Stratification 
There are no stratification factors. 
5.5 
Drug Information 
5.5.1 Pembrolizumab 
5.5.1.1 Mechanism of Action  
Pembrolizumab (MK-3475) is a potent and highly selective IV humanized monoclonal 
antibody (mAb) of the immunoglobulin (Ig) G4/kappa isotype that directly blocks the 
interaction between Programmed Death-1 (PD-1) and its ligands, PD-L1 and PDL-2. 
KeytrudaTM (Pembrolizumab) has recently been approved (at a dose of 2 mg/kg IV every 
3 weeks) 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. 
5.5.1.2 Drug Supply 
Pembrolizumab will be provided at no cost to the study patient by Merck, the manufacturer 
of the drug. Information on clinical supply, storage and handling requirements are provided 
in Section 9.0 and in the Pharmacy Manual provided as a document separate from this 
protocol. 
5.5.1.3 Adverse Events Associated with Pembrolizumab 
The most common adverse reactions (reported in ≥20% of patients in clinical trials of 
pembrolizumab) included fatigue, cough, nausea, pruritus, rash, decreased appetite, 
constipation, arthralgia, and diarrhea.  
The following warnings are associated with the use of pembrolizumab: 
Immune-Mediated Pneumonitis 


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Pneumonitis occurred in ~3% of melanoma patients treated in clinical trials of 
pembrolizumab. The median time to development of pneumonitis was 5 months with a 
median duration of 4.9 months.  The one patient with Grade 3 pneumonitis required initial 
treatment with high-dose systemic corticosteroids (greater than or equal to 40 mg prednisone 
or equivalent per day) followed by a corticosteroid taper. Pneumonitis completely resolved 
in seven of the nine patients with Grade 2-3 pneumonitis. 
Immune-Mediated Colitis 
Colitis (including microscopic colitis) occurred in 1% of melanoma patients treated in 
clinical trials of pembrolizumab. The median time to onset of was 6.5 months with a median 
duration of 2.6 months. All three patients with Grade 2 or 3 colitis were treated with high-
dose corticosteroids (greater than or equal to 40 mg prednisone or equivalent per day). 
Immune-Mediated Hepatitis  
Hepatitis (including autoimmune hepatitis) occurred in 0.5% of melanoma patients treated 
in clinical trials of pembrolizumab. The time to onset was 22 days for the case of Grade 4 
hepatitis which lasted 1.1 months. The patient with Grade 4 hepatitis permanently 
discontinued pembrolizumab and was treated with high-dose (greater than or equal to 40 mg 
prednisone or equivalent per day) systemic corticosteroids followed by a corticosteroid 
taper. Both patients with hepatitis experienced complete resolution of the event.  
Immune-Mediated Hypophysitis  
Hypophysitis occurred in 0.5% of melanoma patients treated in clinical trials of 
pembrolizumab. The time to onset was 1.7 months for the patient with Grade 4 hypophysitis 
and 1.3 months for the patient with Grade 2 hypophysitis. Both patients were treated with 
high-dose (greater than or equal to 40 mg prednisone or equivalent per day) corticosteroids 
followed by a corticosteroid taper and remained on a physiologic replacement dose.  
Renal Failure and Immune-Mediated Nephritis  
Nephritis occurred in 3 (0.7%) patients of melanoma patients treated in clinical trials of 
pembrolizumab, consisting of one case of Grade 2 autoimmune nephritis (0.2%) and two 
cases of interstitial nephritis with renal failure (0.5%), one Grade 3 and one Grade 4. The 
time to onset of autoimmune nephritis was 11.6 months after the first dose of pembrolizumab 
(5 months after the last dose) and lasted 3.2 months; this patient did not have a biopsy. Acute 
interstitial nephritis was confirmed by renal biopsy in two patients with Grades 3-4 renal 
failure. All three patients fully recovered renal function with treatment with high-dose 
corticosteroids (greater than or equal to 40 mg prednisone or equivalent per day) followed 
by a corticosteroid taper. 
Immune-Mediated Hyperthyroidism  
Hyperthyroidism occurred in 5 (1.2%) of 411 melanoma patients treated in clinical trials of 
pembrolizumab. The median time to onset was1.5 months and the median duration was 2.8 
months (range 0.9 to 6.1). One of two patients with Grade 2 and the one patient with Grade 
3 hyperthyroidism required initial treatment with high-dose corticosteroids (greater than or 
equal to 40 mg prednisone or equivalent per day) followed by a corticosteroid taper. One 


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patient (0.2%) required permanent discontinuation of pembrolizumab due to 
hyperthyroidism. All five patients with hyperthyroidism experienced complete resolution of 
the event. 
Immune-Mediated Hypothyroidism  
Hypothyroidism occurred in 34 (8.3%) of 411 melanoma patients treated in clinical trials of 
pembrolizumab. The median time to onset of hypothyroidism was 3.5 months. All but two 
of the patients with hypothyroidism were treated with long-term thyroid hormone 
replacement therapy. The other two patients only required short-term thyroid hormone 
replacement therapy. No patient received corticosteroids or discontinued pembrolizumab for 
management of hypothyroidism. Thyroid disorders can occur at any time during treatment.  
Other Immune-Mediated Adverse Reactions 
Other clinically important immune-mediated adverse reactions can occur. The following 
clinically significant, immune-mediated adverse reactions occurred in less than 1% of 
patients treated with pembrolizumab, including exfoliative dermatitis, uveitis, arthritis, 
myositis, pancreatitis, hemolytic anemia, partial seizures arising in a patient with 
inflammatory foci in brain parenchyma, and adrenal insufficiency. 
Across clinical studies with pembrolizumab in approximately 2000 patients, the following 
additional clinically significant, immune-mediated adverse reactions were reported in less 
than 1% of patients: myasthenic syndrome, optic neuritis, and rhabdomyolysis. 
Embryofetal Toxicity 
Based on its mechanism of action, pembrolizumab may cause fetal harm when administered 
to a pregnant woman. Animal models link the PD-1/PDL-1 signaling pathway with 
maintenance of pregnancy through induction of maternal immune tolerance to fetal tissue. 
5.5.2 Azacitidine 
5.5.2.1 Mechanism of Action 
Azacitidine is an analogue of the naturally occurring pyrimidine nucleoside cytidine. Two 
main mechanisms behind antitumor activity of azacitidine include cytotoxicity, resulting 
from incorporation into RNA and DNA, and DNA hypomethylation, restoring normal 
growth control and differentiation in hematopoietic cells. Induction of DNA 
hypomethylation appears to require lower azacitidine doses than does cytotoxicity, as the 
concentration of azacitidine required for maximum inhibition of DNA methylation in vitro 
does not suppress DNA synthesis. Upon uptake by cells, azacitidine is converted to its active 
compounds, 5-Azacitidine triphosphate, which is incorporated into RNA, and 5-
azadeoxycitidine triphosphate, which is incorporated into DNA. Azacitidine inhibits 
methylation of replicating DNA by stoichiometric binding with DNA methyltransferase 1, 
resulting in DNA hypomethylation. DNA hypermethylation at the CpG islands has been 
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5.5.2.2 Drug Supply and Preparation 
Azacitidine is commercially available. Azacitidine is supplied as 100 mg of white, 
lyophilized powder with 100 mg of mannitol, USP in 30 ml flint vials. For subcutaneous 
injection: The contents of each vial should be dissolved in 4mL of sterile water or 0.9% 
sodium chloride to provide a 25 mg/ml slurry. Azacitidine does not go into solution but 
forms a loose slurry when reconstituted in this fashion. Do not inject the slurry intravenously. 
Single injections should not exceed 2ml. Doses requiring larger volumes may be split into 
multiple injection sites if volume to be administered is too large. Injection sites should be 
rotated on a daily basis. For intravenous injection: Reconstitute the appropriate number of 
azacitidine vials to achieve desired dose. Reconstitute each vial with 10 milliliters (mL) of 
sterile water for injection for a resulting concentration of 10 milligrams/mL. Shake 
vigorously or roll the vial until solution is clear. The desired amount of azacitidine solution 
should be withdrawn and injected into 50 to 100 milliliters of either 0.9% Sodium Chloride 
or Lactated Ringer’s Injection. 
5.5.2.3 Storage and Stability 
Store un-reconstituted vials at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) (See 
USP Controlled Room Temperature). Azacitidine reconstituted for subcutaneous 
administration may be stored for up to 1 hour at 25°C (77°F) or for up to 8 hours between 
2-8°C (36 and 46°F). The constituted solutions hydrolyze at room temperature and should 
be used within 30 minutes for delivery of maximum potency. Administration of Azacitidine 
reconstituted for intravenous administration must be completed within 1 hour of 
reconstitution. The reconstituted azacitidine may be stored for up to 1 hour at 25°C (77°). 
5.5.2.4 Route of Administration 
Route of administration is via subcutaneous or intravenous injections. Injections are to be 
given by trained nursing staff at each institution. Reconstituted solutions of azacitidine are 
unstable. Upon reconstitution, the material should be injected within 30 minutes. To provide 
a homogeneous suspension, the contents of the syringe must be re-suspended by inverting 
the syringe 2-3 times and vigorously rolling the syringe between the palms for 30 seconds 
immediately prior to administration until a uniform, cloudy suspension is achieved. For 
intravenous administration, the total dose of diluted azacitidine solution should be 
administered over 10 to 40 minutes. Administration must be completed within 1 hour of the 
reconstitution of the azacitidine vial. 
5.5.2.5 Adverse Events Associated with Azacitidine 
Hematologic toxicities include leukopenia, neutropenia, thrombocytopenia, and anemia. GI 
toxicities include nausea and vomiting, diarrhea, stomatitis and mucositis. Increased liver 
function tests and renal tubular acidosis can be seen. Rarely, pulmonary edema, arrhythmia, 
pericarditis, hypotension, hepatic coma, CNS and neuromuscular toxicity have been seen. 
Rash, allergic reactions, fever, conjunctivitis and alopecia have also been noted. Local 


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injection reactions are common and include burning, pain, violaceous (purple) discoloration 
lasting up to ten days, and persistent brown discoloration. In clinical studies, the most 
commonly 
occurring 
adverse 
reactions 
were 
nausea 
(71%), 
anemia 
(70%), 
thrombocytopenia (66%), vomiting (54%), pyrexia (52%), leukopenia (48%), diarrhea 
(36%), fatigue (36%), injection site erythema (35%), constipation (34%), neutropenia (32%) 
and ecchymosis (31%). Other adverse reactions included dizziness (19%), chest pain (16%), 
febrile neutropenia (16%), myalgia (16%), injection site reaction (14%) and malaise (11%). 
5.6 
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 is be required.  The investigator should discuss any questions regarding this with 
the Merck Clinical team.  The final decision on any supportive therapy or vaccination rests 
with the investigator and/or the subject's primary physician.  
5.6.1 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 after 30 days after the last dose of trial treatment should be recorded for SAEs 
and ECIs as defined in Section 7.2. 
5.6.2 Prohibited Concomitant Medications 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase of this trial: 
 Antineoplastic systemic chemotherapy or biological therapy with the exception of 
hydroxyurea (to be stopped ≥12 hours prior to first chemotherapy dose on study). If the 
WBC increases > 30,000/µl during cycle 1, hydroxyurea may be resumed, to be 
discontinued prior to day 1 of cycle 2. If the WBC increases to > 30,000/µl prior to 
cycle 3, the patient will discontinue study treatment (unless increase in WBC is not 
leukemia-related, such as with steroid use, growth factors or infection). 
 Immunotherapy not specified in this protocol 
 Chemotherapy not specified in this protocol 


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 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, varicella/zoster, yellow fever, rabies, BCG, and 
typhoid vaccine.  
 Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
event of clinical interest of suspected immunologic etiology.  The use of physiologic 
doses of corticosteroids may be approved after consultation with the Sponsor. 
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. 
5.7 
 Rescue Medications & Supportive Care 
5.7.1 Antiemetics 
Antiemetics will be used according to standard practices with the exception of systemic 
steroids (i.e. dexamethasone). Use of systemic steroids during this trial is not allowed. Any 
5-HT3 receptor inhibitor, or alternative antiemetics such as prochlorperazine, haloperidol, 
lorazepam, or similar as needed, will be used during azacitidine treatment and 
pembrolizumab administration as needed. 
5.7.2 Antimicrobial Prophylaxis 
Patients will receive prophylaxis against gram-negative gastrointestinal infections, 
candidiasis or other fungal infections, and herpes simplex virus, as per standard of care. 
5.7.3 Colony Stimulating Factors 
The routine use of colony stimulating factors is not allowed. The use of colony stimulating 
factors in the presence of severe or life-threatening infection should be discussed with the 
principal investigator before implementation. 
5.7.4 Prevention and Management of Tumor Lysis Syndrome 
Tumor lysis may occur as part of initial cytoreductive therapy for AML. Tumor lysis labs 
consisting of comprehensive metabolic panel, uric acid, phosphate, and LDH will be 
monitored at least twice a week during the first week of treatment or more frequently if 
clinically indicated and according to standard practice. 


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The following prophylaxis regimen is suggested prior to and during chemotherapy 
administration:  
 To prevent hyperuricemia, all patients without known allergy can receive 
Allopurinol 300 – 600 mg orally daily with chemotherapy as long as clinically 
indicated based on the laboratory parameters and the risk of tumor lysis. 
Rasburicase can be used per institutional policy for hyperuricemia. Screening 
for G6PD deficiency should be obtained in susceptible population before 
beginning rasburicase. 
 To decrease the risk of hyperphosphatemia, an oral phosphate binder per 
institutional practice (e.g. sevelamer 400-800 mg) can be administered orally 
every 4 to 6 hours with the start of chemotherapy and continue as long as 
clinically indicate based on the laboratory parameters and the risk of tumor 
lysis. 
5.7.5 Supportive Care Guidelines for Pembrolizumab 
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. 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 does not 
need to follow the treatment guidance (as outlined below). Refer to Section 5.2.1 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.  
 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. 


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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, administer oral corticosteroids.  
o For Grade 3 or 4 diarrhea/colitis, 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. 
 
 


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 Hyperthyroidism or Hypothyroidism:  
Thyroid disorders can occur at any time during treatment. Monitor patients for changes 
in thyroid function (at the start of treatment, periodically during treatment, and as 
indicated based on clinical evaluation) and for clinical signs and symptoms of thyroid 
disorders. 
 
o Grade 2 hyperthyroidism events (and Grade 2-4 hypothyroidism): 
 In hyperthyroidism, non-selective beta-blockers (e.g. propranolol) are 
suggested as initial therapy. 
 In hypothyroidism, thyroid hormone replacement therapy, with 
levothyroxine or liothyroinine, is indicated per standard of care. 
o Grade 3-4 hyperthyroidism  
 Treat with an initial dose of IV corticosteroid followed by oral 
corticosteroids. When symptoms improve to Grade 1 or less, steroid 
taper should be started and continued over no less than 4 weeks. 
Replacement of appropriate hormones may be required as the steroid 
dose is tapered. 
 
 
 Hepatic: 
o For Grade 2 events, monitor liver function tests more frequently until returned 
to baseline values (consider weekly). 
 Treat with IV or oral corticosteroids 
o For Grade 3-4 events, treat with intravenous corticosteroids for 24 to 48 hours.  
o When symptoms improve to Grade 1 or less, a steroid taper should be started 
and continued over no less than 4 weeks. 
 
 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 6 below shows treatment guidelines for subjects who experience an infusion 
reaction associated with administration of pembrolizumab (MK-3475). 
Table 6. Infusion Reaction Treatment Guidelines 


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NCI CTCAE Grade 
Treatment 
Premedication at subsequent 
dosing 
Grade 1 
Mild reaction; infusion interruption 
not indicated; intervention not 
indicated 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
None 
Grade 2 
Requires infusion interruption but 
responds promptly to symptomatic 
treatment (e.g., antihistamines, 
NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated for 
< =24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
If symptoms resolve within one hour of stopping 
drug infusion, the infusion may be restarted at 
50% of the original infusion rate (e.g., from 100 
mL/hr to 50 mL/hr).  Otherwise dosing will be 
held until symptoms resolve and the subject 
should be premedicated for the next scheduled 
dose. 
Subjects who develop Grade 2 toxicity despite 
adequate premedication should be 
permanently discontinued from further trial 
treatment administration.
Subject may be premedicated 1.5h 
(± 30 minutes) prior to infusion of 
pembrolizumab (MK-3475) with: 
 
Diphenhydramine 50 mg po (or 
equivalent dose of antihistamine). 
 
Acetaminophen 500-1000 mg po 
(or equivalent dose of antipyretic). 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly responsive 
to symptomatic medication and/or 
brief interruption of infusion); 
recurrence of symptoms following 
initial improvement; hospitalization 
indicated for other clinical sequelae 
(e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or ventilatory 
support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued from 
further trial treatment administration.
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period of drug 
administration. 
 
 
 
5.8 
Diet/Activity/Other Considerations 
5.8.1 Diet 
Subjects should maintain a normal diet appropriate for patients with AML unless modifications 
are required to manage an AE such as diarrhea, nausea or vomiting. 


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5.8.2 Contraception 
Pembrolizumab and azacitidine may have adverse effects on a fetus in utero.  Furthermore, it 
is not known if pembrolizumab and azacitidine have transient adverse effects on the 
composition of sperm.   
For this trial, male subjects will be considered to be of non-reproductive potential if they have 
azoospermia (whether due to having had a vasectomy or due to an underlying medical 
condition).   
Female subjects will be considered of non-reproductive potential if they are either:  
(1) postmenopausal (defined as at least 12 months with no menses without an alternative 
medical cause; in women < 45 years of age a high follicle stimulating hormone (FSH) level in 
the postmenopausal range may be used to confirm a post-menopausal state in women not using 
hormonal contraception or hormonal replacement therapy. In the absence of 12 months of 
amenorrhea, a single FSH measurement is insufficient.);  
OR  
(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy or bilateral 
tubal ligation/occlusion, at least 6 weeks prior to screening;  
OR  
(3) has a congenital or acquired condition that prevents childbearing. 
Female and male subjects of reproductive potential must agree to avoid becoming pregnant or 
impregnating a partner, respectively, while receiving study drug and for 120 days after the last 
dose of study drug by complying with one of the following:   
(1) practice abstinence† from heterosexual activity;  
OR  
(2) use (or have their partner use) acceptable contraception during heterosexual activity.   
Acceptable methods of contraception are‡:  
Single method (one of the following is acceptable): 
• 
intrauterine device (IUD) 
• 
vasectomy of a female subject’s male partner  
• 
contraceptive rod implanted into the skin 


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Combination method (requires use of two of the following): 
• 
diaphragm with spermicide (cannot be used in conjunction with cervical 
cap/spermicide) 
• 
cervical cap with spermicide (nulliparous women only)   
• 
contraceptive sponge (nulliparous women only)  
• 
male condom or female condom (cannot be used together) 
• 
hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin-
only pill), contraceptive skin patch, vaginal contraceptive ring, or subcutaneous contraceptive 
injection 
  
†Abstinence (relative to heterosexual activity) can be used as the sole method of contraception 
if it is consistently employed as the subject’s preferred and usual lifestyle and if considered 
acceptable by local regulatory agencies and ERCs/IRBs.  Periodic abstinence (e.g., calendar, 
ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are not acceptable 
methods of contraception.  
‡If a contraceptive method listed above is restricted by local regulations/guidelines, then it 
does not qualify as an acceptable method of contraception for subjects participating at sites in 
this country/region. 
Subjects should be informed that taking the study medications may involve unknown risks to 
the fetus (unborn baby) if pregnancy were to occur during the study.  In order to participate in 
the study subjects of childbearing potential must adhere to the contraception requirement 
(described above) from the day of study medication initiation (or 14 days prior to the initiation 
of study medication for oral contraception) throughout the study period up to 120 days after 
the last dose of trial therapy.  If there is any question that a subject of childbearing potential 
will not reliably comply with the requirements for contraception, that subject should not be 
entered into the study. 
5.8.3 Use in Pregnancy 
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab and 
azacitidine, the subject will immediately be removed from the study.  The site will contact the 
subject at least monthly and document the subject’s status until the pregnancy has been 
completed or terminated.  The outcome of the pregnancy will be reported to the Sponsor and 
to Merck without delay and within 24 hours to the Sponsor and within 2 working days to Merck 


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if the outcome is a serious adverse experience (e.g., death, abortion, congenital anomaly, or 
other disabling or life-threatening complication to the mother or newborn).   
The study investigator will make every effort to obtain permission to follow the outcome of 
the pregnancy and report the condition of the fetus or newborn to the Sponsor.   If a male 
subject impregnates his female partner the study personnel at the site must be informed 
immediately and the pregnancy reported to the Sponsor and to Merck and followed as 
described above and in Section 7.2.2. 
5.8.4 Use in Nursing Women 
It is unknown whether pembrolizumab or azacitidine are 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. 
5.9 
Subject Withdrawal/Discontinuation Criteria 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the 
discretion of the investigator should any untoward effect occur.  In addition, a subject may be 
withdrawn by the investigator or the Sponsor if enrollment into the trial is inappropriate, the 
trial plan is violated, or for administrative and/or other safety reasons.  Specific details 
regarding discontinuation or withdrawal are provided in Section 7.1.4 – 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. 
 Failure to achieve WBC ≤ 30 x 109/L off hydroxyurea after 2 cycles of therapy.  
Note: If increase in WBC is not leukemia-related such as seen with the use of 
steroids, infections, or growth factors and does not require hydroxyurea patient can 
remain on the study. 
 Confirmed disease progression or relapse 
Note: Please see Section 7.1.2.6 for explanation. 
 Unacceptable adverse experiences as described in Section 5.2.1.4 and 5.2.1.5 
 Intercurrent illness that prevents further administration of treatment 
 Investigator’s decision to withdraw the subject 
 The subject has a confirmed positive serum pregnancy test 


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 Noncompliance with trial treatment or procedure requirements 
 The subject is lost to follow-up 
 Completed 24 months of treatment (interrupted or uninterrupted) with azacitidine and 
pembrolizumab. Note: 24 months of study medication is calculated from the date of 
first dose. Subjects who stop azacitidine and pembrolizumab after 24 months may be 
eligible for up to one year of additional study treatment if they progress after stopping 
study treatment provided they meet the requirements detailed in Section 7.1.5.5 
 Administrative reasons 
The End of Treatment and Follow-up visit procedures are listed in Section 6 (Protocol Flow 
Chart) and Section 7.1.5 (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 7.2.3.3.2). 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. 
5.9.1 Discontinuation of Study Therapy after CR  
Discontinuation of treatment after achievement of CR/CRi is not recommended and the goal 
would be to administer up to 24 months of treatment; however, discontinuation of treatment 
may be considered at the discretion of the investigator for subjects who have attained a 
confirmed CR/CRi that have been treated for at least 6 cycles with azacitidine/pembrolizumab 
and had at least four treatments (cycles) with azacitidine/pembrolizumab beyond the date when 
the initial CR/CRi was declared.  Subjects who then experience disease relapse may be eligible 
for up to one year of additional treatment with azacitidine/pembrolizumab via the Second 
Course Phase at the discretion of the investigator if no cancer treatment was administered since 
the last dose of azacitidine/pembrolizumab, the subject meets the safety parameters listed in 
the Inclusion/Exclusion criteria, and the trial is open.  Subjects will resume therapy at the same 
dose and schedule at the time of initial discontinuation.  Additional details are provided in 
Section 7.1.5.5. 
5.10 Subject Replacement Strategy 
Safety Run In Phase:  
 If laboratory abnormalities and clinical situation exist on day 8 during cycle 1 
precluding pembrolizumab administration, pembrolizumab administration can be 
delayed for 2 weeks, up to day 22, provided laboratory abnormalities correct 
themselves to the levels defined in Section 5.1 and clinical situation resolves/improves. 


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Patients who are ineligible for pembrolizumab administration by day 22 of cycle 1 will 
be removed from the study and replaced by another subject. 
 If subject discontinue study treatment for any reason other than drug-related toxicity 
prior to completing 2 study cycles, this subject will be replaced.  
 If subject discontinue study treatment before receiving a single dose of pembrolizumab, 
this subject will be replaced. 
5.11 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. 
 


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6.0 TRIAL FLOW CHART 
6.1 
Study Flow Chart 
Trial Period: 
Screening 
Phase 
Treatment Cycles 
End of Treatment 
Post-Treatment 
Treatment Cycle/Title:
Main Study 
Screening  
C1 
and 
C2  
D1 
C1 
and 
C2 
D2-7 
 
 
 
 
C1 
D8 
C1 
and 
C2 
D15, 
D22 
To be repeated beyond 
Cycle 3 
Discontinuat
ion 
Safety 
Follow-up
Follow Up 
Visitsj 
Survival Follow-Up 
C3
D1 
C3 
D2-7 
 
C3 
D8, 
D15 
C3 
D22
 
 
 
 
Scheduling Window (Days):
-14 to -1 
±3 
± 3 
 
 
 
± 3 
± 3 
± 3
± 3 
 
 
 
± 3 
± 3 
At time of 
Discontinuat
ion 
 
30 days 
post 
discon  
(± 4 days)
Every 8 
weeks post 
disconj 
Every 12 weeks  
 
 
Administrative Procedures 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics and Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Prior and Concomitant Medication Review 
X 
X 
 
 
 
X 
 
 
 
 
 
 
 
Azacitidine Administration 
 
Xa 
Xa 
 
 
Xa 
Xa 
 
 
 
 
 
 
Pembrolizumab Administration 
 
Xa 
 
Xa 
Xa 
Xa 
 
Xa 
Xa 
 
 
 
 
Post-study anticancer therapy status 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
Survival Status 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
 
 
Clinical Procedures/Assessments 
Review Adverse Events 
 
X 
X 
X 
X 
X 
 
Xb 
Xb 
X 
X 
 
 
Full Physical Examination 
X 
X 
 
 
 
X 
 
 
 
X 
X 
 
 
Directed Physical Examination 
 
X 
 
Xb 
Xb 
 
 
Xb 
Xb 
X 
X 
X 
 
Vital Signs and Weightg 
X 
X 
X 
Xb 
X 
X 
X 
Xb 
Xb 
X 
X 
X 
 


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Trial Period: 
Screening 
Phase 
Treatment Cycles 
End of Treatment 
Post-Treatment 
Treatment Cycle/Title:
Main Study 
Screening  
C1 
and 
C2  
D1 
C1 
and 
C2 
D2-7 
 
 
 
 
C1 
D8 
C1 
and 
C2 
D15, 
D22 
To be repeated beyond 
Cycle 3 
Discontinuat
ion 
Safety 
Follow-up
Follow Up 
Visitsj 
Survival Follow-Up 
C3
D1 
C3 
D2-7 
 
C3 
D8, 
D15 
C3 
D22
 
 
 
 
Scheduling Window (Days):
-14 to -1 
±3 
± 3 
 
 
 
± 3 
± 3 
± 3
± 3 
 
 
 
± 3 
± 3 
At time of 
Discontinuat
ion 
 
30 days 
post 
discon  
(± 4 days)
Every 8 
weeks post 
disconj 
Every 12 weeks  
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
ECOG Performance Status 
X 
X 
 
 
 
X 
 
 
 
 
 
X 
 
Electrocardiogram 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Echocardiogramk
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laboratory Procedures/Assessments: analysis performed by LOCAL laboratory 
Pregnancy Test – Urine or Serum -HCGh 
X 
 
 
 
 
X 
 
 
 
 
 
 
 
PT/INR, aPTT, fibrinogen 
X 
X 
 
X 
X 
X 
 
 
 
 
 
 
 
CBC with Differential 
X 
X 
X 
X 
X 
 
XC 
Xc 
X 
X 
X 
 
Comprehensive Serum Chemistry Panel 
X 
X 
X 
X 
X 
 
XC 
Xc 
X 
X 
X 
 
Uric Acid, Phosphate, Magnesium, LDH 
X 
X 
 
X 
X 
X 
 
Xc 
Xc 
X 
X 
X 
 
T3, FT4 and TSH 
X 
 
 
 
 
Xi
 
 
 
 
 
 
 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Efficacy Measurements 
Bone Marrow Aspirate/Biopsyd,f  
Xd,f 
 
 
 
Xd,f 
 
 
 
Xd,f 
Xd,f 
 
Xd,f 
 
 
 
Tumor Biopsies/Archival Tissue Collection/Correlative Studies Blood 
Correlative Studies Peripheral Blood 
Collection 
Xe 
Xe 
 
Xe 
Xe 
Xe 
 
 
 
Xe 
 
Xe 
 


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Trial Period: 
Screening 
Phase 
Treatment Cycles 
End of Treatment 
Post-Treatment 
Treatment Cycle/Title:
Main Study 
Screening  
C1 
and 
C2  
D1 
C1 
and 
C2 
D2-7 
 
 
 
 
C1 
D8 
C1 
and 
C2 
D15, 
D22 
To be repeated beyond 
Cycle 3 
Discontinuat
ion 
Safety 
Follow-up
Follow Up 
Visitsj 
Survival Follow-Up 
C3
D1 
C3 
D2-7 
 
C3 
D8, 
D15 
C3 
D22
 
 
 
 
Scheduling Window (Days):
-14 to -1 
±3 
± 3 
 
 
 
± 3 
± 3 
± 3
± 3 
 
 
 
± 3 
± 3 
At time of 
Discontinuat
ion 
 
30 days 
post 
discon  
(± 4 days)
Every 8 
weeks post 
disconj 
Every 12 weeks  
Correlative Studies Bone Marrow 
Collection 
Xd,f 
 
 
 
Xd,f 
 
 
 
Xd,f 
Xd,f 
 
Xd,f 
 
a Azacitidine should be administered without interruption in each cycle. Pembrolizumab to be administered starting on day 8 cycle 1 every 3 weeks. 
(See Section 5.2.1.4., 5.2.1.5, and 5.2.1.5.1 for specific exceptions) 
bDuring cycle 1 and 2, patients will be seen weekly. In subsequent cycles, the frequency of study required visits will be reduced to d1 prior to 
azacitidine and prior to each pembrolizumab administration. However, patients may be seen more frequently as needed according to standard of care 
for management of patients with AML as determined and at the discretion of investigator/treating physician. 
 
c During cycle 1 and 2, patients will have laboratory tests weekly. However, patients may have laboratory tests more frequently (twice or more per 
week) as needed according to standard of care for management of patients with AML as determined and at the discretion of the investigator/treating 
physician. In subsequent cycles, patient is required to have laboratory tests on day 1 and days of pembrolizumab administration in that cycle. 
However, patients may have laboratory tests more frequently (once or more per week) as needed according to standard of care for management of 
patients with AML as determined and at the discretion of the investigator/treating physician. 
 
dBone marrow aspirate and biopsy will be done as per standard of care: pre-treatment, after the completion of cycle 2, cycle 6, and every 3 months 
thereafter (up to 1 yr). If necessary (in the absence of count recovery as defined in Section 5.2.1.3 and 5.2.1.5.2) bone marrow as per standard of 
care will be done after cycle 1. In a second year, bone marrow aspirate and biopsy can be performed every 4-6 months and at the end of treatment. 
Bone marrow aspirate and biopsies will be performed every 4-6 months in a follow up phase. Bone marrow aspirate and biopsies can be performed 
at any time to evaluate for hematologic toxicity (Section 5.2.1.5.3) or if disease progression/relapse is suspected either during treatment or in follow 
up, or at treatment discontinuation. Each bone marrow should include morphologic assessment (aspirate/biopsy), flow cytometry, and karyotype 


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and/or molecular study if indicated. If karyotype was performed within 3 months prior to day 1 of treatment, it does not need to be repeated pre-
treatment. 
eFor peripheral blood samples for research, 5x8.5mL light yellow top ACD tubes (or 4x10mL green top heparin tubes) of blood (~40mLs) will be 
collected pre-treatment on D1 of cycle 1 (for cycle 1 sample can be collected any time within 14 days prior to treatment) and cycle 2, on D8 of cycle 
1 and D22 of cycle 2 (or on days of pembrolizumab administration in either cycle). Starting with cycle 3, peripheral blood samples will be collected 
only on day 1 of every other cycle (Cycle 3, 5, etc), at the time of the follow up visits. All samples should be collected prior to 
azacitidine/pembrolizumab administration if on a treatment day. Repeat blood sample at any time if there is a suspicion of leukemia recurrence either 
during maintenance phase or in follow-up, or at treatment discontinuation. 
fThe schedule of bone marrow procedures performed according to standard of care is delineated under d. Each time a bone marrow biopsy is done 
as per standard of care, additional ~40 mL of bone marrow will be collected in 5x8.5mL light yellow  top ACD tubes (or 4x10mL green top heparin 
tubes).). 
g Weight should be recorder only prior to start of each Cycle. Vital signs including temperature, pulse, respiratory rate, and blood pressure will be 
checked immediately before pembrolizumab infusion. 
hPregnancy test will be repeated every 3 cycles in women of childbearing potential. 
iThyroid function monitoring every 3 cycles.  
j This applies only to patients who completed treatment and were not taken from study for progressive disease and did not start any other treatment.    
k If an echocardiogram was conducted within the 3 months prior to the screening date and the patient has not received any chemotherapy in the 
time between and has not experienced any cardiac symptoms or events (heart attack, chest pain, arrhythmia, etc), then the screening 
echocardiogram does not need to be repeated,  unless it is clinically indicated per investigator’s discretion. 
* In order to minimize the need for research-only in-person visits, telemedicine visits may be substituted for in-person clinical trial visits or 
portions of clinical trial visits where determined to be appropriate and where determined by the investigator not to increase the participant’s risks. 
Prior to initiating telemedicine for study visits the study team will explain to the participant, what a telemedicine visit entails and confirm that the 
study participant is in agreement and able to proceed with this method. Telemedicine acknowledgement will be obtained in accordance with the 
Guidance for Use of Telemedicine in Research. In the event telemedicine is not deemed feasible, the study visit will proceed as an in-person visit. 
Telemedicine visits will be conducted using HIPAA compliant method approved by the Health System and within licensing restrictions. 


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7.0 TRIAL PROCEDURES 
7.1 
Trial Procedures 
The Trial Flow Chart - Section 6.0 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 Sponsor and/or 
Merck 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. 
7.1.1 Administrative Procedures 
7.1.1.1 Informed Consent 
The Investigator must obtain documented consent from each potential subject prior to 
participating in a clinical trial. 
7.1.1.1.1 General Informed Consent 
In obtaining and documenting informed consent, the investigator should comply with the 
applicable regulatory requirement(s), and should adhere to Good Clinical Practice (GCP) and 
to ethical principles that have their origin in the Declaration of Helsinki. 
Before recruitment and enrollment onto this study, the patient will be given a full explanation 
of the study and will be given the opportunity to review the consent form. Each consent form 
must include all the relevant elements currently required by the FDA Regulations and local or 
state regulations. Once this essential information has been provided to the patient and the 
investigator is assured that the patient understands the implications of participating in the 
study, the patient will be asked to give consent to participate in the study by signing an 
IRB-approved consent form. 
Consent must be documented by the subject’s dated signature or by the subject’s legally 
acceptable representative’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 or his/her legally acceptable 
representative should be informed in a timely manner if new information becomes available 


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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 signature or 
by the subject’s legally acceptable representative’s dated signature. 
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 IRB/ERC requirements, applicable laws and regulations 
and Sponsor requirements. 
7.1.1.2 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.  
7.1.1.3 Medical History 
A medical history will be obtained by the investigator or qualified designee.  Medical history 
will include all active conditions, and any condition diagnosed within the prior 10 years that 
are considered to be clinically significant by the Investigator.  Details regarding the disease for 
which the subject has enrolled in this study will be recorded separately and not listed as medical 
history.   
7.1.1.4 Prior and Concomitant Medications Review 
7.1.1.4.1 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.  
7.1.1.4.2 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 7.2. 
7.1.1.5 Disease Details and Treatments 
7.1.1.5.1 Disease Details 
The investigator or qualified designee will obtain prior and current details regarding disease 
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7.1.1.5.2 Prior Treatment Details 
The investigator or qualified designee will review all prior cancer treatments including 
systemic treatments, radiation and surgeries. 
7.1.1.5.3 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.  
7.1.1.6 Assignment of Screening Number 
The research nurse or data manager at the Coordinating Center, Johns Hopkins, should be 
contacted to confirm a treatment slot is available before approaching a subject. 
All subjects must be registered with the Clinical Research Office at Johns Hopkins SKCCC 
before enrollment to study.  
To register a patient, the following documents should be completed by the research 
nurse or data manager and faxed (410-614-2449) or e-mailed onc-coordcnt@jhmi.edu 
to the Study 
Coordinator: 
 Signed patient consent form 
 Registration form 
 Source documents 
 
Subjects will be assigned a screening number (ID) at screening. The screening ID will be 
used on all correlative samples.  
Treatment may not begin until eligibility has been confirmed by the Coordinating 
Center. 
Confirmation will be scanned and e-mailed, or faxed to the registering site. The 
screening ID number will become the study ID. 
 


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7.1.1.7 Assignment of Randomization Number 
This study has no randomization. However, there are two separate Cohorts of patients, 
Cohort 1 and Cohort 2. Each Cohort will have a unique study ID. 
7.1.1.8 Trial Compliance (Medication/Diet/Activity/Other) 
Compliance to the study procedures will be assessed at each visit and documented in the 
source document. 
7.1.2 Clinical Procedures/Assessments 
7.1.2.1 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.  
Please refer to section 7.2 for detailed information regarding the assessment and recording of 
AEs.   
7.1.2.2 Full Physical Exam 
The investigator or qualified designee will perform a complete physical exam during the 
screening period and prior to each cycle.  Clinically significant abnormal findings should be 
recorded as medical history.  A full physical exam should be performed during screening,  
7.1.2.3 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.   
7.1.2.4 Vital Signs 
The investigator or qualified designee will take vital signs at screening, prior to the 
administration of each dose of trial treatment and at treatment discontinuation as specified in 
the Trial Flow Chart (Section 6.0).  Vital signs should include temperature, pulse, respiratory 
rate, and blood pressure.  Weight will be measured at screening and prior to start (day 1) of 
each Cycle. Height will be measured at screening only. 


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7.1.2.5 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 cycle and discontinuation of trial treatment as specified in 
the Trial Flow Chart.   
7.1.2.6 Assessment of Disease 
Bone marrow aspirate and biopsy and peripheral blood counts will be used to assess disease as 
per the Trial Flow Chart. Response will be assessed by standard international criteria proposed 
by the European LeukemiaNet Guidelines (update 2017) in AML63  and by IWG Modified 
Response Criteria (2006) for MDS (for definition of HI)64.  
Complete remission (CR): Bone marrow blasts <5%; absence of circulating blasts or blasts 
with Auer rods; absence of extramedullary disease; absolute neutrophil count ≥1,000/mcL; 
platelet count ≥100,000/mcL.  
Complete remission with incomplete recovery (CRi): All CR criteria except for residual 
neutropenia (<1,000/mcL) or thrombocytopenia (<100,000/mcL). 
Complete remission without minimal residual disease (MRD): If studied pre-treatment, CR 
with negativity for a genetic marker by realtime quantitative polymerase chain reaction (RT-
qPCR), or CR with negativity by multi-color flow cytometry. Sensitivities vary by marker 
tested, and by method used. Since this study does not use centralized laboratory, MRD status 
will be recorded if available for each patient that achieves CR or CRi. 
Morphologic leukemia-free state (MLFS): Bone marrow blasts <5%; absence of blasts with 
Auer rods; absence of extramedullary disease; no hematologic recovery required (marrow 
should not be merely aplastic (marrow should not be merely “aplastic”; at least 200 cells should 
be enumerated or cellularity should be at least 10%). 
Partial response (PR): bone marrow blasts 5-25% and decrease of pretreatment bone marrow 
blast % by >50%; all hematologic criteria of CR. 
 
Hematologic Improvement (HI)-major: 
Hematologic improvement –unconfirmed will be documented following the first cycle after 
which it is achieved. If hematologic improvement persists after the following cycle, the 
response will be changed to hematologic improvement –confirmed. Responses of hematologic 
improvement confirmed may be recorded prior to the formal response assessment. It is 
understood that after the four-month or more likely six-month assessment, some patients with 
hematologic improvement will have responses upgraded to complete and partial responses. 
 
For the purpose of this study, the criteria for HI-major developed for the grading of response 
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HI-major response (must have at least one of the three listed below) must persist for a minimum 
of two months to be considered a confirmed response. 
 
HI-major Erythroid: 
For patients with pretreatment hemoglobin <11 g/dL, greater than 2 g/dL increase in 
hemoglobin; for RBC transfusion-dependent patients, transfusion independence. 
 
HI-major Platelet: 
For patients with a pretreatment platelet count less than 100,000/μL, an absolute increase of 
30,000/μL or more; for platelet transfusion dependent patients, stabilization of platelet counts 
and platelet transfusion independence. 
 
HI-major Neutrophil: 
For absolute neutrophil count (ANC) less than 1000/μL before therapy, at least a 100% 
increase, or an absolute increase of more than 500/μL, whichever is greater. 
 
Stable disease (SD): Absence of CR, CRi, PR, MLFS; and criteria for PD not met. Period of 
stable disease should last at least 3 months. 
 
Progressive disease: Evidence for an increase in bone marrow blast percentage and/or increase 
of absolute blast counts in the blood: 
• >50% increase in marrow blasts over baseline (a minimum 15% point increase is required in 
cases with <30% blasts at baseline; or persistent marrow blast percentage of >70% over at least 
3 months; without at least a 100% improvement in ANC to an absolute level >500/mcL, and/or 
platelet count to >50,000/μL non-transfused]; or 
• >50% increase in peripheral blasts (WBC x % blasts) to >25,000/μl (in the absence of 
differentiation syndrome); or 
• New extramedullary disease 
 
Progression is not a useful concept for monitoring in AML. Further, pembrolizumab is 
expected to trigger immune-mediated responses, which require activation of the immune 
system prior to the observation of clinical responses. Such immune activation may take weeks 
to months to be evident. Azacitidine is a low-intensity chemotherapy agent that usually 
requires at least 4-6 cycles of therapy to exert its full anti-leukemia effect. Thus, some patients 
may have objective increase in leukemia burden or other disease parameters within weeks 
following the start of pembrolizumab/azacitidine dosing. Such patients may not have had 
sufficient time to develop the required immune activation or for azacitidine/pembrolizumab to 
exert their anti-leukemia effect. In conventional studies, such increase in leukemia burden 
(bone marrow, peripheral blood, extramedullary disease) or other disease parameters during 
the first 2-4 months of the study would constitute progressive disease as per above criteria and 
lead to premature discontinuation of therapy, thus disregarding the potential for subsequent 
immune-mediated clinical response. Therefore, patients with leukemia progression by bone 
marrow or peripheral blood laboratory parameters prior to completion of 6 cycles of therapy 
but without rapid clinical deterioration and who do not require additional immediate therapy, 


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may continue to be treated with pembrolizumab /azacitidine and clinically observed to allow 
detection of a subsequent tumor response. Subjects that meet the PD criteria and continue on 
study therapy must discontinue azacitidine/pembrolizumab if there are no signs of disease 
stabilization by end of 6 cycles of therapy (approximately 6 months). The date of progression 
will be defined as of the first observation date of progressive disease in those patients who do 
not upgrade response with continuous therapy. 
 
However, we are still using progression of AML as a reason for early discontinuation of study 
treatment (before completing 6 cycles) with the following criteria: 
1. Progression of the leukemia such that clinical sequelae would result from a high WBC blast 
count such as hyperleukocytosis, or due to increasing size of spleen or extramedullary disease..  
2. Failure to achieve WBC ≤ 30 x 109/L off hydroxyurea after 2 cycles of therapy.  
Note: If increase in WBC is not leukemia-related such as seen with the use of steroids, 
infections, or growth factors and does not require hydroxyurea patient can remain on the study. 
3. New CNS leukemia or new extramedullary disease.  
4. Progressive disease is usually accompanied by a decline in ANC and platelets and increased 
transfusion requirement and decline in performance status or increase in symptoms. Patient 
can be removed from the study before cycle 6 at the discretion of the investigator / treating 
physician if in their assessment further treatment on the study would not be in patient’s best 
interest. This should be discussed with the Protocol Chair and the reason for study treatment 
discontinuation at any time should be documented and confirmed by BM assessment. (Note: 
the goal is to administer at minimum 2 cycles of therapy before initial assessment.) 
 
Relapse: 
Relapse following CR/CRi is defined as: 
Peripheral Blood Counts-Reappearance of blasts in the blood that persist and are not 
considered to be due to count or marrow recovery. 
Bone Marrow Aspirate and Biopsy-Presence of ≥ 5% blasts, not attributable to another cause 
(e.g., bone marrow regeneration).If there are no circulating blasts and the bone marrow 
contains 5% to 20% blasts, and if unclear if increase in the blasts is due to regeneration, reactive 
process or leukemia, then a repeat bone marrow performed ≥ 1 week later documenting ≥ 5% 
blasts is necessary to meet the criteria for relapse. 
 
Molecular Relapse (after CRMRD-): If studied pre-treatment, reoccurrence of MRD as assessed 
by quantitative RTqPCR or by multi-color flow cytometry. Sensitivities vary by marker tested, 
and by method used. Since this study does not use centralized laboratory, MRD status will be 
recorded but clinical relapse parameters will be used for survival endpoint assessment. 
 
Progression after Hematologic Improvement 
One or more of the following: a 50% or greater decrement from maximum response levels in 
granulocytes or platelets, a reduction in hemoglobin concentration by at least 2 g/dL, or 
transfusion dependence not due to other toxicities and bone marrow blasts ≥ 5%. 
 


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7.1.2.7 Tumor Tissue Collection and Correlative Studies Blood Sampling 
Tumor tissue collection and blood collection will be performed as the Trial Flow Chart and 
processed as detailed in in the Appendix 11.5. 
7.1.3 Laboratory Procedures/Assessments 
Details regarding specific laboratory procedures/assessments to be performed in this trial are 
provided in Trial Flow Chart and below in Laboratory Safety Evaluations (Hematology, 
Chemistry and Urinalysis) 
Laboratory tests for hematology, chemistry, urinalysis, and others are specified in Table 7.  


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Table 7.  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, fibrinogen 
Red Blood Cell Count 
Lactate dehydrogenase (LDH) 
Microscopic exam (If abnormal)  
Total thriiodothyronine (T3) 
Absolute Neutrophil Count 
Carbon Dioxide ‡ 
results are noted 
Free tyroxine (T4) 
Absolute Lymphocyte Count 
  (CO2 or biocarbonate) 
Urine pregnancy test † 
Thyroid stimulating hormone (TSH) 
 
Uric Acid 
 
PK 
 
Calcium 
 
 
 
Chloride 
 
Blood for correlative studies 
 
Glucose 
 
  
 
Phosphorus 
 
  
 
Potassium   
 
  
 
Sodium 
 
  
 
Magnesium 
 
  
 
Total Bilirubin 
 
  
 
Direct Bilirubin (If total bilirubin is 
elevated above the upper limit of 
normal) 
 
 
 
Total protein 
 
 
 
Blood Urea Nitrogen 
 
 
† Perform on women of childbearing potential only. If urine pregnancy results cannot be confirmed as negative, a serum pregnancy test will be required.   
‡ If considered standard of care in your region. 
 
 
 


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Laboratory tests for screening or entry should be performed within 14 days prior to the first 
dose of treatment.  However, repeat laboratory tests are required within 72 hours prior to the 
first dose of treatment in Cycle 1. 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.  
7.1.3.1 Pharmacokinetic/Pharmacodynamic Evaluations 
7.1.3.1.1 Blood Collection for Serum Pembrolizumab- N/A 
7.1.3.1.2 Blood Collection for Anti-Pembrolizumab Antibodies- N/A  
7.1.3.1.3 Correlative Studies Procedures (Exploratory Biomarkers) 
Samples will be immediately processed following our Standard Operating Procedure 
(Appendix 11.4) in the laboratory of Dr. Leo Luznik. Participating institutions will have an 
option to process specimens locally and batch ship or to ship specimens within 24 hours of 
collection to the laboratory of Dr. Luznik.  
The pharmacodynamics of azacitidine and pembrolizumab treatment will be assessed by 
examining (quantifying) biomarkers in peripheral blood and bone marrow (tumor tissue). 
Additional biomarkers may be analyzed in peripheral blood and tumor tissue collected prior to 
and after initiation of therapy in order to identify markers that may predict response to 
treatment. The proposed studies will be done in collaboration with Univ of North Carolina. 
Detailed schedules of pharmacodynamic evaluations are provided in Trial Flow Chart Section 
6.0. 
7.1.3.1.3.1 Flow Cytometry Studies 
 
We will perform multi-color flow cytometry on PB and BM specimens before and after AZA 
and AZA/pembrolizumab treatment using three pre-determined panels of mAbs including but 
not limited to those specific for CD3, CD4, CD8, PD-1, CD45RA, CCR7, CD27, CD28, Ki-
67, T-bet, CD127, CD25, FoxP3, HLA-DR, CTLA-4, TNFRII, ICOS, TIM3, LAG-3, CD160, 
2B4, BTLA, KLRG-1, CD16, CD14, and CD56. This multi-color approach allows phenotypic 
separation of human CD4+FoxP3+ T cells into three distinct subpopulations as well as 
assessment of their proliferative status (% Ki-67 positive cells). The expression of HLA-DR, 
TNFRII and ICOS will be measured to characterize their activation status. The expression of 
co-inhibitory molecules (PD-1, TIM3, LAG-3, CD160, 2B4, BTLA, KLRG-1) will also be 
examined in relation to different CD4+
 
and CD8+
 
T cell subpopulations (expressing CD45RA, 
CCR7, CD27, and CD28). This panel will be combined with assessment of effector cytokines 
(IL-2, IFN-γ, IL-17) or canonical transcription factors (T-bet, Eomes, Blimp-1). Additionally, 
natural killer cells (NK), NK-T cells, and myeloid- derived suppressor cells (MDSCs) will be 
enumerated using the following gating strategies: CD14+HLA-DRneg/low (MDSCs); CD16 and 
CD56 (NK/NK-T cells). We will also use a highly multiplexed flow cytometry panels to 
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CD86) on MDSCs, leukemia blasts, and leukemia stem cells. We will analyze three distinct 
AML subpopulations defined as CD33+CD117+CD14- (AML progenitors) CD33+CD117-
CD14- (AML myelo/monoblasts), CD33+CD117-CD14+ (AML promonocytes)59 and 
CD34+CD38-ALDHintermediate (leukemia stem cells),65 when feasible. Our group has extensive 
experience in characterizing immune recovery in AML patients during and after chemotherapy 
and allo-SCT66,67. 
7.1.3.1.3.2 Immune Profiling of T cell Repertoire 
The studies proposed will evaluate the T cell receptor (TCR) diversity in T cells isolated from 
PB and BM from AML patients before and after treatment with AZA/pembrolizumab on the 
parent clinical trial. We will determine TCR diversity and clonal composition using a 
molecular and computational approach based on high-throughput DNA sequencing of 
rearranged TCRβ CDR3 regions from T cell genomic DNA. This approach allows direct 
measurement of the TCRβ CDR3 region sequence diversity in any arbitrarily complex 
population of T cells, and also permits quantitative description of the clonal composition of 
the population. The Luznik laboratory in collaboration with the E. Warren laboratory from 
Fred Hutchinson Cancer Research Center (FHCRC) is routinely performing this 
comprehensive in-depth analysis of the TCR repertoire in patients with MDS/AML treated 
with ipilimumab and have performed extensive monitoring and tracking of the TCR repertoires 
in patients undergoing allo-SCT (manuscript in preparation). We are utilizing an established 
multiplex PCR strategy to amplify the CDR3 region of the TCR, spanning the variable region 
formed by the junction of the V, D and J segments and their associated non-template insertions 
followed by Illumina-based sequencing methodology, an well-characterized methodology 
developed 
by 
Adaptive 
Technology 
(http://www.adaptivebiotech.com/technology/)68. 
Sequencing is followed by comprehensive bioinformatics analyses focused on determining the 
diversity of the T cell and B cell repertoires as well as the entropy and clonality of each 
repertoire consistent with previous studies69. Through these ongoing studies we have 
developed substantial experience not only in using and analyzing DNA retrieved from unsorted 
PBMCs but also from sorted T cells subpopulations (naïve vs memory vs regulatory), paired 
PB and BM samples and as well from DNA retrieved from FFPE archived tissues. We 
hypothesize that a primary action of AZA/pembrolizumab will be to disrupt the skewed T cell 
pattern present in AML patients prior to treatment toward increased TCR diversity and the 
emergence of unique TCR clonotypes that may be relevant in the anti-leukemia response. The 
long-term goal of this work is to uncover antigen- specific responses that, together with the 
other proposed correlative studies, will provide deeper insight into the mechanisms involved 
in anti-leukemic immune responses after AZA/pembrolizumab treatment.  
7.1.3.1.3.3 T cell Methylation Analysis 
We will examine IL-2 and PD-1 promoter methylation status in T cell subsets to gain insight 
into the changes in DNA methylation and expression of IL-2 and PD-1 before and after 
treatment. We will perform bisulfite sequencing to assess the level of DNA methylation at the 
individual CpG sites of the IL-2 and PD-1 promoter in T cells. Both CD4+ and CD8+ T cells 
from PB and BM will be analyzed. CD4+ and CD8+ T cells will be isolated by either magnetic 
cell separation of by flow cytometric sorting. Sequencing of at least 10 individual clones from 


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each sample will be performed. All independent experiments will be duplicated to avoid any 
PCR amplification bias. These studies will be coupled with those measuring mRNA production 
of IL-2, PD-1 and other effector cytokines. The overarching goal of these studies is to 
determining the relationship between IL-2 and PD-1 promoter DNA methylation and T cell 
differentiation status and its relation to the response to AZA/pembrolizumab treatment.  
7.1.3.1.3.4 Assessment of serum pro-inflammatory and inhibitory cytokines 
We will investigate changes in the cytokine levels in patients before and after treatment with 
azacitidine/pembrolizumab. We predict that levels of pro-inflammatory cytokines (Il-12, IFN-
γ, RANTES) will be higher while those of inhibitory ones (IL-10, TGF-β) will be lower in 
patients treated with azacitidine/pembrolizumab. 
7.1.3.1.3.5 DNA Sequencing and Gene expression profiling   
Bone marrow aspirates will be used to perform RNA sequencing, or to examine mRNA gene 
expression by gene array technology and/or quantitative real-time polymerase chain reaction 
(qPCR) to detect expression of selected immune related genes before and after treatment.  In 
addition, whole or targeted exome sequencing on the leukemia cells may be performed 
(lymphocyte control) for detection of immunogenic neoepitopes.  
7.1.3.1.3.6 Characterization of tumor-infiltrating lymphocytes (TILs) and tumor 
antigens 
Immunohistochemistry (IHC) will be used to assess the number and composition of immune 
infiltrates in order to define the immune cell subsets present within bone marrow before and 
after exposure to azacitidine and pembrolizumab These IHC analyses will include, but not 
necessarily be limited to, the following markers: CD4, CD8, FOXp3, PD-L1, and PD-L2. 
Correlations between gene expression and IHC expression will be made between assays 
performed if deemed to be informative. 
  
7.1.4 Other Procedures 
7.1.4.1 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.  Subjects who a) attain a CR as specified in Section 5.9.1 or b) complete 24 
months of treatment with azacitidine and pembrolizumab may discontinue treatment with the 
option of restarting treatment if they meet the criteria specified in Section 7.1.5.5.  After 
discontinuing treatment following assessment of CR, these subjects should return to the site 
for a Safety Follow-up Visit (described in Section 7.1.5.3.1) and then proceed to the Follow-
Up Period of the study (described in Section 7.1.5.4). 


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7.1.4.2 Blinding/Unblinding 
N/A 
7.1.5 Visit Requirements 
Visit requirements are outlined in Section 6.0 - Trial Flow Chart.   Specific procedure-related 
details are provided above in Section 7.1 - Trial Procedures. 
7.1.5.1 Screening 
7.1.5.1.1 Screening Period (day -14 to day -1) 
Unless otherwise noted, evaluations may be performed up to 2 weeks prior to Cycle 1 Day 1 
of treatment. Informed consent should be obtained prior to any screening procedure. 
Clinical evaluation:  demographics and medical history, prior and concomitant medications, 
full physical examination to include height (baseline only) and weight, ECOG performance 
status. 
Laboratory studies:   
 Pregnancy Test: A serum or urine pregnancy test (β-HCG) is required 
for all women of childbearing potential at screening within 72 hours prior 
to the first dose of azacitdine. If urine test is positive or cannot be 
confirmed as negative, a serum pregnancy test will be required. 
 CBC with differential and platelets 
 Serum Chemistries (include Comprehensive Chemistry, uric acid, 
phosphate, magnesium): These include the following parameters: 
sodium, potassium, chloride, bicarbonate (or CO2), LDH, BUN, serum 
creatinine, glucose, calcium, magnesium, phosphorus, uric acid, total 
protein, and albumin  
 LFTs: These include total bilirubin (direct if total bilirubin is elevated), 
alkaline phosphatase, AST (SGOT), ALT (SGPT) 
 Thyroid Function Tests: These include TSH and if clinically 
appropriate free T3 and T4 
 Coagulation Tests: These include PT/INR, aPTT, and fibrinogen 
 Urinalysis 
 Electrocardiogram 
 Echocardiogram 
o If an echocardiogram was conducted within the 3 months prior to the 
screening date and the patient has not received any chemotherapy in 
the time between and has not experienced any cardiac symptoms or 
events (heart attack, chest pain, arrhythmia etc), then the screening 


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echocardiogram does not need to be repeated, unless it is clinically 
indicated per investigator’s discretion. 
 
Tissue Acquisition/Disease Assessment: Primary tumor will be collected by peripheral blood 
and bone marrow biopsy. Bone marrow biopsy and blood sample should be obtained within 
14 days prior to day 1 of treatment. 
7.1.5.2 Treatment Period 
Subjects will be followed with provider visits, physical exams, adverse event monitoring, 
laboratory tests, disease assessments as per the Trial Flow Chart 6.0. Collection of specimens 
for exploratory correlative studies will be done according to Trial Flow Chart 6.0 
7.1.5.3 Post-Treatment Visits 
7.1.5.3.1  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.  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.  Subjects who are eligible for retreatment with 
azacitidine/pembrolizumab (as described in Section 7.1.5.5) may have up to two safety follow-
up visits, one after the Treatment Period and one after the Second Course Phase. 
7.1.5.4 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 8 weeks (± 14 days) as per Trial Flow 
Chart including by bone marrow exam every 4-6 months to monitor disease status as 
appropriate.  Every effort should be made to collect information regarding disease status until 
the start of new anti-neoplastic therapy, disease progression, death, end of the study or if the 
subject begins retreatment with azacitidine/pembrolizumab as detailed in Section 7.1.5.5.  
Information regarding post-study anti-neoplastic treatment will be collected if new treatment 
is initiated. 
Subjects who are eligible to receive retreatment with azacitidine/pembrolizumab according to 
the criteria in Section 7.1.5.5 will move from the follow-up phase to the Second Course Phase 
when they experience disease progression/relapse.  Details are provided in Section 5.9.1. The 
same procedures will need to be followed for Retreatment as per Trial Flow Chart for Initial 
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7.1.5.4.1 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.  
7.1.5.5 Second Course Phase (Retreatment Period) 
Subjects who stop azacitidine/pembrolizumab with CR/CRi may be eligible for up to one year 
of additional azacitidine/pembrolizumab therapy if they progress after stopping study 
treatment.  This retreatment is termed the Second Course Phase of this study and is only 
available if the study remains open and the subject meets the following conditions: 
 Either  
o Stopped initial treatment with azacitidine/pembrolizumab after attaining an 
investigator-determined confirmed CR/CRi 
 Was treated for at least  6 cycles with azacitidine/pembrolizumab before 
discontinuing therapy 
 Received at least four treatments with azacitidine/pembrolizumab beyond the 
date when the initial CR/CRi was declared 
 
 
OR 
o Had SD, MLFS, PR or CR and stopped pembrolizumab treatment after 24 months 
of study therapy for reasons other than disease progression or intolerability 
AND 
 Experienced an investigator-determined bone marrow confirmed disease progression 
after stopping their initial treatment with azacitidine/pembrolizumab 
 Did 
not 
receive 
any 
anti-cancer 
treatment 
since 
the 
last 
dose 
of 
azacitidine/pembrolizumab 
 Has a performance status of 0 or 1 on the ECOG Performance Scale 
 Demonstrates adequate counts and organ function as detailed in Section 5.1.2/5.1.3 
 Female subject of childbearing potential should have a negative serum or urine 
pregnancy test within 72 hours prior to receiving retreatment with study medication.   


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 Female subject of childbearing potential should be willing to use 2 methods of birth 
control or be surgically sterile, or abstain from heterosexual activity for the course of 
the study through 120 days after the last dose of study medication (Reference Section 
5.8.2).  Subjects of child bearing potential are those who have not been surgically 
sterilized or have been free from menses for > 1 year.  
 Male subject should agree to use an adequate method of contraception starting with the 
first dose of study therapy through 120 days after the last dose of study therapy.   
 Does not have a history or current evidence of any condition, therapy, or laboratory 
abnormality that might 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. 
Subjects who restart treatment will be retreated at the same dose and dose interval as when 
they last received pembrolizumab.  Treatment will be administered for up to one additional 
year. 
Visit requirements are outlined in Section 6.0 – Trial Flow Chart and should follow the same 
procedure as for initial treatment. 
 
7.2 
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 products, 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. 
Merck product includes any pharmaceutical product, biological product, device, diagnostic 
agent or protocol-specified procedure, whether investigational (including placebo or active 
comparator medication) or marketed, manufactured by, licensed by, provided by or distributed 
by Merck for human use. 


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Adverse events may occur during the course of the use of Merck product in clinical trials or as 
prescribed in clinical practice, from overdose (whether accidental or intentional), from abuse 
and from withdrawal. 
Progression of the cancer under study is not considered an adverse event.  
 
 
All adverse events that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be 
excluded from the trial, or are the result of a protocol-specified intervention, including but not 
limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. 
From the time of treatment allocation/randomization through 30 days following cessation of 
treatment, all adverse events must be reported by the investigator. Such events will be recorded 
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 7.2.3.1. The 
investigator will make every attempt to follow all subjects with non-serious adverse events for 
outcome. 
Adverse events will not be collected for subjects during the pre-screening period 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. 
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 7.2.3. 
7.2.1 Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Sponsor and to Merck 
For purposes of this trial, an overdose will be defined as any dose exceeding the prescribed 
dose of pembrolizumab or azacitidine by 20% over the prescribed daily dose.  No specific 
information is available on the treatment of overdose of pembrolizumab. Appropriate 
supportive treatment should be provided if clinically indicated. In the event of overdose, the 
subject should be observed closely for signs of toxicity.  Appropriate supportive treatment 
should be provided if clinically indicated. 
If an adverse event(s) is associated with (“results from”) the overdose of a Merck product 
pembrolizumab or the overdose of azacitidine, the adverse event(s) is reported as a serious 
adverse event, even if no other seriousness criteria are met. 


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If a dose of Merck’s product-pembrolizumab or a dose of azacitidine 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 Sponsor and within 2 working days hours to Merck Global Safety. (Attn: Worldwide 
Product Safety; FAX 215 993-1220) 
7.2.2 Reporting of Pregnancy and Lactation to the Sponsor 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), that occurs during the trial. 
Pregnancies and lactations that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be 
excluded from the trial, or are the result of a protocol-specified intervention, including but not 
limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure.   
Pregnancies and lactations that occur from the time of treatment allocation/randomization 
through 120 days following cessation of Sponsor’s product, or 30 days following cessation of 
treatment if the subject initiates new anticancer therapy, whichever is earlier, must be reported 
by the investigator.  All reported pregnancies 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 Coordinating Center (Sponsor) and within 
2 working days to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-
1220) 
7.2.3 Immediate Reporting of Adverse Events to the Sponsor and to Merck 
7.2.3.1 Responsibility for Data Submission 
Study participants are responsible for submitting data and/or data forms to the Coordinating 
Center within two weeks of the completion of the time point.  Adverse event review will be 
performed at a minimum every two weeks on the submission by the coordinating center 
contact and the study chair. 
7.2.3.2 Routine Adverse Event Reporting 
All Adverse Events must be reported in routine study data submissions. AEs reported 
through MedWatch must also be reported in routine study data submissions. 


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7.2.3.2.1 Protocol-Specific Expedited Adverse Event Reporting Exclusions 
For this protocol only, certain AEs/grades are exceptions to the Expedited Reporting 
Guidelines and do not require expedited reporting (i.e., MedWatch).  The following AEs 
must be reported through the routine reporting mechanism. 
Adverse Events 
CTCAE v4.0 
Anemia 
Anemia 
Leukopenia 
White blood cell decreased 
Neutropenic Fever 
Febrile neutropenia with or without 
hospitalization 
Infection 
Infection with Grade 3 or 4 neutrophils with 
or without hospitalization 
Thrombocytopenia 
Platelet count decreased 
 
Grades 3 and 4 adverse events (including hospitalization/prolonged hospitalization) of 
expected events list do not require expedited reporting: 
 Progression of the malignancy should NOT be reported as an AE/SAE unless it is 
considered to be drug related by the investigator.  
 Hospitalization due to signs and symptoms of malignancy progression does NOT 
require reporting as an SAE.  
 
7.2.3.3 Serious Adverse Events 
A serious adverse event is any adverse event occurring at any dose or during any use of study 
drugs 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 an other important medical event  
 Note: In addition to the above criteria, adverse events meeting either of the below 
criteria, although not serious per ICH definition, are reportable to the Merck in the same 


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timeframe as SAEs to meet certain local requirements. Therefore, these events are 
considered serious by Merck for collection purposes. 
● 
Is a new cancer (that is not a condition of the study); 
● 
Is associated with an overdose. 
 
 
Refer to Table 7 for additional details regarding each of the above criteria. 
 
7.2.3.3.1 Reporting Adverse Events to the Institutional Review Board 
The Principal Investigator is required to notify his/her Institutional Review Board (IRB) of a 
serious adverse event according to institutional policy. The requirements for IRB Protocol 
Problem 
Reporting 
at 
Johns 
Hopkins 
are 
can 
be 
found 
at 
this 
website: 
http://www.hopkinsmedicine.org/institutional_review_board/guidelines_policies/guidelines/ 
7.2.3.3.2 Reporting Adverse Events to the Coordinating Center (Sponsor) and to 
Merck Global Safety 
Participating sites will report to the Coordinating Center (Sponsor) all events meeting the 
criteria of serious adverse events utilizing the MedWatch 3500A form within 24 hours of the 
site becoming aware of the event and to Merck Global Safety within 2 working days. The 
Coordinating Center, JHU, as the sponsor of the study, will make the final determination 
regarding FDA submission. Thus, the Coordinating Center will be responsible for reporting to 
the FDA.  
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, 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 (Section 
7.2.3.5) that occurs to any subject must be reported within 24 hours to the Coordinating Center 
(Sponsor) and within 2 working days to Merck Global Safety if it causes the subject to be 
excluded from the trial, or is the result of a protocol-specified intervention, including but not 
limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure.  
For the time period beginning at treatment allocation/randomization through 90 days following 
cessation of treatment, or 30 days following cessation of treatment if the subject initiates new 
anticancer therapy, whichever is earlier, 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 (Section 7.2.3.5) whether or not related to the Merck product, must be reported within 
24 hours to the Coordinating Center (Sponsor) and within 2 working days to Merck Global 
Safety. 


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Additionally, any serious adverse event, considered by an investigator who is a qualified 
physician to be related to Merck product that is brought to the attention of the investigator at 
any time following consent through the end of the specified safety follow-up period specified 
in the paragraph above, or at any time outside of the time period specified in the previous 
paragraph also must be reported immediately to the Coordinating Center and to Merck Global 
Safety. 
All subjects with serious adverse events must be followed up for outcome. 
SAE reports and any other relevant safety information are to be forwarded to the Merck 
Global Safety facsimile number:  +1-215-993-1220 
7.2.3.3.3 FDA Reporting Requirements 
Unexpected Adverse Event: An AE is considered unexpected if the specificity or severity of it 
is not consistent with the applicable product information (e.g., Investigator’s Brochure (IB) for 
an unapproved investigational product or package insert/summary of product characteristics 
for an approved product).  Unexpected also refers to AEs that are mentioned in the IB as 
occurring with a class of drugs or as anticipated from the pharmacological properties of the 
drug, but are not specifically mentioned as occurring with the particular drug under 
investigation.   
7 Calendar-Day Telephone or Fax IND Safety Report 
Serious adverse events (SAEs) that are unexpected, and at least possibly associated to the 
study drugs, as assessed by the Sponsor-Investigator, should be reported promptly to the Food 
and Drug Administration (FDA) by telephone or by fax. Fatal or life threatening SAEs that 
meet the criteria for reporting to the FDA must be reported to the FDA within 7 calendar 
days after awareness of the event. 
 
15 Calendar-Day Written IND Safety Report 
The Sponsor-Investigator is required to notify the FDA, and all participating investigators in a 
written IND Safety Report, of any serious, unexpected adverse event considered by the 
Sponsor-Investigator to be possibly related to the use of study drugs within 15 calendar-days 
of first learning of the event. If applicable, the Sponsor-Investigator must also notify the FDA, 
and all participating investigators, of any finding from tests in laboratory animals that suggests 
a significant risk for human subjects including reports of mutagenicity, teratogenicity, or 
carcinogenicity within 15 calendar-days of first learning of the event. 
All other SAEs that meet the criteria for reporting to the FDA must be reported to the FDA 
within 15 calendar days after awareness of the event. A clear description of the suspected 
reaction should be provided along with an assessment as to whether the event is drug or disease 
related. 
A copy of all 15 Day Reports and Annual Progress Reports is submitted as required by FDA, 
European Union (EU), Pharmaceutical and Medical Devices agency (PMDA) or other local 
regulators. Investigators will cross reference this submission according to local regulations to 


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the Merck Investigational Compound Number (IND, CSA, etc.) at the time of submission.  
Additionally investigators will submit a copy of these reports to Merck & Co., Inc. (Attn: 
Worldwide Product Safety; FAX 215 993-1220) at the time of submission to FDA. 
All subjects with serious adverse events must be followed up for outcome. 
7.2.3.4 Events of Clinical Interest 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest 
(ECI) and must be reported within 24 hours to the Sponsor and within 2 working days to Merck 
Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220)  
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, any ECI, or follow up to an ECI, that occurs to any subject must be 
reported within 24 hours to the Sponsor and within 2 working days to Merck Global Safety if 
it causes the subject to be excluded from the trial, or is the result of a protocol-specified 
intervention, including but not limited to washout or discontinuation of usual therapy, diet, 
placebo treatment or a procedure. 
For the time period beginning at treatment allocation/randomization through 90 days following 
cessation of treatment, or 30 days following cessation of treatment if the subject initiates new 
anticancer therapy, whichever is earlier, any ECI, or follow up to an ECI, whether or not related 
to Merck product, must be reported within 24 hours to the Sponsor and within 24 hours to 
Merck Global Safety. 
Events of clinical interest for this trial include: 
1.  an overdose of Merck product, as defined in Section 7.2.1 - Definition of an Overdose for 
This Protocol and Reporting of Overdose to the Sponsor, 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). 
7.2.3.5 Protocol-Specific Exceptions to Serious Adverse Event Reporting  
Efficacy endpoints as outlined in this section will not be reported to Merck as described in 
Section 7.2.3.- Immediate Reporting of Adverse Events to the Sponsor and to Merck, unless 


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there is evidence suggesting a causal relationship between the drug and the event. Any such 
event will be submitted to the Sponsor within 24 hours and to Merck Global Safety within 2 
working days either by electronic or paper media. 
Specifically, the suspected/actual events covered in this exception include any event that is 
disease progression of the cancer under study. 
The Sponsor will monitor unblinded aggregated efficacy endpoint events and safety data to 
ensure the safety of the subjects in the trial. Any suspected endpoint which upon review is not 
progression of the cancer under study will be forwarded to Merck Global Safety as a SAE 
within 2 working days of determination that the event is not progression of the cancer under 
study 
Hospitalization related to convenience (e.g. transportation issues etc.) will not be considered a 
SAE. 
7.2.4 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 7.  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 Merck 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 for an elective procedure to treat a preexisting condition that has not 
worsened is not a serious adverse event A pre-existing condition is a clinical condition that is diagnosed prior to the use of a Merck product and is documented in the 
patient’s medical history.); 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) (although not serious per ICH definition, is reportable to the Sponsor within 24 hours and to Merck within 2 
working days to meet certain local requirements); or  
 
Is an overdose (whether accidental or intentional).  Any adverse event associated with an overdose is considered a serious adverse event for collection purposes. 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 to the Coordinating 
Center and to Merck within 2 working days.
 
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 Merck product to be discontinued? 
Relationship to 
Merck Product 
Did Merck product cause the adverse event? The determination of the likelihood that Merck 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 Merck product and the AE; the greater the correlation with the components and 
their respective elements (in number and/or intensity), the more likely Merck product caused the adverse event (AE): 
 
Exposure 
Is there evidence that the subject was actually exposed to Merck 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 Merck 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 Merck 
product 
(continued)  
Dechallenge 
Was Merck 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 Sponsor’s product; or (3) the trial is a single-dose drug trial); or (4) Sponsor’sproduct(s) is/are only used one time.) 
 
Rechallenge 
Was the subject re-exposed to Merck 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) Sponsor’s  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 MERCK PRODUCT, OR IF REEXPOSURE TO MERCK PRODUCT POSES ADDITIONAL POTENTIAL SIGNIFICANT 
RISK TO THE SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE SPONSOR 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 Merck 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 Merck product relationship). 
Yes, there is a reasonable 
possibility of Merck product 
relationship. 
There is evidence of exposure to Merck product.  The temporal sequence of the AE onset relative to the administration of Merck product is 
reasonable.  The AE is more likely explained by the Merck product than by another cause. 
No, there is not a reasonable 
possibility of Merck product 
relationship 
Subject did not receive the Merck product OR temporal sequence of the AE onset relative to administration of Merck product is not reasonable 
OR the AE  is more likely explained by another cause other than the Merck product.  (Also entered for a subject with overdose without an 
associated AE.) 


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7.2.5 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 and as documented in the Section 7.2.  
7.2.6 Reporting Protocol Deviation 
Except for an emergency situation in which proper care for the protection, safety, and well-being of the 
study patient requires alternative treatment, the study shall be conducted exactly as described in the 
approved protocol.   
The term “protocol deviation” is not defined by either the HHS human subjects regulations (45 CFR 46) 
or the FDA human subjects regulations (21 CFR 50). For JHM purposes, a protocol deviation is a minor 
or administrative departure (see definitions below) from the protocol procedures approved by the IRB 
that was made by the PI without prior IRB approval. Please note:  Eligibility exceptions (or eligibility 
waivers granted by a Sponsor) for enrollment of a specific individual who does not meet the 
inclusion/exclusion criteria in the IRB approved protocol are not deviations.  Eligibility exceptions are 
considered changes in research that require IRB review and approval before a subject who does not meet 
the approved protocol inclusion/exclusion criteria may be enrolled. 
Reporting Protocol Deviations to the JHM IRB and the Sponsor 
There are several types of deviations from protocol procedures recognized by the JHM IRB, and each 
type has a different IRB reporting requirement: 
A. Protocol deviations that constitute unanticipated problems involving risks require prompt 
reporting to the JHM IRB:  A protocol deviation that constitutes an “unanticipated problem 
involving risks to subjects or to others” (see Policy No. 103.6(b) for the definition of an 
unanticipated problem) must be reported promptly to the IRB, as follows:1. Emergency deviations: 
When a deviation occurs in an emergency situation, such as when a departure from the protocol is 
required to protect the life or physical well-being of a participant. The Sponsor (JHU Principal 
Investigator) and the reviewing IRB must be notified as soon as possible, but not later than 5 days 
after the emergency situation occurred (21 CFR 812.150(a)(4)). Once IRB’s response is received, 
this should be forwarded to the Coordinating Center Regulatory Specialist. 
2. Major, non-emergent deviations without prior approval: A planned deviation that is non-
emergent and represents a major change in the protocol as approved by the IRB. The Sponsor (JHU 
Principal Investigator) and the IRB must approve the request before the proposed change is 
implemented. Once IRB’s response is received, this should be forwarded to the Coordinating 
Center Regulatory Specialist. If a major, non-emergent deviation occurs without prior IRB 
approval the event is considered non-compliance. Non-compliance must be reported to the IRB 
promptly.  
B.  Protocol deviations that are only minor or administrative: At JHM, minor or administrative 
protocol deviations are defined as those which do not “affect the scientific soundness of the 
research plan or the rights, safety, or welfare of human subjects.”  If a protocol deviation occurs 
which meets this definition, the deviation should be reported to the JHM IRB at the time the 
continuing review application is submitted. Participating sites should record deviation on the 


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deviation form and provide it to the Sponsor and to the IRB according to the local IRB 
requirements. Examples of minor or administrative deviations could include:  follow up visits that 
occurred outside the protocol required time frame because of the participant’s schedule, or blood 
samples obtained at times close to but not precisely at the time points specified in the protocol. 
Protocol Deviation Reporting Requirements for Commercially Sponsored Research 
Sponsored research agreements may require the PI to notify the sponsor of all unplanned deviations or 
departures from IRB approved protocol procedures. Sponsor reporting requirements for deviations may 
differ from JHM IRB reporting requirements. It is the PI's responsibility to comply with the reporting 
requirements outlined in the signed contract. 
 
8.0 STATISTICAL ANALYSIS PLAN 
8.1 
Statistical Analysis Plan Summary 
This multi-center, nonrandomized, open-label Phase II study will enroll two cohorts of patients: 1) Cohort 
1: relapsed/refractory AML, and 2) Cohort 2: newly diagnosed AML in older (≥65 years) patients not 
candidates for induction chemotherapy. 
8.2 
Statistical Analysis Plan 
8.2.1 Safety Run-In 
Each cohort will be enrolled separately with distinct null hypotheses and statistical plans.  Since 
azacitidine and pembrolizumab have not been tested previously in combination in AML patients, we plan 
first to start enrollment with Cohort 1 (a safety run-in phase). Recognizing that Cohort 1 may also include 
patients who relapsed after allogeneic hematopoietic stem cell transplant (alloHSCT) and thus may have 
differential sensitivity (tolerability, immune-related adverse events [IRAEs]) to this drug combination, 
we will start enrollment in Cohort 1 to include patients who did not have prior alloHSCT.  
The primary objective of the safety run-in is to determine the safety and tolerability of AZA followed by 
pembrolizumab in relapsed and refractory AML using a 3+3 design. We plan to monitor for DLTs in 
cycles 1, 2 and 3 as some of immunological side effects associated with pembrolizumab may occur with 
the delay. The first three patients will be enrolled and receive planned azacitidine and pembrolizumab in 
cycle 1. If 0 or 1 patient of the first three patients has a DLT (dose limiting toxicity) in cycle 1, we will 
enroll an additional 3 patients to better assess for toxicities. If less than 2 among first 6 patients 
experiences DLT in the cycle 1-3, we will open enrollment in Cohort 1 for all relapsed/refractory patients 
including those with prior history of alloHSCT and will also start to enroll patients in Cohort 2. If ≥2 of 
the first 3 patients or ≥2 of 6 patients have DLTs during cycle 1, we will perform safety (detailed toxicity) 
review to assess for disease versus treatment-related toxicities. Given that pembrolizumab is given only 
once in cycle 1 (day 8), we will first dose de-escalate azacitidine as detailed in Section 2.2. However, if 
the safety data analysis suggests that the toxicities are more likely pembrolizumab related, an alternative 
approach we may take is to exclude pembrolizumab in cycle 1 and start pembrolizumab dosing in cycle 
2 when AML is better controlled but maintain azacitidine dose/schedule as described in Section 2.2. If 


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≤1 of the 6 patients experience DLTs during cycle 1 but ≥ 2 of 6 patients experience DLTs during cycle 
2 and cycle 3, or cycle 1, 2 and 3, we will first dose de-escalate pembrolizumab as described in Section 
2.2 and maintain azacitidine dose/schedule. When each dose de-escalation occurs (maximum 2), 
additional 6 patients will be enrolled at that dose level. For the details of dose de-escalation, please see 
Section 2.1 and 2.2 Trial Diagram.  
Only after a safe dose/schedule is defined will we start enrollment in the phase 2 cohorts. A full safety 
assessment of the combination of AZA and pembrolizumab will be performed in all patients after 1, 2 
and 3 cycles and in subsequent cycles according to the NCI Common Terminology Criteria for Adverse 
Events (CTCAE), version 4.0. Patients who are treated at dose/schedule selected for Phase 2 will be 
included in the primary efficacy analysis and the analyses of secondary and exploratory objectives. 
8.2.2 Sample Size  
The primary objective of this study is to estimate the complete response (CR/CRi) rate in each cohort. 
We estimated sample sizes for the 2 cohorts using a one-sample, one-sided binomial test, with Type I and 
Type II errors of 0.05 and 0.2, respectively. For Cohort 1, the null and expected response rates were taken 
to be 0.1 and 0.25, respectively. For Cohort 2, the null and expected response rates were taken to be 0.17 
and 0.34, respectively.  The sample sizes were calculated to be 38 (which will be rounded to 40) and 40 
for Cohorts 1 and 2, respectively.   
We used an efficient and flexible design based on Bayesian predictive probability (Lee and Liu, 2008). 
This design controls the type I and type II error rates and also allows flexible monitoring for futility and 
efficacy of the new treatment. Furthermore, this design also has better sampling properties than Simon’s 
2-stage design, i.e. probabilities of early termination for futility under the null hypothesis and for efficacy 
under the alternate hypothesis are higher and the expected sample size is lower than Simon’s 2-stage 
design.  
The following input parameters were assumed in our design: minimum and maximum number of patients 
was 10 and 40, respectively. Type I and II errors were 0.1 and 0.2, respectively.  For cohort 1, the 
treatment effect for current standard was 0.1 (i.e., probability of CR/CRi) and expected treatment effect 
for the new treatment was 0.25.  For cohort 2, the treatment effect for current standard was 0.17 and 
expected treatment effect for the new treatment was 0.34.  A beta (0.25, 0.75) distribution was assumed 
for the prior for the expected effect of the new treatment. This is a weak prior, which has negligible effect 
on the stopping boundaries.   
The stopping boundaries for futility are given in the tables below for cohorts 1 and 2.  For example, the 
first row of Table 1 indicates that we would stop the trial for futility if we see 0 responses (CR/CRi) out 
of the first 10 patients after 6 cycles of therapy (to be evaluable for futility pts must complete at least 2 
cycles of therapy); if the study was not stopped after 10 patients, the next evaluation will be done after 
14 patients (2nd row).  Study will be stopped for futility if we see 1 response or less for futility.  If the 
study continues, the next evaluation happens after 21 patients (3rd row).  Study will be stopped if we see 
2 or fewer responses in the first 21 patients.  
Cohort 1:  Interim monitoring boundaries for stopping for futility. 


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______________________________________ 
Patient. No.      
Futility boundary   
   
                                    (less than or equal to) 
______________________________________ 
 10             
 
0            
    
 14             
 
1             
  
 21             
 
2  
 
  
 27             
 
3             
 
 32             
 
4             
 
 36             
 
5             
 
 40             
 
6             
 
______________________________________ 
 
Cohort 2:  Interim monitoring boundaries for stopping for futility. 
_____________________________________ 
Patient. No.      
Futility boundary   
 
                                    (less than or equal to) 
______________________________________ 
 10             
 
0            
   
 11             
 
1             
   
 16             
 
2             
  
 20             
 
3             
  
 24             
 
4             
  
 27             
 
5             
  
 31             
 
6             
  
 34             
 
7             
  
 36             
 
8             
  
 39             
 
9             
  
 40             
 
10             
 
___________________________________ 
For cohort 1, the expected sample size under the null and alternative hypotheses is 17.7 and 18.3, 
respectively.  For cohort 2, these were 19.2 and 21.0. 
 
8.2.2.1 Early stopping guideline for toxicity 
Toxicity will be monitored after every 5 patients for each cohort. If it becomes evident that the 
proportion of patients being removed from the study for toxicity convincingly exceeds 20%, the study 
will be halted for a safety consultation. The toxicity stopping rule will hold enrollment if the posterior 
probability of failure being larger than 0.20 is 70% or higher. The prior for this monitoring rule is 
beta(0.5,2). This means that our prior guess at the proportion of failures is 20%, and there is 90% 
probability that this proportion is between 0.01% and 65.8%. The monitoring rule and operating 
characteristics are given below.  
 
- Stop if 2 out of 5 patients removed from study: Pr(Risk>0.2 | Data) = 0.77 
- Stop if 3 out of 10 patients removed from study: Pr(Risk>0.2 | Data) = 0.715 


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- Stop if 5 out of 15 patients removed from study: Pr(Risk>0.2 | Data) = 0.852 
- Stop if 6 out of 20 patients removed from study: Pr(Risk>0.2 | Data) = 0.823 
- Stop if 7 out of 25 patients removed from study: Pr(Risk>0.2 | Data) = 0.8 
- Stop if 8 out of 30 patients removed from study: Pr(Risk>0.2 | Data) = 0.781 
- Stop if 9 out of 35 patients removed from study: Pr(Risk>0.2 | Data) = 0.766 
- Stop if 10 out of 40 patients removed from study: Pr(Risk>0.2 | Data) = 0.752 
 
Operating Characteristics of stopping rule for toxicity, based on 5000 simulations: 
True Toxicity 
Rate 
Probability of declaring 
treatment too toxic 
Average sample size 
5% 
10% 
15% 
20% 
25% 
30% 
35% 
40% 
2.9% 
11.5% 
28.9% 
51.1% 
73.1% 
86.8% 
95.9% 
98.8% 
34.1 
31.8 
27.6 
22.8 
17.8 
14.0 
10.7 
8.6 
 
8.2.2.2 Early Stopping for Safety 
The clinical failure of acute graft versus host disease will be monitored after every 5 patients who had a 
prior history of alloHSCT. If it becomes evident that the proportion of acute graft versus host disease 
grade 2-4 is greater than 33% the study would also be held for a safety consultation.  
 
The acute GVHD grade 2-4 stopping rule will hold enrollment if the posterior probability of failure 
being larger than 0.33 is 70% or higher. The prior for this monitoring rule is beta(1,2).   This means that 
our prior guess at the proportion of failures is 33%, and there is 90% probability that this proportion is 
between 2.5% and 77.6%. The monitoring rule and operating characteristics are given below. 
 
- Stop if 3 out of 5 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.832 
- Stop if 5 out of 10 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.829 
- Stop if 7 out of 15 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.836 
- Stop if 8 out of 20 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.719 
- Stop if 10 out of 25 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.746 
- Stop if 12 out of 30 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.77 
- Stop if 14 out of 35 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.79 
- Stop if 15 out of 40 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.709 
- Stop if 17 out of 45 patients with gr2-4 aGVHD: Pr(Risk>0.33 | Data) = 0.735 
 


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True acute GVHD 
grade 2-4 rate 
Probability of stopping 
for excess GVHD grade 2-4
Average 
Sample Size 
10% 
15% 
20% 
25% 
30% 
35% 
40% 
45% 
1.0% 
3.2% 
9.2% 
22.3% 
40.7% 
62.7% 
80.8% 
92.7% 
39.7 
39.0 
37.3 
33.9 
29.4 
24.2 
19.1 
14.5 
 
8.2.3 Analysis of Primary Endpoint 
 
The primary objective of this study is to estimate the complete remission (CR/CRi) rate of AZA 
followed by pembrolizumab in 1) relapsed/refractory AML patients, and 2) older (≥65 years) newly 
diagnosed AML patients not candidates for intensive induction chemotherapy.  The CR/CRi rate will be 
reported with an exact binomial, two-sided, 95% confidence interval, separately by each cohort.  We 
will test for heterogeneity of the treatment effect between cohorts using an interaction test, and if there 
is no evidence of heterogeneity, we will pool all patients treated at the phase II dose/schedule and 
estimate the CR/CRi rate with an exact binomial, two-sided, 95% confidence interval. 
 
8.2.4 Analysis of Secondary Endpoints 
The toxicity of AZA followed by pembrolizumab in 1) relapsed/refractory AML patients, and 2) older 
(≥65 years) newly diagnosed AML patients not candidates for intensive induction chemotherapy will 
described separately for each cohort using summary statistics. 
 
The overall response rate, defined as CR/CRi/partial response (PR)/ morphologic leukemia-free state 
(MLFS)/hematologic improvement (HI) of AZA followed by pembrolizumab, will be estimated for 
each cohort separately and reported with exact 95% confidence intervals. 
 
Disease-free survival (DFS) and overall survival (OS) will be estimated and plotted for patients who 
achieve a CR/CRi, separately by cohort, using the Kaplan Meier method.  DFS will be defined as the 
time from CR/CRi to either progression, relapse, death (event) or last follow-up date (censored).  OS 
will be defined as the time from study initiation to either death (event) or last follow-up date (censored). 
 
Progression-free survival (PFS), time to progression, and OS will be estimated and plotted for all 
patients, separately by cohort, using the Kaplan Meier method.  PFS will be defined as the time from 
study initiation to progression or death (event) or last follow-up date (censored).  The cumulative 
incidence of progression will be estimated for each cohort (Prentice RL and Kalbfleisch JD. The 


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analysis of failure times in the presence of competing risks, Biometrics, 34: 541-554. 1978). Death will 
be considered a competing risk for progression. 
 
8.2.5 Analysis of Correlative Endpoints 
We will perform multi-color flow cytometry on PB and BM specimens before and after AZA and 
AZA/pembrolizumab treatment using three pre-determined panels of mAbs including but not limited to 
those specific for CD3, CD4, CD8, PD-1, CD45RA, CCR7, CD27, CD28, Ki-67, T-bet, CD127, CD25, 
FoxP3, HLA-DR, CTLA-4, TNFRII, ICOS, TIM3, LAG-3, CD160, 2B4, BTLA, KLRG-1, CD16, 
CD14, and CD56.  The analyses of pre- and post-treatment PB and BM specimens for immune 
parameters will be descriptive and graphical in nature.  Data will be summarized for each cohort 
separately.  The change in flow values at each time point after AZA and AZA/pembrolizumab relative 
to the baseline value will be will checked for skewness and log-transformed as appropriate.  The 
changes will be modeled using mixed-effects, linear regression models that included fixed effects for 
time and a random effect for the patient to account for within-patient correlation of measurements.  To 
explore potential differences in the change in flow values across patient subgroups, interaction terms 
will be included in the regression models.  Post-treatment PD changes in gene expression and 
methylation in immune gene signaling circuits in tumor biopsies and PB will be summarized with 
descriptive statistics and correlated with clinical outcomes. 
 
9.0 LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL SUPPLIES 
9.1 
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 7. 
Table 7 Product Descriptions 
Product Name & Potency 
Dosage Form 
Pembrolizumab 50 mg 
Lyophilized Powder for Injection 
Pembrolizumab 100 mg/ 4mL 
Solution for Injection 
 
9.2 
Packaging and Labeling Information 
Clinical supplies will be affixed with a clinical label in accordance with regulatory requirements. 


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9.3 
Clinical Supplies Disclosure 
This trial is open-label; therefore, the subject, the trial site personnel, the Sponsor 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. 
9.4 
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. 
9.5 
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 arrange for 
disposal of all empty containers, provided that procedures for proper disposal have been established 
according to applicable federal, state, local and institutional guidelines and procedures, and provided that 
appropriate records of disposal are kept. 
10.0 ADMINISTRATIVE AND REGULATORY DETAILS 
10.1 Confidentiality 
The subject has a right to protection against invasion of privacy.   In compliance with   United   States   
federal   regulations,  the Investigator   may   permit representatives of Merck and, when necessary, 
representatives of the FDA or other regulatory authorities to review and/or copy any medical records 
relevant to the study in accordance with local laws. 
Should direct access to medical records require a waiver or authorization separate from the subject’s 
statement of informed consent, it is the responsibility of the Investigator to obtain such permission in 
writing from the appropriate individual. 
10.2 Compliance with Financial Disclosure Requirements 
All investigators on the study are expected to maintain up-to-date financial disclosures. Investigators at 
Johns Hopkins will report their financial disclosures through the Johns Hopkins electronic disclosure 
monitoring system. 


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10.3 Compliance with Law, Audit and Debarment 
The protocol for this study has been designed in accordance with the general ethical principles outlined 
in the Declaration of Helsinki.   The review of this protocol by the IRB/EC and the performance of 
all aspects of the study, including the methods used for obtaining informed consent, must also be in 
accordance with principles enunciated in the declaration, as well as ICH Guidelines, Title 21 of the 
Code of Federal Regulations (CFR), Part 50 Protection of Human Subjects and Part 56 Institutional 
Review Boards. 
It is expected that the IRB will have the proper representation and function in accordance with federally 
mandated regulations.  The IRB should approve the consent form and protocol. 
The SKCCC at Johns Hopkins will be coordinating center for this study. The following documentation 
must be provided to the Clinical Research Office (CRO) at the Johns Hopkins SKCCC prior to a 
participating site being authorized to enroll patients: 
 Letter of Understanding 
 IRB protocol approval letter: the letter must include the protocol name, version, and dates of 
protocol approval and expiration 
 IRB approved consent form: the entire consent form must be submitted and must include the 
protocol name and date of approval 
 IRB membership list, if available 
 OHRP Federal Wide Assurance number 
  Form FDA 1572 appropriately filled out and signed with appropriate documentation (NOTE: this 
is required if JHU holds the IND.  Otherwise, the Investigator’s signature documenting 
understanding of the protocol and providing commitment that this trial will be conducted 
according to all stipulations of the protocol is sufficient to ensure compliance) 
 Curriculum vitae, signed and dated within the last two years, of all investigators and sub-
investigators 
 Medical license for all investigators and sub-investigators 
 Financial disclosure forms, if appropriate 
 Human Subjects Training certification for all study personnel 
 Laboratory certification and normal ranges 
 
This protocol will adhere to the policies and requirements of the Multicenter Guidelines. The specific 
responsibilities of the Principal Investigator (Protocol Chair) and the Coordinating Center (Study 
Coordinator) and the procedures for auditing are presented in Appendix 11.6. 
The Protocol Chair (Principal Investigator at JHU SKCCC- Coordinating Center) will be responsible for 
preparing documents for submission to the JHU IRB and obtaining written approval for this study.  The 
approval will be obtained prior to the initiation of the study. Should amendments to the protocol be 
required, the amendments will be originated and documented by the Protocol Chair (Principal Investigator 
at JHU- SKCCC – Coordinating Center).  It should also be noted that when an amendment to the protocol 
substantially alters the study design or the potential risk to the patient, a revised consent form might be 


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required.  The Principal Investigator/Coordinating Center is responsible for distributing all IND Action 
Letters or Safety Reports to all participating institutions for submission to their individual IRBs for action 
as required. 
The Principal Investigator at the participating site must submit the JHU IRB approved protocol, informed 
consent, and amendment to their institution’s IRB for approval.  For multi-center studies, any 
participating site must submit their informed consent revisions to the JHU-SKCCC Regulatory Associate 
prior to submission to their IRB. 
The approval for both the protocol and informed consent must specify the date of approval, protocol 
number and version, or amendment number. 
The Principal Investigator is also responsible for notifying the IRB of any serious deviations from the 
protocol, or anything else that may involve added risk to subjects. Any advertisements used to recruit 
subjects for the study must be reviewed and approved by the IRB prior to use.    
10.4 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.     
10.5 Quality Management System 
This is a DSMP Level II study under the SKCCC Monitoring Plan (9/22/2011). A Level II study requires 
both internal and external data monitoring. The Principal Investigator is responsible for internal 
monitoring for both safety and data quality. External data monitoring will be performed by the SKCCC 
at Johns Hopkins Clinical Research Office Quality Assurance Program (CRO QA). A DSMP Level 2 
study requires that 100% of all subjects will be reviewed for consent and eligibility, while at least 30% 
of all subjects will be monitored in their entirety. Scheduled monitoring visits will occur at least every 6 
months, but may occur more (or less) frequently, depending on the rate of accrual. Data and safety 
monitoring oversight will be conducted by the SKCCC at Johns Hopkins Safety Monitoring Committee. 
Per the SKCCC at Johns Hopkins Safety Monitoring Plan, the CRO QA will forward summaries of all 
monitoring reports to the Safety Monitoring Committee for review. All reportable anticipated and 
unanticipated protocol events/problems and amendments that are submitted to the IRB will also be 
reviewed by the Safety Monitoring Committee Chair (or designee) and QA manager. Monitoring review 
plan: The PI will review data to assure the validity of data, as well as, the safety of the subjects. The PI 
will also monitor the progress of the trial. The PI will review safety reports and clinical trial efficacy 
endpoints and to confirm that the safety outcomes favor continuation of the study. The PI will be 
responsible for maintaining the clinical protocol, reporting adverse events, assuring that consent is 
obtained and documented, reporting of unexpected outcomes, and reporting the status of the trial in the 
annual report submitted to the IRB and the semi-annual report to the SMC. Content of the report at a 


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minimum should include year-to-date and full trial data on: accrual and eligibility, protocol compliance, 
treatment administration, toxicity and ADR reports, response, survival, regulatory compliance, 
compliance with prearranged statistical goals. 
10.6 Data Management 
All information will be collected on study-specific case report forms (CRFs) by study staff. These data 
will be reviewed for completeness and accuracy by the Principal Investigator. Case report forms will be 
provided to the data managers at each participating center. All data relating to a particular cycle of therapy 
must be completed within two weeks of the completion of the time point. The importance of protocol 
adherence and accurate data collection requires that each center have a specifically designated research 
nurse and data manager assigned to the study. The Principal Investigator and Research Nurse at SKCCC 
will be available by phone, e-mail, and pager for protocol and patient management questions. The data 
manager at SKCCC will be responsible for ensuring compliance with data reporting. Upon patient 
registration (accomplished by faxing a form to SKCCC), the SKCCC data manager will establish a 
projected calendar for patient treatment and submission of data to SKCCC. This calendar will be 
transmitted to the data manager at the treating center. If an expected data collection form is not received 
a week following the expected “due date”, the SKCCC manager will contact the data manager at the 
treating center. If the data is 30 days overdue, a warning letter will be sent to the data manager and 
principal investigator at the treating center. If data is greater than 60 days delinquent, the center’s ability 
to enroll new patients will be suspended until the situation is rectified, and a corrective plan is established.  
10.7 Record Retention 
Study documentation includes all eCRFs, data correction forms or queries, source documents, Sponsor-
Investigator correspondence, monitoring logs/letters, and regulatory documents (e.g., protocol and 
amendments, IRB correspondence and approval, signed patient consent forms). 
Source documents include all recordings of observations or notations of clinical activities and all reports 
and records necessary for the evaluation and reconstruction of the clinical research study. 
Government agency regulations and directives require that all study documentation pertaining to the 
conduct of a clinical trial must be retained by the study investigator.  In the case of a study with a drug 
seeking regulatory approval and marketing, these documents shall be retained for at least two years after 
the last approval of marketing application in an International Conference on Harmonization (ICH) region; 
or if an application is not approved for drug, until 2 years after shipment and delivery of the drug for 
investigational use is discontinued and the FDA so notified.” In all other cases, study documents should 
be kept on file until three years after the completion and final study report of this investigational study. 
 
 


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11.0 APPENDICES 
11.1 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. 
 
11.2 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) 
11.3 Response Evaluation Criteria in Acute Myeloid Leukemia  
Response will be assessed using the International European LeukemiaNet Guidelines in AML2017 63 and 
IWG Modified Response Criteria (2006) for MDS (for definition of HI)64. 
Dohner H, Estey EH, Amadori S, et al. Diagnosis and management of AML in adults: 2017 ELN 
recommendations from an international expert panel. Blood. 2016 :blood-2016-08-733196; Updated 
guidelines for 2017 available at http://www.bloodjournal.org/content/early/2016/11/28/blood-2016-08-
733196). 
 
Cheson BD, Greenberg PL, Bennett JM, et al. Clinical application and proposal for modification of the 
International Working Group (IWG) response criteria in myelodysplasia. Blood 2006;108(2); 419-25.


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11.4  Operating Procedures for Specimen Collection 
Peripheral blood and bone marrow specimen collection will be performed as delineated in the 
Trial Flow Chart Section 6.0. and at the times when peripheral blood and bone marrow 
collections are performed for clinical care. Please see details in the Laboratory Manual. 
 
Bone marrow: 5x8.5mL will be collected in light yellow  top ACD tubes (or 4x10mL green 
top heparin tubes) (~40 mL) . Re-adjustment of the direction of bone marrow aspirate 
needle should take a place after each 10 cc is collected to prevent hemodilution. At 
the time of collection, green top tubes must be thoroughly mixed to prevent clotting. 
Peripheral blood: 5x8.5mL light yellow topACD tubes (or 4x10mL green top heparin tubes) 
of blood (~40mLs) will be collected at each time point. 
Specimens should be labeled with the patient’s study number (given at the time of 
registration), study number, sample collection date and time, and sample source (PB 
or BM). Sample collection date and time, and sample source (PB or BM) will be 
recorded on correlative collection worksheet and copy included with delivery. All data 
should be kept in laboratory log. At each sampling time, BM and PB mononuclear cells 
(PBMC) will be processed via Ficoll density gradient centrifugation. The washed cells 
will be counted, triaged for DNA isolation, and viably cryopreserved using a 
controlled-rate freezer with transfer to the vapor phase of liquid nitrogen for long-
term storage.  
 
The Sidney Kimmel Comprehensive Cancer Center (SKCCC) specimens should be 
delivered to the Luznik laboratory immediately after collection.  
 
Specimen collection / processing (Participating Sites). Participating sites should collect 
PB and BM specimens as outlined in the Trial Flow Chart 6.0. Participating sites have 
two options: 
1) To process specimens following the SOP described below. Samples will be stored 
at each study site. Any samples collected under the clinical protocol will be batch 


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shipped on dry ice based on discussions with the participating site PI, Study Chair and 
Dr. Luznik. 
 
2) If participating site does not have capability of processing the specimens as 
described below, then specimens can be shipped overnight to Dr. Luznik laboratory 
using cold shipping packages (boxes) provided by Fedex. Please notify PI (Study Chair), 
study coordinator and Dr. Luznik’s laboratory of specimen shipment. 
 
Shipping of Specimen(s) 
The samples will be processed, stored and analyzed in Dr. Luznik’s laboratory at the SKCCC 
at Johns Hopkins University. Upon request of the Study Chair they will be batch shipped 
to SKCCC. Samples will be shipped or delivered to Dr. Luznik laboratory: 1650 Orleans 
Street, CRB1 Rm 216, Baltimore MD 21287. Tel: (410) 955-8567 
 
Freezing Protocol (SOP) 
 
1. Prepare 50mL falcon tubes with Ficoll density grade media (Histopaque) 
 Ratio Ficoll : blood should be 1:1 
 Do not exceed 20mL Ficoll to 20mL blood (i.e. total volume of 40mL) 
 
2. Slowly layer blood on top of Ficoll 
 Use whole blood or marrow aspirate, do not dilute with PBS or anything else 
 Be careful not to mix the two 
layers 
 
3. Centrifuge: spin at the following settings: 
 1240rpm (=364G) 
 20 Celsius 
 Break off 
 30min 
 


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4. Prepare 6 small Eppendorf tubes 
 Take off 6 x 500ul of plasma (top layer; blood only; not for BM aspirate) and 
put it into Eppendorf tubes 
 Be careful not to get into any layer but the plasma layer 
 Long term storage in -80 Celsius freezer 
 
5. Soak up PBMC layer with transferring pipette and put it into a new 50mL Falcon tube 
 Fill up with PBS up to 45mL, vortex 
 Centrifuge: Spin at 1240 rpm (=364G), 4 Celsius, break high, for 5 minutes 
 
6. First wash 
 Dump supernatant 
 In case of visible RBC contamination add 1Ml of lysing buffer to the cell 
pellet, vortex, and leave for 1 minute. Then add 20mL of PBS 
 If there is no RBC contamination only add 20mL of PBS and vortex 
 Centrifuge: Spin at 1240 rpm (=364G), 4 Celsius, break high, for 5 minutes 
 
7. Second wash 
 Dump supernatant 
 just add 20mL of PBS and vortex 
 Centrifuge: Spin at 1240 rpm (=364G), 4 Celsius, break high, for 5 minutes 
 
8. Count cells 
 Dump supernatant 
 add 1mL of PBS and vortex thoroughly 
 take 10ul out and mix with 90ul of trypan blue 
 count in hematocytometer  
 
9. Prepare freezing tubes and media 
 Put cells in the meantime on ice 
 Freezing media: FBS containing 10% DMSO 
 1.8mL vials labeled with study #, timepoint, cell count, date, type of 
specimen, 
 


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10. Final spin 
 Add 20ml of PBS to the cells, vortex  
 Centrifuge: Spin at 1240 rpm (=364G), 4°C, break high, for 5 minutes 
 
11. Freeze cells - General rules 
 PBMCs: 1.5mL freezing media per 10 million cells (=1 vial) 
 BMMCs: 1.5mL freezing media per 30 million cells (=1 vial) 
 
12. Freezing 
 Put vials into Mr. Frosty® (container with Ethanol, that gradually cools down 
samples) and put into -80 Celsius fridge for about 24 hours 
 After 24 hrs (up to 48hrs) transfer vials into liquid nitrogen tanks (to minimize 
temperature fluctuations make sure you transport them there on dry ice) 
 
Considerations regarding freezing and shipping 
 
 
Samples should optimally be processed the same day  
 
If there is a sample coming in late, keep it in the fridge (in 4◦C) overnight and process 
them early the next morning.  
 
Samples processed  should be stored in -80 Celsius for 24-48 hours and get transferred 
into liquid nitrogen thereafter 
 
As soon as there is a good amount of samples accumulated, samples should be shipped 
(Fedex) in batches on dry ice to  
 
Luznik Lab 
Hopkins CRB1, Room 216 
1650 Orleans Street 
Baltimore, MD 21287 
  


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 
If there are no liquid nitrogen tanks available, it’s ok to keep samples in -80 Celsius for 
up to 2 weeks, but no longer. Shipments to Hopkins should then be done more 
frequently. 
 
Important considerations: 
1. All work should be done using standard BSL2 procedures (blood and body fluid 
precautions). 
2. Maintain a clean workspace and use a containment laminar airflow hood when possible. 
3. Minimize the chance of contamination. 
4. Work quickly but methodically. 
5. Keep tubes closed as much as possible and work quickly. 
6. Change gloves frequently and maintain situational awareness. 
 
 
 
11.5   Multicenter Guidelines 
If an institution wishes to collaborate with other participating institutions in performing a 
sponsored research protocol, then the following guidelines must be followed. 
Responsibility of the Protocol Chair  
 The Protocol Chair will be the single liaison for the study.  The Protocol Chair is 
responsible for the coordination, development, submission, and approval of the 
protocol as well as its subsequent amendments.  The protocol must not be rewritten or 
modified by anyone other than the Protocol Chair.  There will be only one version of 
the protocol, and each participating institution will use that document.  The Protocol 
Chair is responsible for assuring that all participating institutions are using the correct 
version of the protocol. 
 The Protocol Chair is responsible for the overall conduct of the study at all 
participating institutions and for monitoring its progress.   
 The Protocol Chair is responsible for the timely review of Adverse Events (AE) to 
assure safety of the patients. 
 The Protocol Chair will be responsible for the review of and timely submission of 
data for study analysis. 
 
Responsibilities of the Coordinating Center 


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 Each participating institution will have an appropriate assurance on file with the 
Office for Human Research Protection (OHRP), NIH.  The Coordinating Center is 
responsible for assuring that each participating institution has an OHRP assurance 
and must maintain copies of IRB approvals from each participating site.  
  The Coordinating Center is responsible for central patient registration.  The 
Coordinating Center is responsible for assuring that IRB approval has been obtained 
at each participating site prior to the first patient registration from that site. 
 The Coordinating Center is responsible for the preparation of all submitted data for 
review by the Protocol Chair.   
 The Coordinating Center will maintain documentation of AE reports.  The 
Coordinating Center will submit AE reports to the Protocol Chair for timely review. 
 Audits may be accomplished in one of two ways:  (1) source documents and research 
records for selected patients are brought from participating sites to the Coordinating 
Center for audit, or (2) selected patient records may be audited on-site at participating 
sites.  Coordinating Center is responsible for having all source documents, research 
records, all IRB approval documents, Drug Accountability Record forms, patient 
registration lists, response assessments scans, x-rays, etc. available for the audit. 
 
 


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