Conditions: Extensive Stage Lung Small Cell Carcinoma Malignant Solid Neoplasm Metastatic Malignant Neoplasm in the Brain
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 3
Healthy volunteers: no

Brief summary:
This phase I trial seeks to find out the best dose, possible benefits and/or side effects of entinostat in combination with atezolizumab, carboplatin and etoposide for the treatment of previously untreated aggressive lung cancer that has spread (extensive-stage small cell lung cancer). Entinostat and etoposide may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Immunotherapy with monoclonal antibodies, such as atezolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Carboplatin is a chemotherapy drug that attaches to deoxyribonucleic acid (DNA) and may kill tumor cells. Giving entinostat in combination with atezolizumab, carboplatin and etoposide may work better than atezolizumab, carboplatin and etoposide alone.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine the maximum tolerated dose (MTD) of entinostat in combination with carboplatin, etoposide, and atezolizumab.

II. To determine safety and tolerability of adding entinostat to carboplatin / etoposide / atezolizumab for extensive-stage small cell lung cancer (ES-SCLC).

III. To determine the feasibility of administering entinostat concomitantly with atezolizumab, carboplatin, and etoposide as determined by the proportion of patients who receive 3 or more cycles of the combination.

SECONDARY OBJECTIVES:

I. To observe and record anti-tumor activity. II. To determine the proportion of patients who are alive and without disease progression at 9 months (9 month progression free survival \[PFS\]) after starting entinostat, carboplatin, etoposide, and atezolizumab.

EXPLORATORY OBJECTIVES:

I. To estimate the clinical activity of entinostat plus carboplatin/etoposide/atezolizumab as determined by response rate (RR), progression free survival (PFS), and overall survival (OS).

II. To explore the prevalence of cyclic adenosine monophosphate (cAMP) response element binding protein (CREB) binding protein (CREBBP)/ histone acetyltransferase p300 (EP300) mutations in newly diagnosed ES-SCLC population.

III. To explore the relationship between CREBBP/EP300 mutations and clinical outcomes.

IV. To explore immune biomarkers that may predict response to atezolizumab and entinostat and changes in these biomarkers over the course of study treatment.

V. To explore entinostat exposure-response relationships with toxicity and clinical outcomes (PFS and OS).

VI. To evaluate baseline atezolizumab clearance as an early biomarker for OS and to assess the relationship between atezolizumab time-varying clearance, cachexia and clinical outcomes (PFS and OS).

OUTLINE: This is a dose-escalation study of entinostat.

INDUCTION THERAPY: Patients receive carboplatin intravenously (IV) over 30-60 minutes on day 1, etoposide IV over 60 minutes on days 1-3, atezolizumab IV over 30-60 minutes on day 1, and entinostat orally (PO) on days 1, 8, and 15. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

MAINTENANCE THERAPY: Patients receive atezolizumab IV over 30 minutes on day 1 and entinostat PO on days 1, 8, and 15. Treatment repeats every 21 days for up to 13 cycles in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up at 30 days, every 3 months for 2 years, then every 6 months for 3 years.

Arms:
arm 1: INDUCTION THERAPY: Patients receive carboplatin IV over 30-60 minutes on day 1, etoposide IV over 60 minutes on days 1-3, atezolizumab IV over 30-60 minutes on day 1, and entinostat PO on days 1, 8, and 15. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

MAINTENANCE THERAPY: Patients receive atezolizumab IV over 30 minutes on day 1 and entinostat PO on days 1, 8, and 15. Treatment repeats every 21 days for up to 13 cycles in the absence of disease progression or unacceptable toxicity.

Interventions: intervention 1: Atezolizumab intervention 2: Carboplatin intervention 3: Entinostat intervention 4: Etoposide
Intervention descriptions: intervention 1: Given IV intervention 2: Given IV intervention 3: Given PO intervention 4: Given IV

Protocol document:
Prot_SAP_000.pdf: 
NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
i 
Date:  
August 17, 2021 
 
To:  
CTEP Protocol and Information Office 
 
From: 
Ryan D. Gentzler, MD, MS 
 
Subject:  Amendment to update the consent form with the increased volume of blood collected 
for research specimens that was amended in pv06/28/2021 and inadvertently not 
amended in the consent form at that time and to clarify the timing of brain MRIs. 
 
 
SUMMARY OF CHANGES – Protocol 
 
I. 
Changes requested by the PI: 
 
# 
Section 
Comments  
1. 
Header,  
Title Page 
Updated version date. 
2. 
Study 
Calendar 
Clarified Footnote ‘g’ regarding the timing of brain MRIs for 
participants with untreated brain mets. 
 
 
SUMMARY OF CHANGES – Consent Form 
 
# 
Section 
Comments  
1. 
Header 
Updated version date. 
2. 
All 
General formatting changes throughout the document. 
3. 
What exams, tests, and 
procedures are 
involved in this study? 
Updated the volume of research blood to be collected to state 
“up to 7 tablespoons”. This is based on the previous protocol 
amendment. 


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
1 
NCI Protocol #: 
10399 
 
Local Protocol #: 
TBD 
 
ClinicalTrials.gov Identifier:  NCT04631029 
 
TITLE:  A Phase 1 Study of Entinostat in Combination with Atezolizumab / Carboplatin / 
Etoposide in Previously Untreated Extensive-Stage Small Cell Lung Cancer 
 
Corresponding Organization: LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer 
Center LAO  
 
Principal Investigator: 
Ryan D. Gentzler, MD, MS 
University of Virginia, School of Medicine 
Department of Hematology/Oncology 
PO Box 800716 
Charlottesville, VA 22908, USA 
434-243-6797 
434-243-6086 (fax) 
Rg2uc@virginia.edu 
 
Translational PI: 
Charles M. Rudin, MD, PhD 
Memorial Sloan Kettering Cancer Center 
1275 York Ave 
New York, NY 10065, USA 
646-888-4527 
Rudinc@mskcc.org 
 
Participating Organizations  
LAO-11030 / University Health Network Princess Margaret Cancer Center LAO 
LAO-CA043 / City of Hope Comprehensive Cancer Center LAO 
LAO-CT018 / Yale University Cancer Center LAO 
LAO-MA036 / Dana-Farber - Harvard Cancer Center LAO 
LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer Center LAO 
LAO-OH007 / Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015 / University of Pittsburgh Cancer Institute LAO 
LAO-TX035 / University of Texas MD Anderson Cancer Center LAO 
LAO-NCI / National Cancer Institute LAO 
CATCHUP / Creating Access to Targeted Cancer Therapy for Underserved Populations 
 
 
 
 


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
2 
 
Interventional Radiologist:  
 
Statistician: 
Michael Hanley, MD 
 
Bethany J. Horton 
Associate Professor of Radiology 
University of Virginia, School of Medicine 
University of Virginia Health System 
Department of Public Health Sciences,  
1215 Lee Street P.O. Box 800170 
Division of Applied Statistics and 
Charlottesville, VA 22908 
Translational Research 
Telephone: (434) 982 6018 
PO Box 800717 
hanleym@virginia.edu 
Charlottesville, VA 22908 
 
 
Telephone: 434-243-7236 
 
 
Fax: 434-243-5787 
 
 
bhorton@virginia.edu 
 
Protocol Contact: 
 
 
Judy Murray, CCRC 
Johns Hopkins University 
201 N. Broadway Street, 9130 
Baltimore, MD 21287 
Telephone: 410-955-4044 
jmurra33@jhmi.edu 
 
 
 
NCI-Supplied Agent:  Entinostat (MS-275, SNDX-275) (NSC 706995) 
Other Agent(s):  Carboplatin (NSC 241240), Etoposide (VP-16) (NSC 141540), Atezolizumab 
(MPDL3280A) (NSC 783608) 
 
IND #:   
IND Sponsor:  DCTD, NCI  
 
Protocol Type / Version # / Version Date: 
Original / June 18, 2020 
 
 
 
 
Revision 1 / August 27, 2020 
 
 
 
 
Revision 2 / October 20, 2020 
 
 
 
 
Revision 3b / December 10, 2020 
 
 
 
 
Revision 3a / December 4, 2020 
 
 
 
 
Revision 4 / January 13, 2021 
 
Amendment 1 / February 12, 2021 
 
Amendment 2 / May 17, 2021 
 
Amendment 3 / June 28, 2021 
 
Amendment 4 / August 17, 2021 
 
 


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
3 
SCHEMA 
  
 
 
Figure 1: Study Schema 
 
 


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
4 
 
 
 
 
Patients will receive up to 4 cycles of induction followed by maintenance treatment for a 
maximum of 1 year of combined treatment (or a total of 17 cycles). Patients who are unable to 
tolerate carboplatin and etoposide, may discontinue induction and receive the maintenance 
regimen. If this occurs, maintenance may begin prior to Cycle 5 and can continue for a total of 1 
year of treatment. 
 
 
Dose Escalation Schedule 
Dose 
Level 
Induction (Cycles 1-4) 
Maintenance (Cycles 5-17) 
Cycle 
Length 
Dose 
Dose 
Carboplatin 
Etoposide 
Atezolizumab 
Entinostat 
Atezolizumab 
Entinostat 
Level -1 
(ME) 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
None 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
Level 
1* 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
2 mg PO  
D1, 8, 15 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
Level 2 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
3 mg PO  
D1, 8, 15 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
Level 3 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
5 mg PO  
D1, 8, 15 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
*Starting Dose Level.  
IV = intravenous, AUC = Area Under Curve, PO = Orally, ME = Maintenance entinostat. 


NCI Protocol #:  10399 
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TABLE OF CONTENTS 
SCHEMA 
......................................................................................................................3 
1. 
OBJECTIVES ......................................................................................................................8 
1.1 
Primary Objectives ...................................................................................................8 
1.2 
Secondary Objectives ...............................................................................................8 
1.3 
Exploratory Objectives ............................................................................................8 
2. 
BACKGROUND .................................................................................................................9 
2.1 
Study Disease(s).......................................................................................................9 
2.2 
CTEP IND Agent .....................................................................................................9 
2.3 
Other Agents ..........................................................................................................12 
2.4 
Rationale ................................................................................................................14 
2.5 
Correlative Studies Background ............................................................................16 
3. 
PATIENT SELECTION ....................................................................................................19 
3.1 
Eligibility Criteria ..................................................................................................19 
3.2 
Exclusion Criteria ..................................................................................................21 
3.3 
Inclusion of Women and Minorities ......................................................................23 
4. 
REGISTRATION PROCEDURES ...................................................................................24 
4.1 
Investigator and Research Associate Registration with CTEP ..............................24 
4.2 
Site Registration .....................................................................................................25 
4.3 
Patient Registration ................................................................................................27 
4.4 
General Guidelines .................................................................................................29 
5. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................30 
5.1 
Summary Table for Specimen Collection ..............................................................30 
5.2 
Summary Tables for Interventional Radiologist for Research Biopsies ................33 
5.3 
Specimen Procurement Kits and Scheduling .........................................................34 
5.4 
Specimen Tracking System Instructions ................................................................35 
5.5 
Specimen Collection ..............................................................................................39 
5.6 
Shipping Specimens from Clinical Site to the EET Biobank ................................44 
5.7 
Shipping of Specimens from Clinical Site to Other Laboratories .........................46 
5.8 
Biomarker Plan ......................................................................................................49 
5.9 
Integrated Correlative Studies ................................................................................54 
5.10 
Exploratory/Ancillary Correlative Studies ............................................................54 
6. 
TREATMENT PLAN ........................................................................................................59 
6.1 
Agent Administration .............................................................................................59 
6.2 
Definition of Dose-Limiting Toxicity ....................................................................63 
6.3 
General Concomitant Medication and Supportive Care Guidelines ......................64 
6.4 
Duration of Therapy ...............................................................................................66 
6.5 
Duration of Follow-Up ..........................................................................................67 
7. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................68 


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7.1 
Carboplatin and Etoposide .....................................................................................68 
7.2 
Entinostat ...............................................................................................................69 
7.3 
Atezolizumab .........................................................................................................71 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................74 
8.1 
CTEP IND Agents .................................................................................................74 
8.2 
Commercial Agents ...............................................................................................77 
9. 
STATISTICAL CONSIDERATIONS...............................................................................80 
9.1 
Study Design/Endpoints.........................................................................................80 
9.2 
Sample Size/Accrual Rate ......................................................................................83 
9.3 
Analysis of Secondary Endpoints ..........................................................................84 
10. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................85 
10.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) .................85 
10.2 
Adverse Event Characteristics ...............................................................................92 
10.3 
Expedited Adverse Event Reporting ......................................................................92 
10.4 
Routine Adverse Event Reporting .........................................................................95 
10.5 
Pregnancy ...............................................................................................................95 
10.6 
Secondary Malignancy ...........................................................................................96 
10.7 
Second Malignancy ................................................................................................96 
11. 
STUDY CALENDAR .......................................................................................................97 
11.1 
Management of Study Patients During Local Epidemic or Pandemic ................100 
12. 
MEASUREMENT OF EFFECT......................................................................................101 
12.1 
Antitumor Effect – Solid Tumors ........................................................................101 
13. 
STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS ...........................................................................................................108 
13.1 
Study Oversight ...................................................................................................108 
13.2 
Data Reporting .....................................................................................................108 
13.3 
Data Quality Portal ..............................................................................................110 
13.4 
CTEP Multicenter Guidelines ..............................................................................111 
13.5 
Collaborative Agreements Language ...................................................................111 
13.6 
Incidental/Secondary Findings Disclosure Procedure .........................................113 
14. 
REFERENCES ................................................................................................................114 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ................................................118 
APPENDIX B 
FORMULA TO ESTIMATE RENAL FUNCTION USING 
SERUM CREATININE ...................................................................................................119 
APPENDIX C 
PATIENT DRUG INTERACTIONS HANDOUT AND 
WALLET CARD .............................................................................................................120 
APPENDIX D 
PRE-BIOPSY ASSESSMENT ................................................................123 


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APPENDIX E 
TISSUE BIOPSY VERIFICATION .....................................................124 
APPENDIX F 
MEDICATION DIARY .........................................................................125 
 
 
 


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1. 
OBJECTIVES 
 
1.1 
Primary Objectives 
 
1.1.1 To determine the maximum tolerated dose (MTD) of entinostat in combination with 
carboplatin, etoposide, and atezolizumab. 
 
1.1.2 To determine safety and tolerability of adding entinostat to carboplatin / etoposide / 
atezolizumab for extensive-stage small cell lung cancer (ES-SCLC). 
 
1.1.3 To determine the feasibility of administering entinostat concomitantly with atezolizumab, 
carboplatin, and etoposide as determined by the proportion of patients who receive 3 or 
more cycles of the combination. 
 
1.2 
Secondary Objectives 
 
1.2.1 To observe and record anti-tumor activity.  Although the clinical benefit of these drugs 
has not yet been established, the intent of offering this treatment is to provide a possible 
therapeutic benefit, and thus the patient will be carefully monitored for tumor response 
and symptom relief in addition to safety and tolerability. 
 
1.2.2 To determine the proportion of patients who are alive and without disease progression at 
9 months (9 month PFS) after starting entinostat, carboplatin, etoposide, and 
atezolizumab. 
 
1.3 
Exploratory Objectives 
 
1.3.1 To estimate the clinical activity of entinostat plus carboplatin/etoposide/atezolizumab as 
determined by response rate (RR), progression free survival (PFS), and overall survival 
(OS). 
 
1.3.2 To explore the prevalence of cyclic adenosine monophosphate (cAMP) response element 
binding protein (CREB) binding protein (CREBBP)/ histone acetyltransferase p300 
(EP300) mutations in newly diagnosed ES-SCLC population. 
 
1.3.3 To explore the relationship between CREBBP/EP300 mutations and clinical outcomes. 
 
1.3.4 To explore immune biomarkers that may predict response to atezolizumab and entinostat 
and changes in these biomarkers over the course of study treatment. 
 
1.3.5 To explore entinostat exposure-response relationships with toxicity and clinical outcomes 
(PFS and OS). 
 
1.3.6 To evaluate baseline atezolizumab clearance as an early biomarker for OS and to assess 
the relationship between atezolizumab time-varying clearance, cachexia and clinical 
outcomes (PFS and OS). 
 


NCI Protocol #:  10399 
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9 
2. 
BACKGROUND 
 
2.1 
Study Disease(s) 
 
In 2018 there were an estimated 234,000 new cases of lung cancer diagnosed in the United 
States.  Approximately 10-15% of lung cancer cases are small cell histology, and the majority of 
these cases are advanced or “extensive-stage” at diagnosis (Govindan et al., 2006).  Although 
small cell lung cancer (SCLC) tends to be more sensitive to chemotherapy, resistance and 
progression occur most commonly within months of initial treatment, and patients with this 
disease have an especially poor prognosis.  Historically, 2-year survival rates were <5%.  Recent 
clinical and pre-clinical data, detailed below, suggest SCLC can be effectively targeted with 
immunotherapy by blocking programmed death-ligand 1 (PD-L1) signaling together with histone 
deacetylase (HDAC) inhibition, which may be particularly effective in a molecular subset of 
small cell tumors harboring CREBBP or EP300 mutations.  Moreover, HDAC inhibitors 
(HDACi) may have immunomodulatory properties capable of augmenting the effectiveness of 
immunotherapy. 
 
2.1.1 CREBBP and EP300 loss in SCLC and increased susceptibility to HDAC inhibition 
 
One of the hallmarks of SCLC is the inactivation of tumor suppressor genes tumor protein 53 
(TP53) and retinoblastoma 1 (RB1).  In a study of comprehensive genomic profiling of SCLC, it 
was determined that mutations in CREBBP and EP300 acetyltransferases were among the most 
frequent after TP53 and RB1, occurring at frequencies of 15% and 13%, respectively.  Mutations 
in CREBBP and EP300 were generally mutually exclusive of other mutations, suggesting a 
potential role as oncogenes (Jia et al., 2018).  A recent study showed SCLC cells with loss of 
CREBBP had reduced histone acetylation, driving tumorigenesis.  When these CREBBP-deleted 
tumors in patient-derived xenografts were treated with the HDAC inhibitor pracinostat, increased 
anti-tumor activity was observed compared to SCLC with p53/RB1 alterations alone (Jia et al., 
2018).  HDAC inhibition also had some anti-tumor effect in tumors with intact CREBBP but to a 
lesser degree.  HDAC inhibitors may have anti-tumor activity in SCLC, especially for the 
approximately one-third of cases where tumors have loss of CREBBP or EP300. 
 
2.2 
CTEP IND Agent 
 
2.2.1 Entinostat (MS-275, SNDX-275) 
 
Syndax licensed MS-275, a novel, potent, orally (PO) bioavailable, class I selective HDACi from 
Bayer Schering Pharma in March 2007 (Entinostat Investigator’s Brochure, 2018).  Syndax has 
also entered into licensing agreements for the development and commercialization rights for 
entinostat in Japan and certain other Asian countries with Kyowa Hakko Kirin Co., Ltd. (KHK), 
and in China and certain other Asian countries with EddingPharm.  Each of these companies is 
conducting studies to support local applications in Japan (KHK 2375-001 and KHK 2375-002) 
and China (EOC 103-001).  The United States Adopted Name (USAN) and International 
Nonproprietary Name (INN) is entinostat.  The INN chemical name is (pyridin-3-yl)methyl({4-
[(2-aminophenyl)carbamoyl] phenyl}methyl)carbamate, and the laboratory code is SNDX-275.  
Entinostat belongs to the pharmacologic class of antineoplastic agents, and it is formulated as a 


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
10 
tablet for PO administration. 
 
2.2.1.1 
Mechanism of Action 
 
Entinostat increases the acetylation of histones and other nuclear and cytoplasmic proteins 
(Entinostat Investigator’s Brochure, 2018).  Although the mechanisms of action are not entirely 
elucidated, ample evidence has demonstrated that entinostat resultantly alters chromatin structure 
of genes involved in malignancy (epigenetic modulation).  These epigenetic changes result in re-
expression of tumor suppressor genes, up-regulation of pro-apoptotic genes, down-regulation of 
cell-survival genes, and down-regulation of oncogenic signaling pathways.  These events restore 
the ability of cells to undergo cell-cycle arrest, differentiation, and apoptosis, restore sensitivity 
to antineoplastic agents, and reverse malignant characteristics.  Additionally, HDACi can 
increase immunogenicity of tumor cells by activating expression of tumor antigen, antigen 
presentation, and co-stimulatory molecules in tumor cells. 
 
2.2.1.2 
Nonclinical Summary 
 
In nonclinical pharmacology studies, entinostat inhibited the activity of partially purified class I 
but not class II HDACs (Entinostat Investigator’s Brochure, 2018).  In vitro, entinostat 
demonstrated antitumor activity across a wide range of tumor cell lines.  In vivo, entinostat 
inhibited the growth of a wide variety of human tumor xenografts, including breast, lung, 
pancreatic, prostate, renal cell cancer, and glioblastoma.  Furthermore, entinostat augmented in 
an additive or synergistic manner the antitumor activity of other antineoplastic agents.  These 
agents include a wide range of chemotherapeutic agents as well as targeted therapies such as 
immune checkpoint inhibitors, aromatase inhibitors (AIs), anti-estrogens, and epidermal growth 
factor receptor inhibitors (EGFRi). 
 
In addition to direct effects on tumor cells, entinostat inhibits the growth and function of myeloid 
derived suppressor cells (MDSCs) taken from tumor bearing mice and restores cytotoxic T cell 
proliferation and activation (Entinostat Investigator’s Brochure, 2018).  Entinostat has also been 
shown to inhibit immunosuppressive regulatory T cells (Tregs).  Marked tumor growth inhibition 
has been demonstrated in multiple murine tumor models including 4T1 breast cancer, RENCA 
renal cell cancer, and LLC lung cancer when entinostat was administered in combination with an 
anti-PD-1 or cytotoxic-T-lymphocyte-associated antigen-4 (CTLA-4) antibody as compared to 
either entinostat alone or the checkpoint blockade therapy control groups. 
 
In safety pharmacology studies, no adverse functional effects were seen in the cardiovascular, 
central nervous, respiratory, or gastrointestinal (GI) systems (Entinostat Investigator’s Brochure, 
2018).  In particular, no adverse effects were noted on blood pressure or heart rate in rats or on 
hemodynamics and electrocardiograms (ECGs) in dogs.  A maximum 10% inhibition of human 
ether-à-go-go related gene (hERG) channel current was noted at 100 mcM, indicating a low 
potential for proarrhythmic risk.  Diuresis with accompanying increased excretion of electrolytes 
and creatinine was noted in conscious rats at doses ≥1 mg/kg.  At doses ≥100 mg/kg, adverse 
effects on central nervous system (CNS) function were observed in rats. 
 


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The nonclinical pharmacokinetic (PK) profile of entinostat has been characterized in a variety of 
animal models (Entinostat Investigator’s Brochure, 2018).  PO bioavailability was species-
specific and was influenced by gender, gastric pH, and feeding.  A low degree of metabolism in 
human liver microsomes was observed.  Half-life was short in mice and dogs (1 to 3 hours), 
intermediate in rats (7 to 9 hours), and longer in monkeys (30 hours).  Excretion of the parent 
compound and minor metabolites were via both urine and feces, with most of the radioactivity 
excreted within 1 week in monkeys.  A PK drug interaction study of entinostat and the tyrosine 
kinase inhibitor (TKi) lapatinib was conducted in rats and revealed some PK interaction between 
the two drugs. 
 
Single- and repeated-dose toxicology studies were performed in mice, rats, dogs, and monkeys 
(Entinostat Investigator’s Brochure, 2018).  Adverse effects, such as bone marrow toxicity and 
GI and epithelial effects, were characteristic of antiproliferative properties of entinostat.  
Entinostat was demonstrated to be neither mutagenic nor clastogenic.  In developmental and 
reproductive toxicity studies, adverse effects on male and female fertility and early embryonic 
development were noted in rats, and adverse effects on the developing embryo/fetus were 
demonstrated in both rats and rabbits.  Entinostat did not demonstrate phototoxic potential in a 
standard in vitro phototoxicity assay. 
 
2.2.1.3 
Summary of Clinical Experience 
 
As of January 01, 2018, pooled safety data are available for entinostat monotherapy for 221 
patients with solid tumors and for 93 with hematologic malignancies (Entinostat Investigator’s 
Brochure, 2018).  As combination therapy, pooled safety data are available for 170 patients with 
solid tumors treated with entinostat and AIs, 205 patients with solid tumors treated with 
entinostat and checkpoint inhibitors, 185 patients with solid tumors treated with entinostat and 
azacytidine, 232 patients with solid tumors treated with other combinations, and 205 patients 
treated with combination therapy for hematologic malignancies. 
 
2.2.1.4 
Clinical Pharmacokinetics and Pharmacodynamics 
 
The PKs of entinostat were linear over the dose range of 2 to 12 mg/m2 given weekly (Entinostat 
Investigator’s Brochure, 2018).  Considerable inter-patient variation in absorption was observed.  
The elimination half-life of entinostat ranged from 54 to 161 hours.  The median elimination 
half-life of entinostat under fasted conditions is 140 hours.  Data from in vitro experiments 
showed that, while entinostat inhibited cytochrome P-450 (CYP) enzymes 2C8 and 3A4, the 
degree of the inhibition makes it unlikely that any in vivo systemic interactions will occur.  
Entinostat did not inhibit any tested P glucuronosyltransferase (UGT) enzymes.  However, 
entinostat has the potential to induce CYP1A2 and CYP2C8.  Finally, entinostat is a substrate for 
P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) transporters. 
 
In pharmacodynamic studies, entinostat-dependent protein lysine hyperacetylation in peripheral 
blood mononuclear cells (PBMCs) was observed at all doses tested to date, with preliminary data 
suggesting that hyperacetylation may be associated with improved clinical outcome when 
entinostat is administered in combination with exemestane in breast cancer (phase 2 study 
SNDX-275-301) (Entinostat Investigator’s Brochure, 2018).  An exploratory analysis of 


NCI Protocol #:  10399 
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12 
immunomodulatory activity of entinostat indicated that monocytic MDSC numbers were 
decreased by >60% and granulocytic MDSC numbers decreased by >34% in patients treated 
with entinostat in combination with exemestane (N=20) but remained unchanged in those 
receiving exemestane and placebo (N=14) (Tomita et al., 2016). 
 
2.2.1.5 
Clinical Safety Summary 
 
Overall, entinostat was well tolerated at the doses and schedules investigated (Entinostat 
Investigator’s Brochure, 2018).  At or below the MTD, most side effects were mild to moderate 
and manageable with supportive care.  Indeed, most adverse events (AEs) were grade 1 or 2 in 
severity and non-serious.  Regardless of indication and regimen, the AEs reported most 
frequently with entinostat included:  fatigue; GI disturbances, primarily nausea with or without 
vomiting, anorexia, constipation and diarrhea; hematologic abnormalities, primarily anemia, 
thrombocytopenia, neutropenia, lymphocytopenia, and leukopenia; metabolic abnormalities, 
primarily hypoalbuminemia, hypophosphatemia, hyperglycemia, hyponatremia, and 
hypocalcemia; increased blood alkaline phosphatase; headache; and peripheral edema.  Most 
occurrences of these events were grade 1 or 2 in severity and non-serious.  As would be 
expected, the AE profiles of entinostat when given in combination vary somewhat based on the 
agent with which it is given and the corresponding patient population.  Consistent with the 
overall AE profile of entinostat, nausea with or without vomiting, fatigue, and anemia were the 
most prevalent AEs regardless of the patient population or the agent given in combination. 
 
2.2.1.6 
Clinical Results Summary 
 
Based on the results of the clinical studies, the recommended dose regimens for further 
development are 5 mg weekly, 10 mg every 2 weeks, or 7 mg weekly for 3 weeks of a 4-week 
cycle (Entinostat Investigator’s Brochure, 2018).  A daily dose of 1 mg entinostat for 5 days out 
of 7 was also studied and determined to be well-tolerated (SNDX-275-0141).  These 
recommendations are based on results from phase 1 and 2 studies in which various doses and 
dosing schedules were evaluated.  All doses tested showed evidence of histone hyperacetylation 
in PBMCs.  A dose intensity of approximately 20 mg every 4 weeks, which was well tolerated 
by most patients in the phase 1 and 2 studies, is expected to be pharmacologically active when 
given either alone or in combination with other anticancer treatments. 
 
2.3 
Other Agents 
 
2.3.1 Atezolizumab (MPDL3280A) (NSC 783608) 
 
Atezolizumab is a human immunoglobulin (Ig) G1 monoclonal antibody consisting of two heavy 
chains (448 amino acids) and two light chains (214 amino acids) and is produced in Chinese 
hamster ovary (CHO) cells (Investigator’s Brochure, 2019).  Atezolizumab was engineered to 
eliminate Fc-effector function via a single amino acid substitution (asparagine to alanine) at 
position 298 on the heavy chain, which results in a non-glycosylated antibody that has minimal 
binding to Fc receptors, thus eliminating detectable Fc-effector function and associated antibody-
mediated clearance of activated effector T cells.  Atezolizumab targets human programmed 
death-ligand 1 (PD-L1) and inhibits the interaction with its PD-L1 and its receptors, programmed 


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death 1 (PD-1) and B7-1 (also known as CD80), both of which function as inhibitory receptors 
expressed on T cells. 
 
Atezolizumab shows anti-tumor activity in both nonclinical models and cancer patients and is 
being investigated as a potential therapy in a wide variety of malignancies.  Atezolizumab is 
being studied as a single agent in the advanced cancer and adjuvant therapy settings, as well as in 
combination with chemotherapy, targeted therapy, and cancer immunotherapy. 
 
Atezolizumab is approved for the treatment of urothelial carcinoma (UC), non-small cell lung 
cancer (NSCLC), small-cell lung cancer, triple-negative breast cancer, and hepatocellular 
carcinoma (HCC). 
 
2.3.1.1 
Clinical Safety Summary 
 
As of May 17, 2019, atezolizumab has been administered as monotherapy or in combination with 
other agents to 21,000 patients with solid tumors and hematologic malignancies (Investigator’s 
Brochure, 2019). Currently, no maximum tolerated dose (MTD), no dose-limiting toxicities 
(DLTs), and no clear dose-related trends in the incidence of AEs have been determined.  Pooled 
single-agent safety data from 3178 patients with UC, NSCLC, RCC, and other malignancies 
reported that the most common AEs (≥10%) were fatigue, decreased appetite, nausea, cough, 
dyspnea, constipation, pyrexia, diarrhea, anemia, back pain, vomiting, asthenia, arthralgia, 
pruritus, rash, headache, urinary tract infection, and peripheral edema. 
 
Serious AEs (SAEs) have been reported in 1309 patients (41.2%) (Investigator’s Brochure, 
2019).  The most common SAEs were pneumonia (3.1%), dyspnea (2.8%), pyrexia (2.5%), UTI 
(1.9%), pleural effusion (1.3%), pulmonary embolism (1.3%), and sepsis (1.3%).  Treatment-
related AEs were reported in 2168 patients (68.2%), the most common events (≥20%) were 
fatigue, decreased appetite, nausea, cough, constipation, dyspnea, and pyrexia.  
 
2.3.1.2 
Immune-Related Adverse Events 
 
Given the mechanism of action of atezolizumab, events associated with inflammation and/or 
immune-mediated AEs have been closely monitored during the atezolizumab clinical program 
(Investigator’s Brochure, 2019).  To date, immune-related AEs associated with atezolizumab 
include pneumonitis, hepatitis, colitis, pancreatitis, diabetes mellitus, hypothyroidism, 
hyperthyroidism, adrenal insufficiency, hypophysitis, Guillain-Barré syndrome, myasthenic 
syndrome/myasthenia gravis, meningoencephalitis, myocarditis, nephritis, and myositis.   
 
2.3.1.3 
Clinical Efficacy Summary 
 
As of May 17, 2019, most of the efficacy data was from 1636 NSCLC patients and 983 mUC 
patients enrolled in BIRCH, POPLAR, OAK, IMpower150, Impower131, GO28625, PCD4989g, 
IMvigor210, and IMvigor211 (Investigator’s Brochure, 2019).   Atezolizumab monotherapy 
resulted in clinically meaningful overall survival (OS) improvement in second line (2L)/third line 
(3L) NSCLC ITT population in both nonsquamous and squamous histologies, and across all PD-
L1 expression subgroups.  Clinical benefit was observed in terms of objective response rate 


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14 
(ORR), progression-free survival (PFS), and overall survival (OS) in TNBC, RCC, and 
nonsquamous NSCLC when atezolizumab was administered in combination.   Both the 
preliminary and more mature efficacy data available suggest that treatment with atezolizumab as 
a single agent or in combination with other therapeutic agents results in anti-tumor activity 
across a range of tumor types and hematologic malignancies (including pediatric-type tumors) 
and across lines of therapy.    
 
2.3.2 Carboplatin 
 
Carboplatin (NSC 241240) is one of the most widely utilized chemotherapeutic agents used in 
oncology.  Carboplatin works primarily by forming DNA crosslinks that interrupt cellular DNA 
function and subsequently induce apoptosis, but also forms DNA adducts with other cellular 
components such as proteins, lipids, RNA, and mitochondrial RNA (Reed et al., 1996; Hermann 
et al.,2013).  For more detailed information, please consult the carboplatin package insert (2011). 
 
2.3.3 Etoposide (VP-16)  
 
Etoposide, or VP-16, is an epipodophyllotoxin derived from the mandrake plant Podophyllum 
peltatum (P. peltatum).  Etoposide is a substrate for CYP1A2, CYP2E1, CYP3A4/5, UDP-
glucuronosyltransferase 1A1 (UGT1A1), ATP-binding cassette B1 (ABCB1), ATP-binding 
cassette C1 (ABCC1), and ATP-binding cassette C3 (ABCC3) and a weak inhibitor of CYP2C9 
and CYP3A4.  It is a cell cycle phase-specific agent that blocks topoisomerase II.  It has a 
biphasic t1/2 and is eliminated by both renal clearance and metabolism.  The major and dose-
limiting side effect of etoposide is myelosuppression.  Constipation, diarrhea, dysphagia, 
aftertaste, abdominal pain, stomatitis, and anorexia have also been reported.  Mucositis and 
hepatotoxicity are seen primarily with high doses.  Transient hypotension and other 
anaphylactic-like symptoms are associated with rapid infusion.  Please refer to the FDA 
approved package insert for complete prescribing and toxicity information. 
 
2.4 
Rationale 
 
2.4.1 Checkpoint inhibitor immunotherapy has clinical efficacy in SCLC 
 
Checkpoint inhibitors, especially those targeting PD-1 or PD-L1, have become standard of care 
for many solid tumor and hematologic malignancies.  These agents work by inhibiting the 
negative signaling between T-cells and tumors, allowing for increased CD8+ T-cell infiltration 
of tumors and effector T-cell killing of tumors.  In SCLC, single agent PD-1 inhibitors and 
combination CTLA-4 and PD-1 inhibitors have shown promise.  In the Checkmate 032 phase I/II 
study, patients with SCLC who had received prior platinum-based chemotherapy were treated 
with nivolumab or the combination of nivolumab and ipilimumab at various doses.  There was a 
10% response rate with nivolumab 3 mg/kg and 23% response rate in those receiving nivolumab 
1 mg/kg plus ipilimumab 3 mg/kg (Antonia et al., 2016).  With longer follow-up, the 2-year 
overall survival in these two treatment arms were 17% and 30%, respectively (Hellmann et al., 
2017).  Finally, further analysis of the data from this study identified tumor mutation burden as a 
potential biomarker that enriches response.  Those with higher tumor mutational burden were 
more likely to be alive at 1 year (1-year OS 35% with nivolumab, 62.4% with 


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ipilimumab/nivolumab) (Hellmann et al., 2018a).  In the IMpower 133 phase 3 trial of 
previously untreated patients with extensive-stage SCLC, the combination of carboplatin, 
etoposide, and atezolizumab improved overall survival to 12.3 months compared to 10.3 months 
for patients receiving carboplatin and etoposide alone (Horn et al., 2018). 
 
2.4.2 HDAC inhibition with immunotherapy 
 
2.4.2.1 
Pre-clinical Data 
 
Pre-clinical data from a murine model have shown that HDAC inhibitors (HDACi) up-regulate 
PD-L1 and may have a synergistic effect on response to checkpoint inhibition (Terranova-
Barberio et al., 2017).  Furthermore, HDACi administered in combination with PD-1 inhibitors 
showed a significantly improved response compared to PD-1 monotherapy (Zheng et al., 2016).  
This may be due in part to the ability of HDACi to upregulate T-cell chemokines, particularly 
from CD8+ T cells.  Entinostat is an oral, class I selective HDAC inhibitor that has been shown 
to reduce immunosuppressive T-regulatory cells and myeloid-derived suppressor cells (MDSCs) 
in mice when administered in combination with immune checkpoint inhibition (Kim et al, 2014). 
 
2.4.2.2 
Clinical Data 
 
In a phase II trial of 76 patients with non-small cell lung cancer (NSCLC) previously treated with 
checkpoint inhibitors, the combination of entinostat 5 mg orally given weekly with 
pembrolizumab 200 mg IV every 3 weeks resulted in an objective response rate of 10% 
(Hellmann et al., 2018b).  Responses were seen in patients regardless of prior response to 
checkpoint inhibitors or PD-L1 status.  The combination of entinostat and pembrolizumab was 
tolerable with only 14% of patients discontinuing treatment due to a treatment-related adverse 
event; 17% required a dose reduction of entinostat; and thrombocytopenia and anemia, grade 1-2 
were reported at 15% and 12%, respectively, and grade 3-4 were reported at 1% and 7%, 
respectively. 
 
The combination of entinostat with both immunotherapy and chemotherapy has not been studied.  
Due to potential overlapping toxicity, particularly hematologic toxicity, with entinostat and 
carboplatin and etoposide chemotherapy, this study will evaluate entinostat at 3 mg weekly, 
which is below the recommended phase two dose of 5 mg weekly.  There will also be a phased-
in start of entinostat after the completion of 4 cycles of carboplatin and etoposide, if necessary, 
due to toxicity. 
 
In summary, SCLC is a recalcitrant cancer with poor prognosis.  The addition of atezolizumab to 
carboplatin/etoposide chemotherapy has resulted in an improvement in overall survival, but 
further improvements are needed as the overall survival in this patient population is 
approximately 1 year.  HDAC inhibition may be particularly useful in this disease due to 
immunomodulatory effects as well as direct antitumor effects, particularly in tumors with 
CREBBP or EP300 loss, which may be as prevalent as 25-30% of patients.  Entinostat has shown 
immunomodulatory effects by reducing MDSCs and Tregs and has demonstrated safety (low 
hematologic toxicity) and efficacy in combination with pembrolizumab in patients with NSCLC, 
making it an ideal HDACi to combine with chemotherapy.  Based on this, we propose a phase I 


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16 
trial of carboplatin, etoposide, atezolizumab, and entinostat for patients with previously untreated 
extensive-stage SCLC.   
 
2.5 
Correlative Studies Background 
 
2.5.1 Whole Exome Sequencing (WES) 
 
Previous studies have shown that there is a high frequency of mutations within epigenetic 
regulators in small cell lung cancer.  Of specific interest are CREBBP and EP300 which can be 
mutated in SCLC and are histone acteylases.  Entinostat is an HDACi, and we hypothesize that 
there may be increased anti-tumor activity in SCLC patients that have mutations in genes that 
regulate epigenetic changes.  We aim to identify genomic alterations, specifically CREBBP and 
EP300, and determine if they could be useful biomarkers for predicting response to entinostat for 
SCLC.  By using WES, we will also be able to evaluate the impact of tumor mutation burden 
(TMB).  Lastly, we also aim to identify changes in genomic profile at disease progression for 
patients who are able and willing to submit tissue at the time of progression. 
 
2.5.2 RNA Sequencing (RNASeq) 
 
Epigenetic changes within cancer cells leads to changes in protein expression.  RNAseq has been 
used to characterize small cell lung cancer, with several profiles emerging.  We aim to identify 
the transcriptional characteristics of response to treatment and at disease progression.  RNA 
sequencing may also detect genomic alterations that are not detected on DNA whole exome 
sequencing. 
 
2.5.3 Immune Cell Markers 
 
SCLC patient responsiveness to immune checkpoint therapy is associated with the tumor 
mutational burden and the presence of immune cells within the tumor microenvironment, with 
combination immunotherapies providing up to 23% response rate.  However, SCLC is also 
characterized by a relatively low level of PD-L1 expression (a surrogate marker for immune-
mediated inflammation) and immune-suppressive networks.  The combination therapies involved 
in this study may relieve some of the immunosuppressive effects of the tissue microenvironment, 
but other elements may be resistant and could predict response rate.  Finally, response to 
combination therapies can be dependent upon the presence of dendritic cells within tumors 
(Saida et al., 2015; Hanoteau et al., 2019).  Therefore, we intend to characterize the relative 
presence of effector immune cells to immunosuppressive elements prior to treatment to 
determine whether cellular and molecular components serve as a biomarker to durable response 
and, where biopsies are available on progression, to determine whether tumor escape is 
associated with a change to a more immunosuppressive profile. 
 
The hypothesis is that patient response is predicted by a higher presence of immune effector cells 
compared to suppressive networks.  Progressing tumors will have a higher proportion of immune 
suppression.  Progressing tumors may have been selected for major histocompatibility complex 
(MHC) class I loss (Doyle et al., 1985). 
 


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2.5.4 Transcriptional Regulators 
 
SCLC has been found to be driven by various lineage-specific transcription factors.  We aim to 
further characterize small cell lung cancer based on transcriptional regulators: ASCL1, NeuroD1, 
YAP1, POU2F3.  Recent data suggest that YAP1 profile (SCLC-Y) or subtypes that do not 
express ASCL1, NeuroD1, or POU2F3 (SCLC-I) represent a subtype with a T-cell inflamed 
phenotype that may be associated with response to immune therapy (Rudin et al., 2019; Gay et 
al., 2019; Owonikoko et al., 2020).  We aim to define specific phenotypes and determine 
predictive impact on treatment response. 
 
2.5.5 Circulating Tumor DNA (ctDNA) 
 
Previous studies have shown that there is a high frequency of mutations within epigenetic 
regulators in small cell lung cancer. Of specific interest are CREBBP and EP300 which can be 
mutated in SCLC and are histone acteylases.  Entinostat is a histone deacetylase inhibitor, and 
we hypothesize that there may be increased anti-tumor activity in small cell lung cancer patients 
that have mutations in genes that regulate epigenetic changes. We aim to identify genomic 
alterations, specifically CREBBP and EP300, and determine if they could be useful biomarkers 
for predicting response to entinostat for SCLC.  We plan to use ctDNA to detect these mutations 
to correlate with tissue genomics and identify mutations that may not be detected on tissue 
analysis, particularly when limited tissue is available. We also seek to identify possible 
mechanisms of resistance at the time of progression. 
 
2.5.6 Circulating Immune Cells 
 
On-trial evaluation of patient immunity is a critical correlate for understanding how patients’ 
immune systems are responding to therapy.  On the one hand, combination of carboplatin and 
etoposide may lead to lymphodepletion and limit patient immunity and response to anti-PD1.  
This is not necessarily consistent with other trials combining carboplatin and PD1 blockade.  
Alternatively, the chemotherapies can make space for the expansion of de novo response to 
tumor induced by the tumoricidal effects of the drug combinations and may limit the 
immunosuppressive tumor landscape (An et al., 2019; Suzuki et al., 2019).  Flow cytometric 
analysis of PBMC will provide some insight as to which of these outcomes is dominant.  
 
The hypothesis is that combination therapy in this study will lead to transient lymphodepletion 
and myeloablation.  At later timepoints, activated T cells will rebound.  Circulating 
immunosuppressive myeloid populations will be durably reduced. 
 
2.5.7 Immunogenicity 
 
Combination chemotherapies may lead to transient immunodeficiency due to targeting or rapidly 
dividing lymphocytes and myeloid cells.  The durability of this effect is not well understood, and 
whether relatively-quiescent memory cell populations that protect against pathogenic infections 
are compromised is unclear (Xu et al., 2016; Melief et al, 2020; Van Meir et al, 2017).   
 
The hypothesis is that circulating memory cells specific to pathogens will be resistant to 


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lymphodepleting effects of combination therapy. 
 
2.5.8 Entinostat Exposure-response 
 
Combinations of novel immune therapeutics with cytotoxic and targeted therapy have resulted in 
systemic immune-related AEs with unknown etiology (Harvey et al., 2014).  Alterations in 
chemokines, prostaglandins, and cytokines are possible with novel immune therapeutics.  These 
alterations may even modulate CYP metabolism and other drug elimination and transporter 
pathways.   
 
The hypothesis is that entinostat exposure may be altered with concomitant administration of 
atezolizumab.  We will also correlate entinostat drug exposure with toxicity and clinical 
outcomes (PFS and OS). 
 
2.5.9 Atezolizumab clearance-response 
 
Antibody drug clearance has demonstrated potential as an early biomarker for outcomes from 
immune checkpoint inhibitor therapy (Desnoyer et al., 2020; Mir et al., 2020). In particular, 
baseline clearance (CL0, the clearance of the first dose of antibody drug) and/or changes in 
clearance over time have been demonstrated to associate with progression-free and/or overall 
survival for CTLA4-targeted (Sanghavi et al., 2019), PD1-targeted (Baverel et al., 2018a; Coss 
et al., 2018; Food and Drug Administration. 2016b. {BLA 761097}; Turner et al., 2018; Zheng 
et al., 2018), and PDL1-targeted agents (Wilkins et al., 2019), including atezolizumab (Food and 
Drug Administration. (2016a). {BLA 761041}) (low baseline clearance and decreasing clearance 
over time correlates with better outcomes).  Additionally, elevated baseline clearance is also 
observed in patients with cancer-associated cachexia, and decreasing clearance over time trends 
with weight gain in patients who are responding to therapy. 
 
The hypothesis is that baseline clearance of atezolizumab will correlate with overall survival 
(lower baseline clearance will be associated with longer OS). We will also assess the correlations 
between atezolizumab clearance at baseline and over time, as well as associations between 
cachexia and antibody drug clearance. 
 
 
 
 


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3. 
PATIENT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have histologically or cytologically confirmed extensive stage SCLC (ES-
SCLC) or other solid tumors for which carboplatin and etoposide are considered 
appropriate therapy. 
 
3.1.2 No prior systemic therapy for extensive-stage, metastatic disease.  Patients with prior 
limited stage disease who were treated with chemotherapy and concurrent radiation will 
be permitted to enroll as long as their previous treatment was 12 months or more prior to 
study enrollment. 
 
3.1.3 Patients with treated brain metastases are eligible if they have stable symptoms and no 
ongoing requirement for corticosteroids as therapy for brain metastases.   
 
3.1.4 Patients with untreated or progressive brain metastases (active brain metastases) are 
eligible if the treating physician determines that immediate CNS specific treatment is not 
required and is unlikely to be required during the first cycle of therapy.  There must be no 
ongoing requirement for corticosteroids as therapy for brain metastases. 
 
3.1.5 Previous radiation, including whole brain radiation, is allowed ≥7 days of study 
registration. Stereotactic radiation therapy within 7 days is permitted. 
 
3.1.6 Patients must have measurable disease by RECIST v1.1.  At least one measurable lesion 
should be extra-cranial and outside of any portal of irradiation. 
 
3.1.7 Archival tissue must be available or patients must be willing to undergo a new biopsy to 
provide pre-treatment tumor sample (no intervening chemotherapy treatment, tissue must 
be from current extensive-stage/metastatic diagnosis).  See section 5.5.1 and 5.5.2 for 
tissue requirements. 
 
3.1.8 Age ≥18 years.   
Because no dosing or adverse event data are currently available on the use of entinostat in 
combination with atezolizumab, carboplatin and etoposide in patients <18 years of age, 
children are excluded from this study.   
 
3.1.9 ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A). 
 
3.1.10 Patients must have adequate organ and marrow function as defined below: 
 
− 
absolute neutrophil count 
 
≥1,500/mcL 
− 
hemoglobin 
 
 
 
≥9.0 g/dL 
− 
platelets  
 
≥100,000/mcL 
− 
INR 
 
 
<1.5 
− 
total bilirubin 
 
≤1.5 × institutional upper limit of normal (ULN). 


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(This does not apply to patients with confirmed 
Gilbert’s syndrome) 
− 
AST(SGOT)/ALT(SGPT) 
 
≤3 × institutional ULN, 
(if liver metastases present, can be up to 5 × ULN) 
− 
creatinine  
 
< institutional ULN 
OR 
− 
glomerular filtration rate (GFR) ≥60 mL/min/1.73 m2 (by the Cockcroft-Gault 
equation, see Appendix B) 
− 
serum sodium   
 
 
≥130 mmol/L 
 
3.1.11 Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral 
therapy with undetectable viral load within 6 months are eligible for this trial. 
 
3.1.12 For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral 
load must be undetectable on suppressive therapy, if indicated. 
 
3.1.13 Patients with a history of hepatitis C virus (HCV) infection must have been treated and 
cured.  For patients with HCV infection who are currently on treatment, they are eligible 
if they have an undetectable HCV viral load. 
 
3.1.14 Patients with a prior or concurrent malignancy whose natural history or treatment does 
not have the potential to interfere with the safety or efficacy assessment of the 
investigational regimen are eligible for this trial. 
 
3.1.15 Patients with known history or current symptoms of cardiac disease, or history of 
treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac 
function using the New York Heart Association Functional Classification.  To be eligible 
for this trial, patients should be class II or better. 
 
3.1.16 The effects of entinostat on the developing human fetus are unknown.  For this reason 
and because HDACi agents as well as other therapeutic agents used in this trial are 
known to be teratogenic, women of child-bearing potential and men must agree to use 
adequate contraception (hormonal or barrier method of birth control; abstinence) prior to 
study entry, for the duration of study participation, up to 5 months after the last dose of 
study treatment.  Should a woman become pregnant or suspect she is pregnant while she 
or her partner is participating in this study, she should inform her treating physician 
immediately.  Men treated or enrolled on this protocol must also agree to use adequate 
contraception prior to the study, for the duration of study participation, and 5 months 
after completion of study treatment. 
 
3.1.17 Ability to understand and the willingness to sign a written informed consent document.  
Participants with impaired decision-making capacity (IDMC) who have a legally-
authorized representative (LAR) and/or family member available will also be eligible. 
 
 


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3.2 
Exclusion Criteria 
 
3.2.1 Patients with evidence of leptomeningeal metastases (either by imaging or CNS fluid 
findings) 
 
3.2.2 Patients who are receiving any other investigational agents. 
 
3.2.3 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to entinostat or other agents used in study. 
 
 
3.2.4 Patients with uncontrolled intercurrent illness. 
 
3.2.5 Patients with psychiatric illness/social situations that would limit compliance with study 
requirements. 
 
3.2.6 Pregnant women are excluded from this study because entinostat is HDACi agent with 
the potential for teratogenic or abortifacient effects and because of known teratogenic and 
abortifacient effects of cisplatin and etoposide.  Because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the mother 
with entinostat, and known risks with cisplatin and etoposide, breastfeeding should be 
discontinued if the mother is treated with entinostat.  These potential risks may also apply 
to other agents used in this study. 
 
3.2.7 Patients with a history of autoimmune disease (notable exceptions include 
hypothyroidism on thyroid replacement medication, type I diabetes, psoriasis or other 
cutaneous disease controlled with topical agents and without flare in 12 months 
requiring other treatment, celiac disease controlled with diet alone). 
 
3.2.8 Patients with a history of pulmonary fibrosis (history of radiation pneumonitis/fibrosis in 
the treatment field is permitted if stable and not requiring supplemental oxygen or 
corticosteroid use). 
 
3.2.9 Patients with prior history of allogeneic bone marrow or solid organ transplant. 
 
3.2.10 Ongoing use of systemic corticosteroids or immunosuppressive agents within 14 days 
(inhaled corticosteroids, <7 day course of prednisone for asthma/chronic obstructive 
pulmonary disease (COPD) exacerbation, or chronic low-dose supplemental steroids for 
adrenal insufficiency permitted) 
 
3.2.11 Prior treatment with anti-PD-1, or anti-PD-L1 therapeutic antibody or pathway-targeting 
agents. 
• Patients who have received prior treatment with anti-CTLA-4 may be enrolled, provided 
the following requirements are met: 
o Minimum of 12 weeks from the first dose of anti-CTLA-4 and >6 weeks from the 
last dose 


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o No history of severe immune-related adverse effects from anti-CTLA-4 (NCI 
CTCAE Grade 3 and 4) 
 
3.2.12 Treatment with systemic immunostimulatory agents (including, but not limited to, 
interferon [IFN]-α or interleukin [IL]-2) within 6 weeks prior to study registration. 
 
3.2.13 Patients taking bisphosphonate therapy for symptomatic hypercalcemia.  Use of 
bisphosphonate therapy for other reasons (e.g., bone metastasis or osteoporosis) is 
allowed. 
 
3.2.14 Patients requiring treatment with a receptor activator of nuclear factor kappa-Β ligand 
(RANKL) inhibitor (e.g. denosumab) who cannot discontinue it before treatment with 
atezolizumab. 
 
3.2.15 Patients requiring treatment with strong CYP3A inhibitors and inducers who cannot 
discontinue it before treatment with etoposide 
 
• Because the list of these agents are constantly changing, it is important to regularly 
consult a frequently updated list such as Facts and Comparisons or Lexicompt; 
medical reference texts such as the Physicians’ Desk Reference may also provide this 
information. 
 
3.2.16 Known hypersensitivity to Chinese hamster ovary cell products or other recombinant 
human antibodies. 
 
3.2.17 History of severe allergic, anaphylactic, or other hypersensitivity reactions to chimeric or 
humanized antibodies or fusion proteins. 
 
3.2.18 Known clinically significant liver disease, including active viral, alcoholic, or other 
hepatitis; cirrhosis; fatty liver; and inherited liver disease. 
 
3.2.19 Patients with active tuberculosis (TB) are excluded. 
 
3.2.20 Suspected or confirmed active Severe Acute Respiratory Syndrome Coronavirus 2 
(SARS-CoV-2) infection (COVID-19).  
• Those with a history of COVID-19 are eligible if they meet all of the above eligibility 
criteria after clearance of COVID-19 by one of the following criteria: 
1) 14 days have elapsed since symptom onset, the patient is afebrile, and symptoms 
are improving for at least 72 hours  
2) have 2 negative specimens collected at least 24 hours apart 
 
3.2.21 Severe infections within 2 weeks prior to study registration, including, but not limited to, 
hospitalization for complications of infection, bacteremia, or severe pneumonia. 
 
 
3.2.22 Received oral or intravenous (IV) antibiotics within 1 week prior to study registration.  


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23 
Patients receiving prophylactic antibiotics (e.g., for prevention of a urinary tract infection 
or chronic obstructive pulmonary disease) are eligible. 
 
3.2.23 Major surgical procedure within 4 weeks prior to study registration or anticipation of 
need for a major surgical procedure during the course of the study.  Common procedures 
such as biopsies, port insertions, and thoracenteses are allowed. 
 
3.2.24 Administration of a live, attenuated vaccine within 4 weeks before study registration or 
anticipation that such a live, attenuated vaccine will be required during the study or up to 
5 months after the last dose of atezolizumab. 
 
 
3.3 
Inclusion of Women and Minorities 
 
NIH policy requires that women and members of minority groups and their subpopulations be 
included in all NIH-supported biomedical and behavioral research projects involving NIH-
defined clinical research unless a clear and compelling rationale and justification establishes to 
the satisfaction of the funding Institute & Center (IC) Director that inclusion is inappropriate 
with respect to the health of the subjects or the purpose of the research.  Exclusion under other 
circumstances must be designated by the Director, NIH, upon the recommendation of an IC 
Director based on a compelling rationale and justification.  Cost is not an acceptable reason for 
exclusion except when the study would duplicate data from other sources.  Women of 
childbearing potential should not be routinely excluded from participation in clinical research.  
Please see http://grants.nih.gov/grants/funding/phs398/phs398.pdf. 
 
 
 
 


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24 
4. 
REGISTRATION PROCEDURES 
 
4.1 
Investigator and Research Associate Registration with CTEP 
 
Food and Drug Administration (FDA) regulations and National Cancer Institute (NCI) policy 
require all individuals contributing to NCI-sponsored trials to register and to renew their 
registration annually.  To register, all individuals must obtain a Cancer Therapy Evaluation 
Program (CTEP) Identity and Access Management (IAM) account at 
https://ctepcore.nci.nih.gov/iam.  In addition, persons with a registration type of Investigator 
(IVR), Non-Physician Investigator (NPIVR), or Associate Plus (AP) must complete their annual 
registration using CTEP’s web-based Registration and Credential Repository (RCR) at 
https://ctepcore.nci.nih.gov/rcr.    
 
RCR utilizes five person registration types. 
• IVR:  MD, DO, or international equivalent, 
• NPIVR:  advanced practice providers (e.g., NP or PA) or graduate level researchers (e.g., 
PhD), 
• AP:  clinical site staff (e.g., RN or CRA) with data entry access to CTSU applications 
such as the Roster Update Management System (RUMS), OPEN, Rave, acting as a 
primary site contact, or with consenting privileges, 
• Associate (A):  other clinical site staff involved in the conduct of NCI-sponsored trials, 
and 
• Associate Basic (AB):  individuals (e.g., pharmaceutical company employees) with 
limited access to NCI-supported systems. 
 
RCR requires the following registration documents: 
 
Documentation Required 
IVR NPIVR AP 
A 
AB 
FDA Form 1572 
✔ 
✔ 
 
 
 
Financial Disclosure Form 
✔ 
✔ 
✔ 
 
 
NCI Biosketch (education, training, employment, license, 
and certification) 
✔ 
✔ 
✔ 
GCP training 
✔ 
✔ 
✔ 
Agent Shipment Form (if applicable) 
✔ 
CV (optional) 
✔ 
✔ 
✔ 
 
An active CTEP-IAM user account and appropriate RCR registration is required to access all 
CTEP and Cancer Trials Support Unit (CTSU) websites and applications.  In addition, IVRs and 
NPIVRs must list all clinical practice sites and Institutional Review Boards (IRBs) covering their 
practice sites on the FDA Form 1572 in RCR to allow the following: 
 
• Addition to a site roster, 


NCI Protocol #:  10399 
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25 
• Assign the treating, credit, consenting, or drug shipment (IVR only) tasks in OPEN, 
• Act as the site-protocol Principal Investigator (PI) on the IRB approval, and 
• Assign the Clinical Investigator (CI) role on the Delegation of Tasks Log (DTL).  
 
In addition, all investigators acting as the Site-Protocol PI (Investigator listed on the IRB 
approval), consenting/treating/drug shipment investigator in OPEN, or as the Clinical 
Investigator (CI) on the DTL must be rostered at the enrolling site with a participating 
organization .  
 
Additional information is located on the CTEP website at 
https://ctep.cancer.gov/investigatorResources/default.htm.  For questions, please contact the 
RCR Help Desk by email at RCRHelpDesk@nih.gov. 
 
4.2 
Site Registration 
 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
 
IRB Approval   
 
Sites participating with the NCI Central Institutional Review Board (NCI CIRB) must submit the 
Study Specific Worksheet for Local Context (SSW) to the CIRB using IRBManager to indicate 
their intent to open the study locally.  The NCI CIRB’s approval of the SSW is automatically 
communicated to the CTSU Regulatory Office, but sites are required to contact the CTSU 
Regulatory Office at CTSURegPref@ctsu.coccg.org to establish site preferences for applying 
NCI CIRB approvals across their Signatory Network.  Site preferences can be set at the network 
or protocol level.  Questions about establishing site preferences can be addressed to the CTSU 
Regulatory Office by email or calling 1-888-651-CTSU (2878). 
 
In addition, the Site-Protocol PI (i.e., the investigator on the IRB/REB approval) must meet the 
following five criteria to complete processing of the IRB/REB approval record: 
• Holds an active CTEP status, 
• Rostered at the site on the IRB/REB approval (applies to US and Canadian sites only) and 
on at least one participating roster, 
• If using NCI CIRB, rostered on the NCI CIRB Signatory record, 
• Includes the IRB number of the IRB providing approval in the Form FDA 1572 in the 
RCR profile, and 
• Holds the appropriate CTEP registration type for the protocol.  
 
Additional Requirements 
 
Additional requirements to obtain an approved site registration status include: 
• An active Federalwide Assurance (FWA) number, 
• An active roster affiliation with the Lead Protocol Organization (LPO) or a Participating 
Organization (PO), and 
• Compliance with all protocol-specific requirements (PSRs). 


NCI Protocol #:  10399 
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26 
 
4.2.1 Downloading Regulatory Documents 
 
Download the site registration forms from the protocol-specific page located on the CTSU 
members’ website.  Permission to view and download this protocol and its supporting documents 
is restricted based on person and site roster assignment.  To participate, the institution and its 
associated investigators and staff must be associated with the LPO or a PO on the protocol.  One 
way to search for a protocol is listed below. 
 
• Log in to the CTSU members’ website (https://www.ctsu.org) using your CTEP-IAM 
username and password, 
• Click on Protocols in the upper left of the screen 
o Enter the protocol number in the search field at the top of the protocol tree, or 
o Click on the By Lead Organization folder to expand, then select LAO-MD017, 
and protocol number 10399, 
• Click on Documents, select Site Registration, and download and complete the forms 
provided.  (Note:  For sites under the CIRB, IRB data will load automatically to the 
CTSU.)  
 
4.2.2 Protocol Specific Requirements For 10399 Site Registration 
 
• A Site Initiation Visit (SIV) is required for each participating site prior to activation. The 
local site PI will conduct a review of the protocol and relevant documents with their local 
study team. Upon completion, email the Protocol Contact with the following information:  
o Site Name 
o Site Code 
o Local PI Name 
o Date of the SIV 
o Specific documents and/or information reviewed 
o Names and roles of the attendees 
 
• Specimen Tracking System Training Requirement: 
o All data entry users (Clinical Research Associate role) at each participating site will 
need to complete the Theradex-led training. 
o Theradex will provide a certificate of completion, which will need to be submitted to 
the CTSU through the Regulatory Submission Portal. 
o The training is a one-time only requirement per individual.  If an individual has 
previously completed the training for another ETCTN study, the training does not 
need to be completed again nor does the certificate of completion need to be 
resubmitted to the CTSU.  However, new versions of the Specimen Tracking System 
may require new training. 
o This training will need to be completed before the first patient enrollment at a given 
site. 
o Please contact STS Support at Theradex for the training 
(STS.Support@theradex.com, Theradex phone: 609-799-7580). 
 


NCI Protocol #:  10399 
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27 
4.2.3 Submitting Regulatory Documents 
 
Submit required forms and documents to the CTSU Regulatory Office using the Regulatory 
Submission Portal on the CTSU website.  
 
To access the Regulatory Submission Portal, log on to the CTSU members’ website, go to the 
Regulatory section, and → select Regulatory Submission. 
 
Institutions with patients waiting that are unable to use the Regulatory Submission Portal should 
alert the CTSU Regulatory Office immediately at 1-866-651-2878 in order to receive further 
instruction and support. 
 
Delegation of Tasks Log (DTL) 
 
Each site must complete a protocol-specific DTL using the DTL application in the Delegation 
Log section on the CTSU members’ website.  The Clinical Investigator (CI) is required to review 
and electronically sign the DTL prior to the site receiving an approved site registration status and 
enrolling patients to the study.  To maintain an approved site registration status the CI must re-
sign the DTL at least annually and when a new version of the DTL is released; and activate new 
task assignments requiring CI sign-off.  Any individual at the enrolling site on a participating 
roster may initiate the site DTL.  Once the DTL is submitted for CI approval, only the designated 
DTL Administrators or the CI may update the DTL.  Instructions on completing the DTL are 
available in the Help Topics button in the DTL application and include a Master Task List, 
which describes DTL task assignments, CI signature, and CTEP registration requirements. 
 
4.2.4 Checking Site Registration Status 
 
Site’s registration status may be verified on the CTSU website.  
 
• Click on Regulatory at the top of the screen 
• Click on Site Registration , and 
• Enter the site’s 5-character CTEP Institution Code and click on Go  
o Additional filters are available to sort by Protocol, Registration Status, Protocol 
Status, and/or IRB Type. 
 
Note:  The status shown only reflects institutional compliance with site registration requirements 
as outlined within the protocol.  It does not reflect compliance with protocol requirements for 
individuals participating on the protocol or the enrolling investigator’s status with NCI or their 
affiliated networks. 
 
4.3 
Patient Registration 
 
4.3.1 OPEN / IWRS 
 
The Oncology Patient Enrollment Network (OPEN) is a web-based registration system available 
on a 24/7 basis.  OPEN is integrated with CTSU regulatory and roster data and with the LPOs 


NCI Protocol #:  10399 
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28 
registration/randomization systems or the Theradex Interactive Web Response System (IWRS) 
for retrieval of patient registration/randomization assignment.  OPEN or IWRS will populate the 
patient enrollment data in NCI’s clinical data management system, Medidata Rave. 
 
Requirements for OPEN access:   
 
• A valid CTEP-IAM account. 
• To perform enrollments or request slot reservations:  Must be on an LPO roster, ETCTN 
corresponding roster, or PO roster with the role of Registrar.  Registrars must hold a 
minimum of an Associate Plus (AP) registration type. 
• The registrar(s) must hold the OPEN Registrar task on the DTL for the site. 
• Have an approved site registration for the protocol prior to patient enrollment. 
 
To assign an Investigator (IVR) or Non-Physician Investigator (NPIVR) as the treating, 
crediting, consenting, drug shipment (IVR only), or receiving investigator for a patient transfer in 
OPEN, the IVR or NPIVR must list the IRB number used on the site’s IRB approval on their 
Form FDA 1572 in RCR.  The IVR or NPIVR must be assigned the appropriate OPEN-related 
tasks on the DTL. 
 
Prior to accessing OPEN, site staff should verify the following: 
 
• Patient has met all eligibility criteria within the protocol stated timeframes, and  
• All patients have signed an appropriate consent form and HIPAA authorization form (if 
applicable). 
 
Note:  The OPEN system will provide the site with a printable confirmation of registration and 
treatment information.  IWRS system also sends an email confirmation of the registration.  You 
may print this confirmation for your records.  
 
Access OPEN at https://open.ctsu.org or from the OPEN link on the CTSU members’ website.  
Further instructional information is in the OPEN section of the CTSU website at 
https://www.ctsu.org or https://open.ctsu.org.  For any additional questions, contact the CTSU 
Help Desk at 1-888-823-5923 or ctsucontact@westat.com. 
 
Patient enrollment for this study will be facilitated using the Slot Reservation System in 
conjunction with the registration system in OPEN.  Prior to discussing protocol entry with the 
patient, all site staff must use the CTSU OPEN Slot Reservation System or the IWRS Slot 
Reservation System to ensure that a slot on the protocol is available to the patient.  Once a slot 
reservation confirmation is obtained, site staff may then proceed to enroll the patient to this 
study.  
 
4.3.2 Special Instructions for Patient Enrollment 
 
This Study will use the ETCTN Specimen Tracking System (STS).  
 
• All biospecimens collected for this trial must be submitted using the ETCTN Specimen 


NCI Protocol #:  10399 
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29 
Tracking System (STS) unless otherwise noted.   
• The system is accessed through Rave user roles:  “Rave CRA” and “Rave CRA 
(Labadmin)” for data entry at the treating institutions and “Biorepository” for users 
receiving the specimens for processing and storage at reference labs and the NCI Early-
Phase and Experimental Clinical Trials Biospecimen Bank (EET Biobank, formerly 
known as the ETCTN Biorepository).   
• Please refer to the Medidata Account Activation and Study Invitation Acceptance link on 
the CTSU website in the Data Management section  under the Rave Home tab and then 
under Rave Resource Materials. 
• Important:  Failure to complete required fields in STS may result in a delay in 
sample processing.  Any case reimbursements associated with sample submissions will 
not be credited if samples requiring STS submission are not logged into STS. 
 
Detailed instructions on use of the STS can be found in Section Error! Reference source not 
found.. 
 
4.3.3 OPEN/IWRS Questions? 
 
Further instructional information on OPEN is provided on the OPEN link of the CTSU website 
at https://www.ctsu.org or at https://open.ctsu.org.  For any additional questions contact the 
CTSU Help Desk at 1-888-823-5923 or ctsucontact@westat.com.  
 
Theradex has developed a Slot Reservations and Cohort Management User Guide, which is 
available on the Theradex website:  http://www.theradex.com/clinicalTechnologies/?National-
Cancer-Institute-NCI-11. This link to the Theradex website is also on the CTSU website OPEN 
tab. For questions about the use of IWRS for slot reservations, contact the Theradex Helpdesk at 
609-619-7862 or Theradex main number 609-799-7580; CTMSSupport@theradex.com. 
 
4.4 
General Guidelines 
 
Following registration, patients should begin protocol treatment within 7 days.  Issues that would 
cause treatment delays should be discussed with the Principal Investigator.  Patients that are 
registered for the study but do not go on to receive study treatment will be replaced. These 
registrations will be considered “canceled”. The Protocol Contact should be notified of 
cancellations as soon as possible. 
 
 
 


NCI Protocol #:  10399 
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30 
5. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
5.1 
Summary Table for Specimen Collection 
 
 
Time Point 
Specimen 
Send Specimens To: 
Archival 
 
• Formalin-fixed paraffin-embedded 
(FFPE) tumor tissue block 
(preferred)1 (mandatory) 
 
If archival tissue block is not available, 
then submit: 
• 20-25 (10-micron) unstained 
uncharged slides1 (mandatory)  
• 10 (4-micron) unstained charged 
slides1 (optional) 
EET Biobank 
Baseline (if archival tissue is unavailable) 
 
• 2-3 tissue cores in formalin2 
(mandatory) 
EET Biobank 
Cycle 1 Day 1 
 
• Pre-treatment: 2 x 10 mL whole 
blood in Streck cfDNA tubes 
(mandatory) 
EET Biobank 
 
• Pre-treatment: 6 × 10 mL whole 
blood in sodium heparin (green top) 
tubes processed for flow cytometry 
and ELISpot, then frozen 
(mandatory) 
Bullock Laboratory 
(MITS core) 
 
 
Atezolizumab PK3 
• Pre-dose: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
• After the end of the atezolizumab 
infusion at the same time as the ~2 
hours post entinostat PK: 1 x 6 
whole blood in red-top (e.g. BD 
367815 or 368660) tubes 
(mandatory) 
OSUCCC PhASR  
Entinostat PK3 
• Pre-dose: 1 × 4 mL whole blood in 
sodium heparin (green top; e.g. BD 
367871 or 367884) tubes 
(mandatory)  
• ~0.5 hours post dose: 1 × 4 mL 
whole blood in sodium heparin 
(green top; e.g. BD 367871 or 
JHU APC  


NCI Protocol #:  10399 
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31 
367884) tubes (mandatory) 
• ~2 hours post dose: 1 × 4 mL whole 
blood in sodium heparin (green top; 
e.g. BD 367871 or 367884) tubes 
(mandatory) 
Cycle 1 Day 2 
Entinostat PK4 
• Prior to etoposide-dose: 1 × 4 mL 
whole blood in sodium heparin 
(green top; e.g. BD 367871 or 
367884) tubes (mandatory)  
JHU APC  
Cycle 1 Day 8 
Entinostat PK3 
• Pre-dose: 1 × 4 mL whole blood in 
sodium heparin (green top; e.g. BD 
367871 or 367884) tubes 
(mandatory)  
JHU APC  
Cycle 1 Day 15 
Entinostat PK3 
• Pre-dose: 1 × 4 mL whole blood in 
sodium heparin (green top; e.g. BD 
367871 or 367884) tubes 
(mandatory)  
JHU APC  
Cycle 2 Day 1 
 
• Pre-treatment: 6 × 10 mL whole 
blood in sodium heparin (green top) 
tubes processed for flow cytometry 
and ELISpot, then frozen 
(mandatory) 
Bullock Laboratory 
(MITS core) 
Atezolizumab PK3 
• Pre-dose: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
• After the end of the atezolizumab 
infusion at the same time as the ~2 
hours post entinostat PK: 1 x 6 mL 
whole blood in red-top (e.g. BD 
367815 or 368660) tubes 
(mandatory) 
OSUCCC PhASR  
Entinostat PK3 
• Pre-dose: 1 × 4 mL whole blood in 
sodium heparin (green top; e.g. BD 
367871 or 367884) tubes 
(mandatory)  
• ~0.5 hours post dose: 1 × 4 mL 
whole blood in sodium heparin 
(green top; e.g. BD 367871 or 
367884) tubes (mandatory)  
• ~2 hours post dose: 1 × 4 mL whole 
blood in sodium heparin (green top; 
JHU APC  


NCI Protocol #:  10399 
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32 
e.g. BD 367871 or 367884) tubes 
(mandatory)  
Cycle 2 Day 2 
Entinostat PK4 
• Prior to etoposide-dose: 1 × 4 mL 
whole blood in sodium heparin 
(green top; e.g. BD 367871 or 
367884) tubes (mandatory)  
JHU APC  
Cycle 3 Day 1 
 
• Pre-treatment: 6 × 10 mL whole 
blood in sodium heparin (green top) 
tubes processed for flow cytometry 
and ELISpot, then frozen 
(mandatory) 
Bullock Laboratory 
(MITS core) 
Atezolizumab PK3 
• Pre-dose: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
• ~0.5 hours after the end of the 
infusion: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
OSUCCC PhASR  
Cycle 4 Day 1 
 
• Pre-treatment: 6 × 10 mL whole 
blood in sodium heparin (green top) 
tubes processed for flow cytometry 
and ELISpot, then frozen 
(mandatory) 
Bullock Laboratory 
(MITS core) 
Atezolizumab PK3 
• Pre-dose: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
• ~0.5 hours after the end of the 
infusion: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
OSUCCC PhASR  
Cycle 6 Day 1 
Atezolizumab PK3 
• Pre-dose: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
• ~0.5 hours after the end of the 
infusion: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
OSUCCC PhASR  
Cycle 8 Day 1 
Atezolizumab PK3 
• Pre-dose: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
OSUCCC PhASR  
 


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33 
• ~0.5 hours after the end of the 
infusion: 1 x 6 mL whole blood in 
red-top (e.g. BD 367815 or 368660) 
tubes (mandatory) 
Disease Progression 
 
• 2-3 tissue cores in formalin2 
(optional) 
• 2 x 10 mL whole blood in Streck 
cfDNA tubes (mandatory) 
EET Biobank 
 
• 6 × 10 mL whole blood in sodium 
heparin (green top) tubes processed 
for flow cytometry and ELISpot, 
then frozen (mandatory) 
Bullock Laboratory 
(MITS core) 
1For archival tissue, a copy of the corresponding anatomic pathology report, labeled with the 
patient study ID and Universal ID, must be sent with the tissue and uploaded to Rave.  If 
submitting slides, then slides must be processed in order, and numbered sequentially. 
2 For new biopsies, a fine needle aspirate (FNA) should be obtained for diagnostic purposes and 
submitted to pathology.  Cores should be obtained for research and not submitted to pathology 
for review.  The Tissue Biopsy Verification Form (Appendix E), a copy of the radiology 
and/or operative reports from the tissue removal procedure and the diagnostic anatomic 
pathology report must be sent with the tissue to the EET Biobank.  All reports must be labeled 
with the patient study ID and Universal ID. 
3 For any PK sample, the PK samples are on the days of drug administration.  If drug 
administration is shifted due to a holiday or inclement weather, the PK should be collected on 
that day (and not the exact day listed above).   
4 If etoposide is held for any reason, the accompanying entinostat PK sample should not be 
collected. 
 
 
5.2 
Summary Tables for Interventional Radiologist for Research Biopsies 
 
Biopsy #:  1 
Trial Time Point:  Baseline 
IR Biopsy Definition:  Research – No Clinical Impact (All cores from a single biopsy 
procedure impact research goals, but do not directly impact patient care or benefit the patient.) 
Core 
Priority 
Use in the 
Trial 
Biomarker 
Name(s) 
Tumor 
Content 
Required 
Post-Biopsy Processing 
1 
Integral 
WES 
No minimum 
requirement 
Formalin 
2 
Exploratory 
RNASeq 
No minimum 
requirement 
Formalin 


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34 
3 
Exploratory 
Transcriptional 
regulators, 
Immune cell 
markers 
No minimum 
requirement 
Formalin 
 
 
 
Biopsy #:  2 
Trial Time Point:  Disease Progression 
IR Biopsy Definition:  Research – No Clinical Impact (All cores from a single biopsy 
procedure impact research goals, but do not directly impact patient care or benefit the patient.) 
Core 
Priority 
Use in the 
Trial 
Biomarker 
Name(s) 
Tumor 
Content 
Required 
Post-Biopsy Processing 
1 
Integral 
WES 
No minimum 
requirement 
Formalin 
2 
Exploratory 
RNASeq 
No minimum 
requirement 
Formalin 
3 
Exploratory 
Immune cell 
markers 
No minimum 
requirement 
Formalin 
 
Note:  Pre-biopsy assessments will be reported and tracked through a trial-specific Case Report 
Form (CRF) within the CTEP Medidata Rave system (see Appendix D).  
 
5.3 
Specimen Procurement Kits and Scheduling 
 
5.3.1 Specimen Procurement Kits  
 
Kits for the collection and shipment of tissue cores in formalin and blood in cfDNA Streck tubes 
to the EET Biobank can be ordered online via the Kit Management system: 
(https://ricapps.nationwidechildrens.org/KitManagement).  
 
Users at the clinical sites will need to set up an account in the Kit Management system and select 
a specific clinical trial protocol to request a kit.  Please note that protocol may include more than 
one type of kit.  Each user may order two kits per kit type per day (daily max = 6 kits).  Kits are 
shipped ground, so please allow 5-7 days for receipt.  A complete list of kit contents for each kit 
type is located on the Kit Management system website. 
 
Note:  Kits or supplies are only provided for specimens shipped to the Biobank. Institutional 
supplies must be used for all other specimen collection and processing.  
 
5.3.2 Scheduling of Specimen Collections for EET Biobank 
 
Please adhere to the following guidelines when scheduling procedures to collect tissue:  
• Tumor tissue specimens collected during biopsy procedures and fixed in formalin must 
be shipped on the same day of collection. 


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35 
• Tissue in formalin can be collected Monday through Wednesday and shipped overnight 
for arrival on Tuesday through Thursday at the EET Biobank at Nationwide Children’s 
Hospital. 
• Fresh blood specimens may be collected and shipped Monday through Friday.  
 
 
5.3.3 Scheduling of Specimen Collections for Bullock laboratory (MITS core) 
 
• Blood samples will be collected at the timepoints specified in Section 5.1.  Frozen 
PBMCs will be shipped overnight on either Monday, Tuesday, or Wednesday.  For 
shipping instructions see Section 5.7.1 
 
5.3.4 Scheduling of Specimen Collections for JHU APC  
 
• Blood samples will be collected at the timepoints specified in Section 5.1.  Frozen serum 
will be shipped overnight on either Monday, Tuesday, or Wednesday. 
 
5.3.5 Scheduling of Specimen Collections for OSUCCC PhASR  
 
• Blood samples will be collected at the timepoints specified in Section 5.1.  Frozen serum 
will be shipped overnight on either Monday, Tuesday, or Wednesday. 
 
5.4 
Specimen Tracking System Instructions 
 
5.4.1 Specimen Tracking System Overview and Enrollment Instructions 
 
For the ETCTN STS, the following information will be requested: 
• Protocol Number 
• Investigator Identification  
o Institution and affiliate name 
o Investigator’s name 
• Eligibility Verification:  Patients must meet all the eligibility requirements listed in 
Section 0. 
• Additional Requirements: 
o Patients must provide a signed and dated, written informed consent form. 
 
Upon enrolling a patient, IWRS will communicate with OPEN, assigning two separate and 
unique identification numbers to the patient, a Universal patient ID (UPID) and a Treatment 
patient ID.  The UPID is associated with the patient and used each and every time the patient 
engages with the portion of this or any other protocol that uses the ETCTN Specimen Tracking 
System .  The UPID contains no information or link to the treatment protocol.  IWRS will 
maintain an association between the UPID for ETCTN biobanking and molecular 
characterization and any treatment protocols the patient participates in, thereby allowing analysis 
of the molecular characterization results with the clinical data.   
 
Immediately following enrollment, the institutional anatomical pathology report for the diagnosis 


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36 
under which the patient is being enrolled must be uploaded into Rave.  The report must include 
the surgical pathology ID (SPID), collection date, block number, and the IWRS-assigned UPID 
and patient study ID for this trial.  For newly acquired biopsies, Tissue Biopsy Verification Form 
(Appendix E), the radiology and/or operative report(s) must also be uploaded into Rave.  
Important:  Remove any personally identifying information, including, but not limited to, 
the patient’s name, date of birth, initials, medical record number, and patient contact 
information from the institutional pathology report prior to submission. 
 
Additionally, please note that the STS software creates pop-up windows when reports are 
generated, so you will need to enable pop-ups within your web browser while using the software.   
 
For questions regarding the Specimen Tracking System , please contact STS Support at 
STS.Support@theradex.com. 
 
The Shipping List report must be included with all sample submissions. 
 
5.4.2 Specimen Labeling 
 
5.4.2.1 Blood Specimen Labels  
 
Include the following on blood specimens (including whole blood and frozen, processed blood 
products – like serum and plasma): 
• Patient Study ID 
• Universal Patient ID (UPID) 
• Specimen ID (automatically generated by Rave) 
• Time point 
• Specimen type (e.g., blood, serum) 
• Collection date and time (to be added by hand) 
 
5.4.2.2 Tissue Specimen Labels 
 
Include the following on all tissue specimens or containers (e.g., formalin jar, FFPE block or 
slides):  
• Patient Study ID 
• Universal Patient ID (UPID) 
• Specimen ID (automatically generated by Rave) 
• Time point 
• Specimen type (e.g., formalin-fixed paraffin-embedded [FFPE] Block, Formalin 
Fixed Tissue, Fresh Tissue in Media, etc.) 
• Tissue type (P for primary, M for metastatic or N for normal) 
• Surgical pathology ID (SPID) number (archival only)  
• Block number from the corresponding pathology report (archival only) 
• Collection date and time (to be added by hand) – collection time required for tissue in 
formalin only 
• Slide section number (only if archival tissue is submitted as slides) (to be added by 


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37 
hand) 
 
5.4.2.3 Example of Specimen Label Generated by STS 
 
STS includes a label printing facility, accessed via the Print Label CRF in the All Specimens 
folder. A generated PDF is emailed to the user as a result of saving that form. 
 
The following image is an example of a tissue specimen label printed on a label that is 0.5” high 
and 1.28” wide. 
 
  
 
 
The QR code in the above example is for the Specimen ID shown on the second line.   
 
Labels may be printed on a special purpose label printer, one label at a time, or on a standard 
laser printer, multiple labels per page. Theradex recommends the use of these low temperature 
waterproof labels for standard laser printers: https://www.labtag.com/shop/product/cryo-laser-
labels-1-28-x-0-5-cl-23-colors-available/ 
 
The last line item on the label includes the following data points joined together: 
1. Tissue only: Primary (P), Metastatic (M), Normal (N) tissue indicated at the 
beginning of the specimen ID; this field is blank if not relevant (e.g., for blood) 
2. Block ID or blank if not relevant 
3. SPID (Surgical Pathology ID) or blank if none 
4. An optional alpha-numeric code that is protocol specific and is only included if the 
protocol requires an additional special code classification 
 
Space is provided at the bottom of the label for the handwritten date and optional time.   
The last line on the example label is for the handwritten date and optional time. 
 
5.4.3 Overview of Process at Treating Site 
 
5.4.3.1 OPEN Registration 
 
All registrations will be performed using the Oncology Patient Enrollment Network (OPEN) 
system.  OPEN communicates automatically with the Interactive Web Response System (IWRS) 
which handles identifier assignments, any study randomization, and any prescribed slot 


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assignments.  If specimen analysis is required to determine eligibility, the protocol will be setup 
with multi-step registration. 
 
Registration without eligibility specimen analysis:  
 
1. Site enters registration data into OPEN during one or more steps. 
2. IWRS receives data from OPEN, generates the Patient Study ID and the Universal Patient 
ID, both of which are sent back to OPEN. 
3. IWRS sends all applicable registration data directly to Rave at the end of the final 
registration step. 
 
Any data entry errors made during enrollment should be corrected in Rave. 
 
5.4.3.2 Rave Specimen Tracking Process Steps 
 
Step 0: Log into Rave via your CTEP-IAM account, then navigate to the appropriate participant. 
 
Step 1:  Complete the Histology and Disease form (but do not upload reports until a specimen 
label can be applied to them) and the Baseline forms regarding Prior Therapies.  Enter the 
initial clinical specimen data:  
• Specimen Tracking Enrollment CRF:  Enter Time Point, Specimen Category, 
Specimen Type, Block number, Tissue type, Surgical Path ID, and number of labels 
needed (include extra labels to apply to reports to be uploaded).  CRF generates unique 
Specimen ID.  
 
Step 2:  Print labels using the Print Labels CRF located in the All Specimens folder, then  collect 
specimen. 
• Label specimen containers and write collection date and time on each label.  After 
collection, store labeled specimens as described in Section 5.4.2. 
• Apply an extra specimen label to each report before scanning.  Return to the Histology 
and Disease form to upload any initial Pathology, Radiology, Molecular Reports (up to 
4), Surgical (or Operative) reports and Tissue Biopsy Verification form (when 
applicable).  Return to Specimen Tracking Enrollment CRF to upload any molecular 
report (one per specimen) and/or specimen specific pathology or related report (one per 
specimen).  Uploaded reports should have protected health information (PHI) data, like 
name, date of birth, mailing address, medical record number or social security number 
(SSN), redacted.  Do not redact SPID, block number, diagnosis or relevant dates (such as 
collection date), and include the UPID and patient study ID on each document.  
 
Step 3:  Complete specimen data entry. 
• Specimen Transmittal Form:  Enter collection date and time and other required 
specimen details. 
 
Step 4:  When ready to ship, enter shipment information. 
• Shipping Status CRF:  Enter tracking number, your contact information, recipient, 


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number of sample containers and ship date once for the first specimen in a shipment. 
• Copy Shipping CRF:  In the specimen folders for additional specimens (if any) that will 
be shipped with the initial specimen, please use the Copy Shipping form to derive 
common data into additional Shipping Status forms. A few unique fields will still need 
to be entered in Shipping Status.  . 
 
Step 5:  Print shipping list report and prepare to ship.  
• Shipping List report is available at the site level. 
• Print two copies of the shipping list, one to provide in the box, the other for your own 
records. 
• Print pathology or other required reports to include in the box.  Be sure the printed copy 
includes the specimen label. 
 
Step 6:  Send email notification.  
• For only one of the specimens in the shipment, click “Send Email Alert” checkbox on the 
Shipping Status CRF to email recipient. 
 
Step 7:  Ship the specimen(s). 
 
Step 8: Monitor the Receiving Status form located in each specimen folder for acknowledgment 
of receipt and adequacy. 
 
5.5 
Specimen Collection  
 
5.5.1 Archival or Formalin-Fixed Paraffin-Embedded (FFPE) Tumor Specimen  
 
A copy of the corresponding anatomic pathology report must be sent with the 
Archival tissue and uploaded to Rave. 
 
If previously-collected FFPE tissue will be submitted, then the following criteria must be met: 
 
• Tissue must have been collected within 6 months prior to registration  
• FFPE tumor tissue block(s) must be submitted.  The optimal block is at least 70% tumor.  
Specimen size requirement is as follows: 
o Surface area:  25 mm2 is optimal.  Minimum is 5 mm2. 
o Volume:  1 mm3 optimal.  Minimum volume is 0.2 mm3, however the success of 
DNA extraction decreases at suboptimal tissue volume. 
 
If an existing block cannot be submitted, the following are requested, if available: 
o Twenty to twenty-five (20 – 25) 10 µm unstained air-dried uncharged slides 
(Patients may be enrolled if a minimum of the first 20 slides are available); 
uncharged slides at 10-microns (µm) are preferred for slides intended for 
DNA/RNA extractions (mandatory).   
o Ten (10) 4 µm unstained air-dried charged slides (optional)  
 


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Process and number slides sequentially (e.g., unstained slides should be processed and be labeled 
1 – n). 
 
See Section 5.4.2 for labeling instructions. 
 
5.5.2 Formalin-Fixed Tumor Biopsies  
 
The Tissue Biopsy Verification Form (Appendix E), a copy of the radiology and/or 
operative reports from the tissue removal procedure and the diagnostic anatomic 
pathology report must be sent with the tissue and uploaded to Rave. 
 
1. Label formalin-filled containers according to instructions in Section 5.4.2.  
2. Obtain fine needle aspirate (FNA) and submit to pathology for review.  Rapid On-Site 
Evaluation (ROSE) by a cytopathologist should be used, when available, to confirm 
placement in viable tumor. 
3. Obtain 2-3 16-gauge or 18-gauge core needle biopsy specimens, and place one core in 
each cassette.  
4. Snap the cassette lids closed and place cassettes into a formalin-filled pre-labeled 
container as soon as possible after collection to prevent air drying.  Up to two cassettes 
may be placed in one formalin jar. 
5. Secure the container lids and package containers into the shipping kit according to 
instructions in Section 5.6.  Keep tissue in formalin jars at room temperature until 
shipment to the EET Biobank.  
 
5.5.3 Blood Collection  
 
5.5.3.1 Collection of Blood in Streck cfDNA Tube (EET Biobank) 
 
1. Label two 10 mL Streck cfDNA tubes according to the instructions in Section 5.4.2.  
2. Collect 10 mL of blood into each pre-labeled tube and gently invert to mix.  Note:  blood 
must be thoroughly mixed to ensure preservation of specimen.  Heparin should be 
avoided in pre-collection flush procedures.  If therapeutic heparin dosing contamination 
is a possibility, then venipuncture is recommended as a first choice collection method.  If 
a Streck cfDNA tube immediately follows a heparin tube in the draw order, then 
collecting an EDTA tube as a waste tube prior to collection in the Streck Cell-Free DNA 
BCT is recommended. 
3. After collection, blood in Streck cfDNA tubes should never be refrigerated, as this 
will compromise the specimen.  Blood collected in Streck cfDNA tubes is stable at room 
temperature.  
 
5.5.3.2 Collection of Blood in Sodium Heparin Tubes (Bullock laboratory)  
 
1. Label sodium heparin (green top) tubes according to the instructions in Section 5.4.2.  
2. Collect 10 mL of whole blood in sodium heparin (green top) tubes (6 tubes total).  
3. Collected at C1D1, C2D1, C3D1, C4D1, and at disease progression. 
 


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5.5.3.2.1 
Tubes processing procedure at time of collection 
 
Please contact the Protocol Contact if local standard operating procedure (SOP) for PBMC 
isolation requires deviation from these instructions. 
 
Equipment/Supplies 
1. 50mL Leucosep tubes  
2. Ficoll-Paque PLUS (Amersham Biosciences, Cat. # 17-1440-03) 
3. 5mL and 10mL sterile pipettes, individually wrapped 
4. 50mL polypropylene tubes (sterile) 
5. 15mL polypropylene tubes (sterile) 
6. 1.8mL cryotube vials 
7. Controlled rate freezing containers (Nalgene “Mr. Frostys”) 
8. -80ºC Freezer 
9. Hemocytometer 
 
Reagents 
1. Fetal Bovine Serum (Gibco) 
2. Dulbecco’s Phosphate-Buffered Saline  
3. DMSO (Cat# D2650, endotoxin tested, Sigma) 
4. Trypan Blue for cell counting 
 
Standards and Calibration 
 
Procedure 
 
The desired quantity of peripheral blood mononuclear cells (PBMC) is around 8 million cell per 
vial plus 2 vials for flow cytometry (FACS) at around 2.0-2.4 million cells per vial.  
 
A. Preparation of Ficoll paque /leucosep tube 
1. Pipette 15ml of Ficoll into each of the 50ml Leucosep tubes. 
2. Centrifuge at 1000 RCF for 30s, then store in the dark at room temperature. 
 
B. PBMC isolation, aliquoting and freezing 
1. Pipette whole blood onto the membrane frit of the Leucosep tube. (No more than 
30ml of whole blood in each Leucosep tube.) 
2. Centrifuge at 1000 RCF for 10 minutes  
3. If possible, pipette and save up to 12 mL of plasma from the top layer. Place plasma 
in 15 ml conical tube and place in -80ºC. 
4. Pipette away the buffy-coat PBMC inter-phase layer and the overlaying plasma with a 
5ml pipette.  (You may have to gently scrape the side of the tube with the pipette tip 
to remove adherent PBMC, and be careful that you do not pipette any of the 
underlying Ficoll.) 
5. Transfer buffy-coat into 2 new 50ml tubes and fill each to 45 ml with PBS + 10% 
FBS. 
6. Centrifuge the 50ml tubes with the buffy-coat at 250 RCF for 10 minutes 


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7. Carefully decant the supernatant into a container with bleach (beware of splashing 
bleach) and re-suspend the pellets containing the PBMC in a total of 25ml of PBS in a 
single 50ml tube. 
8. Keep a small aliquot for counting 
9. Centrifuge at 250 RCF for 10 minutes 
10. Determine the number of cryovials needed (see below, Calculations to Determine # 
Cryovials)  
11. Decant supernatant into bleach. 
12. Count cryovials and divide the # by 2. This is the number of mL of FBS   used to re-
suspend the cell pellet  
13. Re-suspend pellet in FBS. 
14. Draw 1ml of suspension. 
15. Place ¼ of above into a new 15ml tube. 
16. Place ¾ back into the original 50ml tube. 
17. Discard pipette. 
18. Draw 1ml of FBS. 
19. Place ¼ into re-suspension (original 50mL tube). 
20. Place ¾ into the 15ml tube. 
21. Using a new pipette, obtain the same number of ml as step 14 of 20% DMSO in FBS. 
22. Add drop wise (while gently swirling the tube) to the re-suspension in the 50ml tube. 
23. Place 1ml of the re-suspension into each cryovial. 
24. Add 1ml of DMSO into the 15ml tube (drop wise/swirl) 
25. Pipette the cell suspension to FACS vials, 1 ml each. 
26. Place the cryovials + FACS vials in a freezing containers  
27. Place in -80ºC freezer for at least an overnight period (12 hours), then transfer 
to liquid Nitrogen freezer.  Samples should be shipped in batch, quarterly. 
 
Calculation to Determine Number of Cryovials 
 
Number of cell counted × 5 × total volume of the suspension × 10,000 = A (Total PBMC) 
 
A / 8,000,000 = B (number of vials you want) 
 
[A / (.5 × B)] x 0.25 = C (Total number of PBMC in both FACS vials) 
 
A – C = D (number of lymphocytes left after FACS lymphocytes removed) 
 
D / B = number of lymphocytes in each regular vial 
 
5.5.3.3 Collection of Blood in Sodium Heparin (Green Top) Tubes for Entinostat PK (JHU 
APC) 
 
1. Label sodium heparin (green top) tubes according to the instructions in Section 5.4.2.  
2. Obtain venous blood by standard phlebotomy technique from a peripheral access point 
(Central access is permissible since entinostat is administered orally). 
3. Collect 4 mL of whole blood in sodium heparin (green top; e.g. BD 367871 or 367884) 
tubes (1 tube total).  
4. Invert each tube several times (8-10 times) immediately after collection. 
5. Place samples immediately on ice after collection; samples must be processed within 30 
minutes. 


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6. Collected at time points listed in section 5.1 
 
 
 
 
5.5.3.3.1 Processing of Blood in Sodium Heparin (Green Top) Tubes for Entinostat PK (JHU 
APC) 
 
1. Invert sample 8-10 times immediately before processing.   
2. Centrifuge at ~1200xg for 10 minutes in swinging bucket (SW) or 15 minutes in a fixed 
angel (FA) rotor at 4ºC in a refrigerated centrifuge.  Make sure that the centrifuge reaches 
speed and is maintained throughout the entire spin. 
3. Carefully remove tube from centrifuge.  
4. Using a pipette, transfer equal aliquots of plasma into 2-3 labeled 1.2 mL cryovials (e.g., 
preferred are external thread, conical self-standing vials like CorningTM 430658), not 
exceeding ~1 mL per cryovial.   
5. Label samples per Section 5.4.2.1 above. 
6. Store plasma samples at -70ºC or below until shipment or transfer to Johns Hopkins. 
 
5.5.3.4 Collection of Blood in Serum (Red Top) Tubes for Atezolizumab PK (OSUCCC 
PhASR) 
 
1. Venous whole blood (6 mL) will be collected into pre-labeled serum (red-top; e.g. BD 
367815 or 368660) tubes at the time points specified. Collect each PK sample as close as 
possible to the planned (nominal) time relative to dosing.  
2. Collected at time points listed in section 5.1 
3. If a cannula is used, the cannula will be inserted into an arm vein within sufficient time 
prior to dosing, kept patent with normal saline or heparin solution, and will be removed 
as instructed by physician or earlier if the subject requests.  To avoid artificial dilution of 
the PK samples by saline, 1 mL of whole blood will be collected and discarded before 
each whole blood PK sample is collected. 
 
5.5.3.4.1 Processing of Blood in Serum (Red Top) Tubes for Atezolizumab PK (OSUCCC 
PhASR) 
 
1. Allow blood to clot upright at room temperature for at least 30 minutes (maximum 60 
minutes) prior to processing.   
2. If the blood is not immediately processed after the clotting period, then tubes should be 
stored (after the 30-60 minutes of clotting time) at 4°C for no longer than 4 hours.   
3. Centrifuging for 10 minutes at 1,200 × g at room temperature. 
4. Using a clean transfer pipette, aliquot serum into the labeled cryovials (~2-3) at an 
aliquot volume of 1 mL per tube. Labeling should be printed from the ETCTN Specimen 
Tracking System (label should include at a minimum the Study ID, Patient ID, sample 
type, sample collection date, exact sample collection time).  
5. Avoid picking up red blood cells when aliquoting by keeping the pipet above the red 
blood cell layer and leaving a small amount of serum in the tube.   


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6. Tightly secure the cap of the vials before storage. 
7. Aliquoting and freezing of serum specimens should be completed within 1 hour of 
centrifugation.  
8. Store serum cryovials upright in a specimen box or rack in a -70°C to -90°C or colder 
freezer. Do not allow specimens to thaw after freezing. 
 
5.6 
Shipping Specimens from Clinical Site to the EET Biobank  
 
5.6.1 General Shipping Information 
 
When kits are provided, the shipping container sent with kit contents should be used to ship 
specimens to the EET Biobank.  In winter months, please include extra insulation, such as bubble 
wrap, inside the shipping container. 
 
For formalin-fixed biopsies, the Tissue Biopsy Verification Form (Appendix E) and a copy 
of the radiology and/or operative reports from the tissue removal procedure and the 
diagnostic anatomic pathology report must be sent with the tissue to the EET Biobank. 
  
For all archival tissue, the corresponding anatomical clinical pathology report is required 
both in the package and uploaded in the ETCTN specimen tracking system.  If this is not 
available at the time of shipment, then it must be sent to the EET Biobank as soon as possible 
and uploaded to the ETCTN specimen tracking system, or the specimen will not be processed.  
The pathology report must state the disease diagnosis made by the reviewing pathologist. 
 
5.6.2 Specimen Shipping Instructions 
 
Tissue in formalin must be shipped on the day of collection.  Collect and ship on Monday 
through Wednesday. 
 
Archival (FFPE) tissue may be shipped on Monday through Thursday.  
 
Fresh blood may be shipped on Monday through Friday.  Please select “Saturday Delivery” 
when shipping fresh blood on a Friday.  
 
5.6.2.1 
Shipping of FFPE Blocks and Glass Slides  
 
1. Before packaging blocks or slides, verify that each specimen is labeled according to 
Section 5.4.2.2. 
2. Blocks should be placed in a hard-sided container, preferably a special block holder, to 
protect the specimen.  Glass slides are to be placed in plastic slide holders.  Place tissue 
paper on top of the separated slides prior to closing the slide holder to reduce slide 
movement during shipment. 
3. Place the blocks or slides in a reinforced cardboard shipping box with appropriate 
packaging filler to minimize movement of specimens within the shipping box. 
4. Include a copy of the forms listed above and a shipping manifest from the Specimen 
Tracking System with each shipment.  


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5. Please include a cold pack when shipping on hot days and extra insulation on cold days. 
6. Ship specimens to the address listed below.  FedEx Priority Overnight is strongly 
recommended to prevent delays in package receipt.  
 
5.6.2.2 
Shipping Blood in an Ambient Shipper  
 
1. Before packaging specimens, verify that each specimen is labeled according to the 
instructions in Section 5.4.2.1 and that the lids of all primary receptacles containing 
liquid are tightly sealed.   
2. Prepare the SAF-T-TEMP Gel Pak for shipment.  Note: If contents of the Pak are 
crunchy, place Pak in a warm water bath until gel is smooth.  Do not refrigerate, freeze, 
or microwave.  
3. Place the SAF-T-TEMP Pak in bottom of insulated chest.  Note:  The insulated chest 
must be shipped inside the provided cardboard box(es).  
4. Place the blood collection tubes in zip-lock bags.   
5. Next, place blood into a biohazard envelope with absorbent material.  Expel as much air 
as possible and seal the envelope securely.  
6. Place the biohazard envelope into a Tyvek envelope.  Expel as much air as possible and 
seal securely. 
7. Place packaged blood collection tube(s) and a copy of the shipping manifest from the 
Sample Tracking System on top of SAF-T-TEMP Pak.  
8.  Place the lid on the insulated chest.  
9. Close the outer flaps of the shipping box and tape shut. 
10. Attach a shipping label to the top of the shipping container.  
11. Attach an Exempt Human Specimen sticker to the side of the box. 
12. Ship specimens via overnight courier to the address below.  FedEx Priority Overnight is 
strongly recommended to prevent delays in package receipt.  
 
5.6.2.3 
Shipping Ambient Tissue in a Single-Chamber Kit  
 
1. Before packaging specimens, verify that each specimen is labeled according to the 
instructions in Section 5.4.2 and that the lids of all primary receptacles containing liquid 
are tightly sealed.  The lids of formalin jars should be wrapped in parafilm.  Absorbent 
material must be placed around each primary container that holds liquid.   
2. Place the specimens in zip-lock bags.  Use a separate bag for each specimen type. 
3. Place specimens into the secondary pressure vessel surrounded by bubble wrap.  Place 
the lid on the secondary pressure vessel and set it inside the kit chamber.  
4. Place a copy of the shipping manifest and corresponding reports such as pathology, 
surgical, or radiology reports into the insulated shipping container.  
5. Set the lid on top of the container.  Close the outer flaps and tape shut. 
6. Attach a shipping label to the top of the shipping container.  
7. Attach an Exempt Human Specimen sticker to the side of the container. 
8. Ship specimens via overnight courier to the address below.  FedEx Priority Overnight is 
strongly recommended to prevent delays in package receipt.  
 


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5.6.3 Shipping Address 
 
Ship to the address below.  Ship formalin-fixed and fresh blood specimens the same day of 
specimen collection.  Do not ship specimens the day before a holiday. 
 
EET Biobank 
The Research Institute at Nationwide Children's Hospital 
700 Children's Drive, WA1340 
Columbus, Ohio 43205 
PH: (614) 722-2865 
FAX: (614) 722-2897 
Email: BPCBank@nationwidechildrens.org 
 
FedEx Priority Overnight service is very strongly preferred.   
 
NOTE:  The EET Biobank FedEx Account will not be provided to submitting institutions.  
There is no central Courier account for this study.  Sites are responsible for the cost of shipments 
to the EET Biobank. 
 
5.6.4 Contact Information for Assistance 
 
For all queries, please use the contact information below: 
 
EET Biobank  
Toll-free Phone: (800) 347-2486 
E-mail:  BPCBank@nationwidechildrens.org 
 
5.7 
Shipping of Specimens from Clinical Site to Other Laboratories  
 
5.7.1 Shipping of Specimens to Bullock laboratory (MITS core) 
 
5.7.1.1 
Specimen Shipping Instructions 
 
PBMC 
• PBMC isolated as described in section 5.5.3.2.1 should be shipped on dry ice, priority 
overnight for next day morning delivery 
• PBMC should be shipped on Monday-Wednesday and should not be sent on Thursdays 
or Fridays. 
• Sites shipping samples should give the UVA MITS Core 24 business hours of notice 
prior to shipping to ensure that staff will be available to receive the package. If Monday 
shipping is planned, please notify during business hours on Friday. 
 
Email: kts4v@virginia.edu (notify immediately of anticipated shipment) 
 
5.7.1.2 
Shipping Address 
 


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47 
Please ship frozen specimens to: 
 
UVA MITS Core Lab 
CC: Bullock Laboratory: Attention: Kelly Smith 
University of Virginia – HITC/MITS Core 
21 Hospital Drive, OMS Building, Rm 3835 
Charlottesville, VA 22908 
Lab Phone: 434‐243‐6505 
Cell Phone: 703‐946‐5152 
 
5.7.1.3 
Contact Information for Assistance 
 
Kelly Smith 
Technical Director, Lab Manager 
434-243-6505 
434-982-6608 (fax) 
kts4v@virginia.edu 
 
5.7.2 Shipping of Blood Samples to JHU APC  
 
5.7.2.1 Specimen Shipping 
 
o Specimens should be stored through the end of Cycle 2 and shipped as a batch by 
participant (more than one participant/shipment is acceptable).  
o A participant's samples should be shipped to the JHU APC lab within 2 weeks of 
the last sample's collection date. (i.e., if C2D2 sample is collected on 9/1/2021, all 
of that participant's samples should be at the JHU APC lab by 9/15/2021).  
o The JHU APC lab may contact the study team to request shipment off-schedule.   
o Please ship only 1 aliquot to the JHU APC laboratory within each shipment. 
Once receipt is confirmed, the back-up aliquot(s) may also be shipped.  The 
back-up aliquots can be shipped at a later date with subsequent batches of 
samples for other participants.  
 
5.7.2.1.1 Preparing the Specimen Shipment 
 
o Samples should be stored in cardboard boxes (5 1/8” x 5 1/8” x 2”, LxWxH) with 
dividers. (e.g., VWR Box item number is 82021-114; divider item number is 
82007-154.) 
o Please organize the samples by Patient and Time point in the box.  
o Do not store in plastic bags (they break on dry ice and labels will detach).  
o A copy of each of the pharmacokinetic sample collection forms for the respective 
patients or a sample list should be included with each shipment. To prevent 
problems with illegible writing on tubes, consider numbering them (in addition to 
sample label) and numbering samples on the sample sheet.  
o Note the study number, PI, and the drugs used/to be measured (i.e. entinostat).  


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48 
o A name, phone number and email address should be included with samples so that 
receipt can be acknowledged. 
o Please notify the lab by email (onc-pharmacology@lists.johnshopkins.edu) or 
telephone (410-502-7192 or 410-955-1129) at least 24 hours prior to shipment.  
 
5.7.2.1.2 Specimen Shipping Instructions 
 
o Samples collected at Johns Hopkins University can be transferred utilizing the 
current SOPs. 
o All samples should be shipped via overnight express courier in insulated containers 
with enough dry ice to maintain the samples in a frozen state.  
o Overnight shipments should occur on Monday through Wednesday except when 
the following day is a holiday. 
o Please notify the lab by email (onc-pharmacology@lists.johnshopkins.edu) or 
telephone (410-502-7192 or 410-955-1129) at least 24 hours prior to shipment. 
 
5.7.2.2 JHU APC Shipping Address 
 
Analytical Pharmacology Core Laboratory 
Attn: Entinostat (NCI10399) Study Samples 
1650 Orleans St. CRB1 Rm 184 
Baltimore, MD 21231-1000* 
Phone: 410-502-7192 or 410-955-1129 
Email: onc-pharmacology@lists.johnshopkins.edu  
 
*This zip code is for FedEx shipments.  Please change to 21287 if utilizing UPS to ship. 
 
5.7.3 Shipping of Blood Samples to OSUCCC PhASR  
 
5.7.3.1 
Specimen Shipping 
 
o Specimens should be stored through the end of Cycle 8 and shipped as a batch by 
participant (more than one participant/shipment is acceptable).  
o A participant's samples should be shipped to the OSUCCC PhASR lab within 2 
weeks of the last sample's collection date. (i.e., if C8D1 sample is collected on 
9/1/2021, all of that participant's samples should be at the OSUCCC PhASR lab 
by 9/15/2021).  
o The OSUCCC PhASR lab may contact the study team to request shipment off-
schedule.   
o Please ship only 1 aliquot to the OSUCCC PhASR laboratory within each 
shipment. Once receipt is confirmed, the back-up aliquot(s) may also be 
shipped.  The back-up aliquots can be shipped at a later date with 
subsequent batches of samples for other participants.   
 
5.7.3.1.1 Preparing the Specimen Shipment 
 


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49 
o Samples should be stored in cardboard boxes (5 1/8” x 5 1/8” x 2”, LxWxH) with 
dividers. (e.g., VWR Box item number is 82021-114; divider item number is 
82007-154.) 
o Please organize the samples by Patient and Time point in the box.  
o Do not store in plastic bags (they break on dry-ice and labels will detach).  
o A copy of each of the pharmacokinetic sample collection forms for the respective 
patients or a sample list should be included with each shipment. To prevent 
problems with illegible writing on tubes, consider numbering them (in addition to 
sample label) and numbering samples on the sample sheet.  
o Note the study number, PI, and the drugs used/to be measured (i.e. atezolizumab). 
o A name, phone number and email address should be included with samples so that 
receipt can be acknowledged. 
 
5.7.3.1.2  Specimen Shipping Instructions 
 
o All samples should be shipped via overnight express courier in insulated containers 
with enough dry ice to maintain the samples in a frozen state.  
o Overnight shipments should occur on Monday through Wednesday except when 
the following day is a holiday. 
o Please notify the OSUCCC PhASR lab by email (PhASR@osumc.edu) within 24 
hours prior to shipment.  
 
5.7.3.2 
OSUCCC PhASR Shipping Address 
The OSUCCC Pharmacoanalytical Shared Resource 
Attn:  Kasey Hill, Ph.D. 
441 Biomedical Research Tower 
460 West 12th Avenue 
Columbus, OH 43210 
Phone:  (614) 688-0578 
Fax:  (614) 292-7766 
Email: PhASR@osumc.edu 
 
5.8 
Biomarker Plan  
 
 


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50 
List of Biomarker Assays in Order of Priority 
Priority 
Biomarker 
Name 
Assay 
(CLIA:  
Y/N) 
Use in the Trial 
and Purpose 
Specimens 
Tested 
Collection Time Points 
Mandatory 
or Optional 
Assay Laboratory 
and Lab PI 
Tissue-based Biomarkers 
1 
Whole Exome 
Sequencing 
(WES) 
NGS 
 
CLIA:  N 
Integrated 
 
To identify 
genomic alterations 
and determine if 
they could be 
useful biomarkers 
for SCLC. Of 
specific interest are 
CREBBP and 
EP300 genes and 
TMB analysis. 
DNA from 
FFPE Tumor 
Archival or Baseline 
 
Disease Progression 
M (archival 
or baseline) 
 
O (disease 
progression) 
NCLN Genomics 
Laboratory 
 
Mickey Williams, 
Ph.D. 
 
mickey.williams@
nih.gov 
 
 
2 
RNA 
Sequencing 
(RNAseq) 
NGS 
 
CLIA:  N 
Exploratory 
 
To identify the 
transcriptional 
characteristics of 
response to 
treatment 
RNA from 
FFPE Tumor 
Archival or Baseline 
 
Disease Progression 
M (archival 
or baseline) 
 
O (disease 
progression) 
NCLN Genomics 
Laboratory 
 
Mickey Williams, 
Ph.D. 
 
mickey.williams@
nih.gov 
 
3 
Transcriptional 
Regulators 
Multiplex 
IHC 
 
CLIA:  N 
Exploratory 
 
To characterize the 
subtype of small 
cell lung cancer 
based on 
transcriptional 
regulators: ASCL1, 
NeuroD1, YAP2, 
POU2F3 
Unstained 
slides from 
FFPE Tumor 
Archival or Baseline 
M 
Rudin Laboratory, 
Memorial-Sloan 
Kettering Cancer 
Center 
Charles Rudin, 
M.D., Ph.D. 
rudinc@mskcc.org 
 


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51 
Priority 
Biomarker 
Name 
Assay 
(CLIA:  
Y/N) 
Use in the Trial 
and Purpose 
Specimens 
Tested 
Collection Time Points 
Mandatory 
or Optional 
Assay Laboratory 
and Lab PI 
4 
Immune Cell 
Markers 
Multispectral 
IHC (Vectra) 
 
CLIA:  N 
Exploratory 
 
To characterize the 
tumor 
microenvironment 
for PDL1, CD8, 
NK cells, 
regulatory and 
effector T-cells, 
arginase, and IDO. 
Unstained 
slides from 
FFPE Tumor 
Archival or Baseline 
 
Disease Progression 
M (archival 
or baseline) 
 
O (disease 
progression) 
Bullock 
Laboratory, 
University of 
Virginia 
 
Timothy Bullock, 
Ph.D. 
 
tb5v@virginia.edu 
 
Blood-based Biomarkers 
1 
Whole Exome 
Sequencing 
(WES) 
NGS 
 
CLIA:  N 
Integrated 
 
Germline Control 
DNA from 
blood in 
cfDNA Streck 
tubes 
C1D1  
 
Collected as part of specimen 
for ctDNA biomarker 
M 
NCLN Genomics 
Laboratory 
 
Mickey Williams, 
Ph.D. 
 
mickey.williams@
nih.gov 
 
2 
ctDNA 
NGS 
 
CLIA:  N 
Exploratory 
 
To identify 
genomic alterations 
in genes of interest, 
CREBBP and 
EP300, that may 
not be detectable in 
tissue. Identify 
possible 
mechanisms of 
resistance at time 
of progression 
Plasma from 
cfDNA Streck 
tubes 
C1D1 
 
Disease Progression 
M 
NCLN Genomics 
Laboratory 
 
Mickey Williams, 
Ph.D. 
 
mickey.williams@
nih.gov 
 


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52 
Priority 
Biomarker 
Name 
Assay 
(CLIA:  
Y/N) 
Use in the Trial 
and Purpose 
Specimens 
Tested 
Collection Time Points 
Mandatory 
or Optional 
Assay Laboratory 
and Lab PI 
3 
Circulating 
Immune Cells 
Flow 
Cytometry 
 
CLIA:  N 
Exploratory 
 
To characterize 
circulating immune 
cells in response to 
treatment 
PBMCs from 
Sodium 
Heparin Tubes 
C1D1 
C2D1 
C3D1 
C4D1 
Disease Progression 
M 
Bullock 
Laboratory, 
University of 
Virginia 
 
Timothy Bullock, 
Ph.D. 
 
tb5v@virginia.edu 
 
4 
Immunogenicity 
ELISpot 
 
CLIA: Y 
Exploratory 
 
To determine 
immunogenicity of 
treatment over time 
PBMCs from 
Sodium 
Heparin Tubes 
C1D1 
C2D1 
C3D1 
C4D1 
Disease Progression 
M 
Bullock 
Laboratory, 
University of 
Virginia 
 
Timothy Bullock, 
Ph.D. 
 
tb5v@virginia.edu 
 
5 
Entinostat 
Exposure 
LC-MS/MS 
CLIA: N 
GLP: Y 
Integrated 
 
Pharmacokinetic 
profile of entinostat 
Plasma from 
Sodium 
Heparin Tubes  
C1D1 pre-dose and 
approximately 0.5 and 2 hours 
after entinostat administration; 
C1 D2: prior to etoposide 
infusion; C1D8 pre-dose, 
C1D15 pre-dose; C2D1 pre-
dose and approximately 0.5 
and 2 hours after entinostat 
administration; C2 D2: prior to 
etoposide infusion 
M 
Johns Hopkins 
University 
Analytical 
Pharmacology 
Core  
 
Michelle Rudek, 
Pharm.D., Ph.D. 
 
Mrudek2@jhmi.ed
u 
 
 


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Priority 
Biomarker 
Name 
Assay 
(CLIA:  
Y/N) 
Use in the Trial 
and Purpose 
Specimens 
Tested 
Collection Time Points 
Mandatory 
or Optional 
Assay Laboratory 
and Lab PI 
6 
Atezolizumab 
ELISA 
CLIA: N 
GLP: Y 
Integrated 
 
Pharmacokinetic 
profile of 
atezolizumab 
Serum from 
Red top Tubes 
C1D1 pre-dose and after the 
end of the atezolizumab 
infusion at the same time as the 
~2 hours post entinostat PK; 
C2D1 pre-dose and after the 
end of the atezolizumab 
infusion at the same time as the 
~2 hours post entinostat PK; 
C3D1 pre-dose and 
approximately 0.5 hours after 
the end of atezolizumab 
administration; C4D1 pre-dose 
and approximately 0.5 hours 
after the end of atezolizumab 
administration; C6D1 pre-dose 
and approximately 0.5 hours 
after the end of atezolizumab 
administration; C8D1 pre-dose 
and approximately 0.5 hours 
after the end of atezolizumab 
administration; 
M 
Pharmacoanalytical 
Shared Resource 
(PhASR), Ohio 
State University 
Comprehensive 
Cancer Center 
 
Mitch Phelps, 
Ph.D. 
 
Phelps.32@osu.ed
u 
 
 


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5.9 
Integrated Correlative Studies 
 
5.9.1 Whole Exome Sequencing (WES) 
 
5.9.1.1 
Specimens Receipt and Processing at the EET Biobank  
 
Tumor tissue received in formalin will be paraffin-embedded.  FFPE tissue blocks will be 
sectioned to generate an initial hematoxylin and eosin (H&E)-stained slide.  All H&E stained 
slides will undergo a pathology QA review and annotation for macrodissection, if needed.  
Following macrodissection, tumor tissue from unstained slides will be scraped for co-extraction 
of DNA and RNA.  The nucleic acids will be analyzed to determine concentration and quality.  
Aliquots of DNA will be shipped to the central sequencing laboratory for analysis. 
 
DNA will be extracted from blood collected in cfDNA Streck tubes at baseline, following 
plasma processing.  DNA will be quantitated, and then stored in a -80°C freezer until shipping 
for analysis. 
 
5.9.1.2 
Site Performing Correlative Study 
 
This assay will be performed at the NCLN Genomics Laboratory under the supervision of 
Mickey Williams, Ph.D. 
 
5.9.1.3 
Contact information for notification of specimen shipment 
 
Mickey Williams, Ph.D. 
Email: mickey.williams@nih.gov  
 
5.10 
Exploratory/Ancillary Correlative Studies 
 
5.10.1 RNA Sequencing 
 
5.10.1.1 
Specimens Receipt and Processing at the EET Biobank  
 
Tumor tissue received in formalin will be paraffin-embedded.  FFPE tissue blocks will be 
sectioned to generate an initial hematoxylin and eosin (H&E)-stained slide.  All H&E stained 
slides will undergo a pathology QA review and annotation for macrodissection, if needed.  
Following macrodissection, tumor tissue from unstained slides will be scraped for co-extraction 
of DNA and RNA.  The nucleic acids will be analyzed to determine concentration and quality.  
Aliquots of RNA will be shipped to the central sequencing laboratory for analysis. 
 
5.10.1.2 
Site Performing Correlative Study 
 
This assay will be performed at the NCLN Genomics Laboratory under the supervision of 
Mickey Williams, Ph.D. 
 


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55 
5.10.1.3 Contact information for notification of specimen shipment 
 
Mickey Williams, Ph.D. 
Email: mickey.williams@nih.gov  
 
5.10.2 Transcriptional Regulators 
 
5.10.2.1 Specimens Receipt and Processing at the EET Biobank  
 
Following standard processing and paraffin embedding at the EET Biobank, tissue blocks will be 
stored at room temperature (not exceeding 25 degrees Celsius) until sectioning. At sectioning, 
five (5) 4µm tissue sections will be cut onto the center of sequentially numbered charged/plus 
slides (1 tissue section per slide) using a standard microtome.  Slides will be dried overnight at 
room temperature.  Five 4µm thick slides will be shipped to the Rudin lab at MSKCC for 
transcription regulator analysis.  Slides will have an inventory of relevant specimen IDs and the 
date of tissue sectioning.  Date of tissue sectioning may be provided in the shipping manifest.  
 
5.10.2.2 
Site Performing Correlative Study   
 
This assay will be performed at the Rudin Laboratory at the Memorial-Sloan Kettering Cancer 
Center, under the supervision of Charles Rudin, M.D., Ph.D. 
 
Tissue on slides not utilized for an assay within 2 weeks of sectioning the tissue block will be 
stored in a closed container at -80 degrees Celsius in the Rudin lab freezer. 
 
The Rudin lab will coordinate and prioritize subsequent studies to include multiplex tissue 
staining.  The multiplex staining studies will involve a variety of relevant disease markers 
including (at a minimum) ASCL1, NeuroD1, Pou2F3, c-Myc, and Yap-1.  Study relevant 
markers will be incorporated into several Vectra panels and supplemented with immune markers 
already validated to work in FFPE multiplex panels by the Hollmann lab who routinely perform 
these studies.   Should desired, unvalidated markers prove technically problematic for multiplex 
staining, standard IHC will be used, slides will be scanned and digitally quantified using the 
Halo image analysis platform. 
 
5.10.2.3 Contact information for notification of specimen shipment 
 
Charles Rudin, M.D., Ph.D. 
rudinc@mskcc.org  
 
5.10.3 Immune Cell Markers 
 
5.10.3.1 
Specimens Receipt and Processing at the EET Biobank  
 
Following standard processing and paraffin embedding at the EET Biobank, tissue blocks will be 
stored at room temperature (not exceeding 25 degrees Celsius) until sectioning.  At sectioning, 
five (5) 4µm tissue sections will be cut onto the center of sequentially numbered charged/plus 


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56 
slides (1 tissue section per slide) using a standard microtome.  Slides will be dried overnight at 
room temperature. Five 4µm thick slides will be shipped to the Bullock lab at UVA for Immune 
Cell Marker analysis.  Slides will have an inventory of relevant specimen IDs and the date of 
tissue sectioning.  Date of tissue sectioning may be provided in the shipping manifest. 
 
5.10.3.2 
Site Performing Correlative Study   
 
This assay will be performed at the Bullock Laboratory at the University of Virginia, under the 
supervision of Timothy Bullock, Ph.D. 
 
The Bullock lab will coordinate and prioritize subsequent studies to include multiplex tissue 
staining.  The multiplex staining studies will involve a variety of relevant immune markers 
including (at a minimum) PDL1, CD8, NK cells, regulatory and effector T-cells, arginase, and 
IDO.  Study relevant markers will be incorporated into Vectra panels. Should desired, 
unvalidated markers prove technically problematic for multiplex staining, standard IHC will be 
used.   
 
5.10.3.3 Contact information for notification of specimen shipment 
 
See Section 5.7.1. 
 
5.10.4 ctDNA 
 
5.10.4.1 
Specimens Receipt and Processing at the EET Biobank  
 
Whole blood collected in Streck tubes will be centrifuged to separate plasma. Following plasma 
processing, DNA will be processed from blood at baseline.  At disease progression, plasma and 
buffy coat will be processed and stored.  Plasma and buffy coat aliquots will be stored in a -80°C 
freezer. 
 
5.10.4.2 
Site Performing Correlative Study   
 
This assay will be performed at the NCLN Genomics Laboratory under the supervision of 
Mickey Williams, Ph.D. 
 
5.10.4.3 Contact information for notification of specimen shipment 
 
Mickey Williams, Ph.D. 
Email: mickey.williams@nih.gov  
 
5.10.5 Circulating Immune Cells 
 
5.10.5.1 
Specimens Receipt and Processing at Bullock Laboratory (MITS core) 
 
Frozen PMBCs will be received by the Bullock Laboratory samples will be processed for 
circulating immune cells using flow cytometry. 


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57 
 
5.10.5.2 
Site Performing Correlative Study   
 
This assay will be performed at the Bullock Laboratory at the University of Virginia, under the 
supervision of Timothy Bullock, Ph.D. 
 
5.10.5.3 Contact information for notification of specimen shipment 
 
See Section 5.7.1. 
 
5.10.6 Immunogenicity 
 
5.10.6.1 
Specimens Receipt and Processing at Bullock Laboratory (MITS core) 
 
PBMCs received by the Bullock Laboratory will be processed for immunogenicity using ELIspot 
assays. The enzyme-linked immunospot (ELISpot) assay is a highly sensitive immunoassay that 
measures the frequency of cytokine-secreting cells at the single-cell level. In this assay, cells are 
cultured on a surface coated with a specific capture antibody in the presence or absence of 
stimuli.  
 
5.10.6.2 
Site Performing Correlative Study   
 
This assay will be performed at the Bullock Laboratory at the University of Virginia, under the 
supervision of Timothy Bullock, Ph.D. 
 
5.10.6.3 Contact information for notification of specimen shipment 
 
See Section 5.7.1. 
 
5.10.7 Entinostat Pharmacokinetics 
 
5.10.7.1 Specimens Receipt and Processing at JHU APC  
 
Plasma will be received by the JHU APC.  Samples will be processed for entinostat 
concentrations using LC/MS/MS. 
 
5.10.7.2 Site Performing Correlative Study 
 
This assay will be performed at the JHU APC, under the supervision of Michelle Rudek, 
Pharm.D., Ph.D. 
 
5.10.7.3 Contact information for notification of specimen shipment. 
 
See Section 5.7.2.  
 


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58 
5.10.8 Atezolizumab Pharmacokinetics 
 
5.10.8.1 Specimens Receipt and Processing at OSUCCC PhASR  
 
Serum will be received by the OSU PhASR.  Samples will be processed for atezolizumab 
concentrations using ELISA kits. 
 
5.10.8.2 Site Performing Correlative Study 
 
This assay will be performed at the OSU PhASR, under the supervision of Mitch Phelps, Ph.D. 
 
5.10.8.3 Contact information for notification of specimen shipment 
 
See Section 5.7.3 
 
 
 
 


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59 
6. 
TREATMENT PLAN 
 
6.1 
Agent Administration 
 
Treatment will be administered on an outpatient basis (inpatient is allowed if clinically 
indicated).  Reported adverse events and potential risks are described in Section 10.  Appropriate 
dose modifications are described in Section 7.  No investigational or commercial agents or 
therapies other than those described below may be administered with the intent to treat the 
patient's malignancy. 
 
Patients will receive up to 4 cycles of induction treatment followed by maintenance treatment for 
a total of 1 year of combined treatment (or 17 cycles).  Patients who are unable to tolerate 
carboplatin and etoposide may discontinue induction and receive maintenance treatment for the 
remaining duration of treatment.  Order of administration during induction should be according 
to institutional standard.  Entinostat should be taken prior to administration of other agents.   
 
On day 1, when patient receives additional therapy, entinostat will be administered prior to other 
chemotherapy or immunotherapy agents. On day 1 of induction cycles, Atezolizumab will be 
administered first, followed by carboplatin, and lastly etoposide. Time intervals between 
infusions are per institutional standards. 
 
 
 
 
 
Dose Escalation Schedule 
Dose 
Level 
Induction (Cycles 1-4) 
Maintenance (Cycles 5-17) 
Cycle 
Length 
Dose 
Dose 
Carboplatin 
Etoposide 
Atezolizumab 
Entinostat 
Atezolizumab 
Entinostat 
Level -1 
(ME) 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
None 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
Level 
1* 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
2 mg PO  
D1, 8, 15 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
Level 2 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
3 mg PO  
D1, 8, 15 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
Level 3 
AUC 5 IV D1 
100 
mg/m2 IV 
D1-3 
1200 mg IV 
D1 
5 mg PO  
D1, 8, 15 
1200 mg IV 
D1 
5 mg PO 
D1, 8, 15 
21 days 
*Starting Dose Level.  
IV = intravenous, AUC = Area Under Curve, PO = Orally, ME = Maintenance entinostat. 


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60 
 
Regimen Description – Induction (up to 4 cycles)# 
Agent 
Premedications; 
Precautions* 
Dose 
Route 
Schedule 
Cycle 
Length 
Entinostat 
Take on an empty 
stomach (at least 1 
hour before and 2 
hours after a meal) 
Assigned 
dose level 
PO 
Day 1, 8, 
15 
 
 
21 days  
(3 weeks) 
 
 
 
Atezolizumab 
 
1200 mg 
IV infusion over 
60 (15) 
minutes** 
Day 1 
Carboplatin 
Dexamethasone 
NK1 antagonist 
5-HT3 antagonist. 
AUC 5*** IV infusion over 
30-60 minutes 
Day 1 
Etoposide 
 
100 mg/m2 IV infusion over 
60 (+/- 15) 
minutes 
Days 1-3 
 
# Patients who are unable to tolerate carboplatin and etoposide, may discontinue induction 
and receive the maintenance regimen. 
* Recommended premedications. Alternative institutional standards may be used. Consider 
minimizing use of corticosteroids due to immunomodulatory effects. Entinostat is taken 1 hour 
before and 2 hours after a meal. 
**If there is no infusion-related reaction after the initial dose, all subsequent doses of 
atezolizumab can be infused over 30 (10) minutes.  
***Doses and volume of diluent per institutional standard. 
 
PO = Orally, IV = Intravenous, AUC = Area Under Curve 
 
Regimen Description – Maintenance (Cycle 5-17)# 
Agent 
Premedications; 
Precautions* 
Dose 
Route 
Schedule 
Cycle 
Length 
Entinostat 
Take on an empty 
stomach (at least 
1 hour before and 
2 hours after a 
meal) 
Assigned 
dose level 
PO 
Day 1, 8, 
15 
21 days 
(3 weeks) 
Atezolizumab 
 
1200 mg 
IV infusion over 
30 (10) 
minutes** 
Day 1 
# Patients who are unable to tolerate carboplatin and etoposide, may discontinue induction 
and receive the maintenance regimen. If this occurs, maintenance may begin prior to Cycle 5 
and can continue for a total of 1 year of treatment. 
* Entinostat is taken 1 hour before and 2 hours after a meal. 


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61 
**If there is no infusion-related reaction after the initial dose, all subsequent doses of 
atezolizumab can be infused over 30 (10) minutes. 
 
PO = Orally, IV = Intravenous, AUC = Area Under Curve 
 
Drug dose calculations 
 
Height and weight should be obtained and recorded on Cycle 1 Day 1.  Body surface area (BSA) 
calculations should be performed using institutional standards and AUC calculations using the 
Calvert formula (see Section 6.2.3.1). The treatment plan weight should be adjusted if patient 
experiences a >10% change in body weight and drug doses should be recalculated accordingly. 
 
6.1.1 Entinostat 
 
Entinostat will be taken once daily on days 1, 8, 15 of a 21-day cycle.  On day 1 when patient 
receives additional therapy, entinostat will be administered prior to other chemotherapy or 
immunotherapy agents.  For many patients, the ideal time to take entinostat may be 2 hours after 
breakfast so that patients can be assessed on day 1 treatment days before their entinostat dose. 
Attempts should be made to take entinostat near the same time of day on days 8 and 15, but it 
may be taken at any time during the scheduled calendar day (24-hour period of 12:00 AM to 
11:59 PM).  
 
When taken with food, entinostat has demonstrated a food effect; exposure is significantly 
reduced when entinostat is administered with a high fat meal.  Accordingly, entinostat is to be 
administered on an empty stomach, at least 1 hour before and 2 hours after a meal.  Tablets 
should not be split, crushed, or chewed.  Missed or vomited doses should not be made up.  
 
Entinostat is known to cause nausea and vomiting. To reduce the incidence of nausea and 
vomiting associated with entinostat administration, subjects will receive an institutional specific 
5-HT3 receptor antagonist prior to taking the dose of entinostat. 
 
Administration of entinostat is contraindicated in patients with a history of allergy to entinostat 
or other medications that have a benzamide structure (e.g., tiapride, remoxipride, clebropride).   
 
Careful monitoring of patients for signs of infection or reactivation of past infections is 
recommended, as reactivation of infection has been reported in patients treated with entinostat, in 
some cases without evidence of neutropenia (Gojo et al., 2007).  The clinical significance of this 
finding and the potential association with entinostat is unknown. 
 
6.1.2 Atezolizumab 
 
Administration of atezolizumab will be performed in a setting with emergency medical facilities 
and staff who are trained to monitor for and respond to medical emergencies. 
 
The initial dose of atezolizumab will be delivered over 60 (15) minutes.  If the first infusion is 
tolerated without infusion-associated AEs, the second infusion may be delivered over 30 (10) 


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62 
minutes.  If the 30-minute infusion is well tolerated, all subsequent infusions may be delivered 
over 30 (10) minutes.   
 
Institutional standards should be followed for the infusion of atezolizumab and monitoring for 
infusion reactions.   
 
Atezolizumab treatment may continue after completion of the study according to 
investigator/patient discretion as standard of care.   
 
6.1.3 Carboplatin 
 
Carboplatin will be administered on Day 1.  Carboplatin at the appropriate dose will be given 
intravenously as a 30-60 minute infusion in Dextrose 5% in Water or Sodium Chloride 0.9%, 
volume per institutional standard. 
 
6.1.3.1 
Carboplatin Dose Calculation and Administration  
 
Carboplatin dose will be calculated using the Calvert formula:  
Total Dose (mg) = target AUC* (GFR+25), GFR may be substituted by Creatinine Clearance 
(CrCl) calculation.  
 
Note: Calculated total dose is in mg – not mg/m2  
 
The CrCl  (replaces GFR in Calvert formula) will be calculated for each treatment course using 
the Cockcroft-Gualt formula: 
 
𝐶𝑟𝐶𝑙= (140 −𝑎𝑔𝑒) ∗𝑤𝑒𝑖𝑔ℎ𝑡(𝑘𝑔)
72 ∗𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒
∗(0.85 𝑖𝑓 𝑓𝑒𝑚𝑎𝑙𝑒) 
 
The minimum serum creatinine value used will be 0.7 mg/dL and a CrCl cap will be 125 
mL/min. Questions about this calculation should be directed to the PI. 
 
Note: Remember to re-calculate the dose for each treatment cycle based on current creatinine 
value.  The actual body weight should be used for all calculations. (As stated above in Section 
6.1, the treatment plan weight should be adjusted if patient experiences a >10% change in body 
weight and drug doses should be recalculated accordingly.) 
 
Carboplatin dose rounding is allowed as per institutional guidelines. 
 
6.1.4 Etoposide 
 
Etoposide will be administered at a dose of 100 mg/m2 IV over 60 minutes on Days 1-3 of each 
cycle.  Preparation of each agent, administration instructions, and order of infusions should 
follow institutional policy. 
 
Etoposide dose rounding is allowed as per institutional guidelines. 


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63 
 
6.2 
Definition of Dose-Limiting Toxicity 
 
Management and dose modifications associated with the above adverse events are outlined in 
Section 7. 
 
Dose limiting toxicity (DLT) is defined as the occurrence of any of the following toxicities listed 
below.  The DLT period will be from Cycle 1, Day 1 through the first cycle.  To be evaluable for 
a DLT, at least 66% of the prescribed dose of each drug must be received during cycle 1 (i.e., 2 
of 3 doses of entinostat must be received or 66% of prescribed carboplatin, etoposide, or 
atezolizumab dose must be infused to be considered evaluable if no DLT occurred).  If 
treatment-related adverse events result in <66% of drug doses received, patients will be 
evaluable for DLTs.  Any toxicities attributable to cancer or cancer progression will not be 
considered DLTs. 
 
DLTs if felt to be possibly, probably, or definitely related to entinostat: 
• Less than 66% of entinostat (0 or 1 doses) received during the first cycle due to 
treatment-related adverse event(s) 
• Death in the absence of progressive cancer (Any grade 5 adverse event) 
• Any adverse event resulting in discontinuation of carboplatin/etoposide chemotherapy 
prior to Cycle 2 
• Any treatment-related toxicity causing delay of more than 3 weeks from planned cycle 2 
day 1 
• Any ≥ Grade 3 non-hematologic adverse event (non-laboratory), excluding alopecia, 
uncontrolled nausea or vomiting.  Grade ≥4 uncontrolled nausea or vomiting should be 
considered a DLT if it persists ≥72 hours despite maximal medical management. 
• Any ≥ Grade 3 non-hematologic laboratory value if medical intervention is required (not 
including endocrinopathies requiring hormone replacement) or leads to hospitalization  
 
DLTs regardless of relatedness to entinostat (attribution to any study drug): 
• Hematologic events 
o Grade ≥ 4 febrile neutropenia 
o Grade 4 neutropenia lasting >7 days 
o Grade 3 thrombocytopenia associated with bleeding requiring transfusion or 
Grade ≥ 4 thrombocytopenia. 
 
Dose escalation will proceed within each cohort of 3 patients according to the following scheme.  
Dose-limiting toxicity (DLT) is defined above.  
 
Escalation/De-escalation Rule 
Number of patients treated 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
Escalate if # of DLT <= 
0 
0 
0 
0 
0 
0 
1 
1 
1 
1 
1 
1 
Deescalate if # of DLT >= 
1 
1 
1 
1 
2 
2 
2 
2 
3 
3 
3 
3 
Eliminate if # of DLT >= 
NA NA 
2 
3 
3 
3 
4 
4 
4 
5 
5 
5 
 


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64 
The study team will review adverse events as listed above that occur outside the DLT window, 
events that lead to treatment discontinuation, or other adverse events of clinical concern 
attributed to entinostat on an ongoing basis throughout the trial.  If frequent or serious events are 
noted in a cohort, the study team may close a cohort to enrollment and proceed with the above 
design but allocating patients only to dose levels below the closed cohort. 
 
6.3 
General Concomitant Medication and Supportive Care Guidelines 
 
Because there is a potential for interaction of entinostat with other concomitantly administered 
drugs, the case report form must capture the concurrent use of all other drugs, over-the-counter 
medications, or alternative therapies.  The Principal Investigator should be alerted if the patient is 
taking any agent known to affect or with the potential for drug interactions.  The study team 
should check a frequently-updated medical reference for a list of drugs to avoid or minimize use 
of.  Appendix C (Patient Drug Interactions Handout and Wallet Card) should be provided to 
patients if available. 
 
After Cycle 1, certain forms of radiotherapy may be considered for pain palliation if patients are 
deriving benefit (e.g., treatment of known bony metastases); administration of study drugs may 
be suspended during radiotherapy. 
 
6.3.1 Entinostat 
 
6.3.1.1 
Concurrent Medications 
 
Caution is warranted when administering entinostat to patients taking drugs that are highly 
dependent on CYP2B6 and CYP3A4 for metabolism and have a narrow therapeutic index.   
 
In vitro studies show that entinostat is not metabolized by CYP enzymes, but rather by UGT 1A4 
to form a glucuronide metabolite. Data from in vitro experiments showed that, while entinostat 
inhibited cytochrome P-450 (CYP) enzymes 2C8 and 3A4, the degree of the inhibition makes it 
unlikely that any in vivo systemic interactions would occur. Entinostat did not inhibit any tested 
UDP glucuronosyltransferase (UGT) enzymes. However, entinostat has the potential to induce 
CYP 1A2 and CYP 2C8. Finally, entinostat is a substrate for P-glycoprotein (P-gp) and breast 
cancer resistance protein (BCRP) transporters and does not inhibit either of these transport 
proteins 
 
Caution is warranted when administering entinostat to patients taking CYP2C8 substrates. In 
vitro study results indicate that entinostat has the potential to inhibit CYP2C8. 
 
6.3.1.2 
Contraindications, Warnings, and Precautions 
 
The following should be observed in all clinical settings with entinostat administration: 
1. Administration of entinostat is contraindicated in patients with a history of allergy to 
entinostat or other medications that have a benzamide structure (e.g., tiapride, 
remoxipride, clebropride). 


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2. Careful monitoring of patients for signs of infection or reactivation of past infections is 
recommended, as reactivation of infection has been reported in patients treated with 
entinostat, in some cases without evidence of neutropenia (Gojo et al., 2007).  The 
clinical significance of this finding and the potential association with entinostat is 
unknown. 
 
6.3.1.3 
Overdose 
 
Doses in excess of 12 mg/m2 have not been evaluated clinically.  Risk of overdose may be 
minimized by providing careful instructions to patients on dosing as well as compliance 
assessments that include diaries and pill counts. 
 
No antidote for entinostat is available.  It is not known if entinostat is removed from the blood by 
hemodialysis, charcoal hemoperfusion, or peritoneal dialysis. 
 
Overdoses should be managed with supportive care as appropriate. 
 
6.3.2 Atezolizumab 
 
6.3.2.1 
Atezolizumab General Concomitant Medication Guidelines 
 
Patients who experience infusion-associated symptoms may be treated symptomatically with 
acetaminophen, ibuprofen, diphenhydramine, and/or cimetidine or another H2 receptor 
antagonist, as per standard practice (for sites outside the United States, equivalent medications 
may be substituted per local practice).  Serious infusion associated events manifested by 
dyspnea, hypotension, wheezing, bronchospasm, tachycardia, reduced oxygen saturation, or 
respiratory distress should be managed with supportive therapies as clinically indicated (e.g., 
supplemental oxygen and β2-adrenergic agonists; see Section 6.1.2). 
 
Systemic corticosteroids and tumor necrosis factor alpha (TNF)α inhibitors may attenuate 
potential beneficial immunologic effects of treatment with atezolizumab but may be 
administered at the discretion of the treating physician.  If feasible, alternatives to corticosteroids 
should be considered.  Premedication may be administered for Cycles ≥2 at the discretion of the 
treating physician.  The use of inhaled corticosteroids and mineralocorticoids (e.g., 
fludrocortisone) for patients with orthostatic hypotension or adrenocortical insufficiency is 
allowed.  Megestrol administered as appetite stimulant is acceptable while the patient is enrolled 
in the study.   
 
Patients who use oral contraceptives, hormone-replacement therapy, prophylactic or therapeutic 
anticoagulation therapy (such as low-molecular-weight heparin or warfarin at a stable dose 
level), or other allowed maintenance therapy [describe here, if applicable] should continue their 
use.  Males and females of reproductive potential should use highly effective means of 
contraception. 
 
 


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6.3.2.2 
Atezolizumab Excluded Therapies 
 
Any concomitant therapy intended for the treatment of cancer, whether health authority approved 
or experimental, is prohibited unless it is specifically included in the treatment regimen described 
in this protocol.  This includes but is not limited to the following: 
Chemotherapy, hormonal therapy, immunotherapy, radiotherapy, investigational agents, or 
herbal therapy (except for maintenance therapies outlined in Section 6.3.2.1). 
 
It is strongly recommended that:  
• Traditional herbal medicines not be administered because the ingredients of many herbal 
medicines are not fully studied and their use may result in unanticipated drug drug 
interactions that may cause, or confound assessment of, toxicity. 
 
• The use of a RANKL inhibitor (denosumab) be discontinued during the study; this agent 
could potentially alter the activity and the safety of atezolizumab. 
 
• Initiation or increased dose of granulocyte colony stimulating factors (e.g., granulocyte 
colony stimulating factor, granulocyte/macrophage colony stimulating factor, and/or 
pegfilgrastim) is prohibited for patients with solid malignancies. 
 
• Patients are not allowed to receive immunostimulatory agents, including, but not limited 
to, interferon-alpha (IFN-α), IFN-gamma(), or interleukin (IL)-2, during the entire study.  
These agents, in combination with atezolizumab, could potentially increase the risk for 
autoimmune conditions. 
 
• Patients should also not be receiving immunosuppressive medications, including, but not 
limited to, cyclophosphamide, azathioprine, methotrexate, and thalidomide.  These agents 
could potentially alter the activity and the safety of atezolizumab.  Systemic 
corticosteroids and anti-TNFα agents may attenuate potential beneficial immunologic 
effects of treatment with atezolizumab but may be administered at the discretion of the 
treating physician.  If feasible, alternatives to these agents should be considered. 
 
6.4 
Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue for a total of 
17 cycles or until one of the following criteria applies: 
 
• 
Disease progression per RECIST v1.1 
 
• 
Intercurrent illness that prevents further administration of treatment 
 
• 
Unacceptable adverse event(s) 
 
• 
Patient decides to withdraw from the study 
 
• 
General or specific changes in the patient's condition render the patient unacceptable for 


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further treatment in the judgment of the investigator 
 
• 
Clinical progression 
 
• 
Patient non-compliance 
 
• 
Pregnancy 
 
o All women of child bearing potential should be instructed to contact the investigator 
immediately if they suspect they might be pregnant (e.g., missed or late menstrual 
period) at any time during study participation. 
 
o The investigator must immediately notify CTEP in the event of a confirmed 
pregnancy in a patient participating in the study. 
 
• 
Termination of the study by sponsor 
 
• 
The drug manufacturer can no longer provide the study agent 
 
The reason(s) for protocol therapy discontinuation, the reason(s) for study removal, and the 
corresponding dates must be documented in the Case Report Form (CRF). 
 
6.5 
Duration of Follow-Up 
 
Patients will be followed for up to 5 years from registration or until death, whichever occurs first.  
Patients will be seen in clinic 30 days after their last study treatment.  Patients that discontinue 
study treatment for reasons other than disease progression will follow the imaging schedule – 
every 6 weeks in the first year, every 3 months in year 2, and then every 6 months until 5 years 
from registration. Patients who discontinue study treatment for disease progression will be 
followed every 3 months for the first 2 years from registration and then every 6 months until 5 
years from registration. Follow-up assessment for survival may be done by telephone or email 
(preferred) if patients are no longer seeing the doctor in clinic.   
 
 
 
 


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7. 
DOSING DELAYS/DOSE MODIFICATIONS 
 
A window of ±2 days during induction is allowed for all in-clinic treatment days to account for 
holidays, inclement weather, and other unexpected conflicts.  A window of ±3 days for day 1 of 
each cycle is allowed during the maintenance phase.  
 
7.1 
Carboplatin and Etoposide 
 
The following hematologic parameters must be met on Day 1 of Cycles 1-4: 
• Absolute neutrophil count (ANC) ≥ 1500/mm3 
• Hemoglobin ≥ 8.0 g/dL 
• Platelets ≥ 100/mm3 
 
If Day 1 parameters are not met and carboplatin and etoposide are held, all Day 1 treatments 
(carboplatin, etoposide, atezolizumab, and entinostat) will be delayed until parameters are met.  
 
If delays >3 weeks are required before carboplatin and etoposide can be resumed, induction will 
be discontinued.  The patient may then initiate the maintenance regimen. Alternatively, the 
patient may discontinue all study treatment and standard of care atezolizumab may be continued 
per investigator discretion. 
 
Supportive therapy with granulocyte colony stimulating factor (GCSF) in order to achieve Day 1 
treatment parameters may be used per ASCO or NCCN guidelines.  
 
Dose modifications for carboplatin and etoposide should be conducted per investigator discretion 
based on institutional standards and guidance from package inserts for each drug. In general, 
when dose modifications to entinostat are required (e.g., for hematologic adverse events), dose 
reductions for carboplatin and etoposide should strongly be considered unless the adverse event 
is clearly attributable to entinostat alone. 
 
 


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7.2 
Entinostat 
 
7.2.1 Dose reductions for entinostat during induction 
 
 
Dose Level 1 
Dose Reduction  
Entinostat Dose 
Starting Dose Level 
2 mg, PO weekly 
1st Dose Reduction 
Discontinue entinostat 
PO = Orally 
 
 
Dose Level 2 
Dose Reduction  
Entinostat Dose 
Starting Dose Level 
3 mg, PO weekly 
1st Dose Reduction 
2 mg, PO weekly 
2nd Dose Reduction 
Discontinue entinostat 
PO = Orally 
 
 
Dose Level 3 
Dose Reduction  
Entinostat Dose 
Starting Dose Level 
5 mg, PO weekly 
1st Dose Reduction 
3 mg, PO weekly 
2nd Dose Reduction 
2 mg, PO weekly 
3rd Dose Reduction 
Discontinue entinostat 
PO = Orally 
 
 
7.2.2 
Dose reductions for entinostat during maintenance 
 
Regardless of dose level assignment at the start of the trial, 5 mg PO weekly will be the starting 
dose in the maintenance phase for all patients who did not require entinostat dose reductions 


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during induction.  If entinostat is reduced or discontinued during the induction phase of the trial 
due to hematologic adverse events, entinostat will be resumed at the maintenance dose of 5 mg 
PO weekly as long as the adverse event(s) that led to discontinuation of entinostat have improved 
to grade ≤ 1; otherwise resume at the same dose as the end of the induction phase.  If entinostat 
was reduced due to non-hematologic adverse events during induction, it will be continued at the 
same dose level in maintenance.  If entinostat was discontinued due to non-hematologic adverse 
events in the induction phase, it will not be restarted in the maintenance phase. 
 
Dose Level 
Entinostat Dose 
Starting Dose Level* 
5 mg, PO weekly 
1st Dose Reduction 
3 mg, PO weekly 
2nd Dose Reduction 
2 mg, PO weekly 
3rd Dose Reduction 
Discontinue entinostat 
* Starting dose level of entinostat for maintenance cycles is 5 
mg, PO weekly, irrespective of assigned dose level during 
induction cycles. 
PO = orally 
 
7.2.3  
Management and Dose Modifications for Entinostat 
 
If carboplatin and etoposide are held during induction, entinostat and atezolizumab will also be 
held. 
 
If at any time atezolizumab is held for atezolizumab-related AEs, instruct the patient to continue 
to take entinostat and to notify the study team if the event gets worse. If the adverse event 
worsens, entinostat should then be held with atezolizumab until the adverse event improves as 
specified in the below management and dose modification tables for both drugs. Entinostat may 
also be held at the investigator discretion for severe or life-threating events. 
 
If entinostat is held in either induction or maintenance regimen, the other study drug(s) will also 
be held, unless the adverse event can clearly be attributed only to entinostat and not to the other 
study drugs, in which case carboplatin, etoposide, and atezolizumab may be given in accordance 
with the regimen at the time (i.e. induction or maintenance). 
 
The following specific management and dose modifications will be made for adverse events 
thought to be at least possibly related to entinostat.  Patients requiring a delay of > 3 weeks will 
discontinue entinostat.  Patients that require a dose reduction when already receiving dose level -
1 (2 mg PO, weekly, as per table above) will discontinue entinostat.  It is recommended that 
investigators maximize treatment for nausea, vomiting and diarrhea.  No specific entinostat dose 
reductions are required for anemia. 
 


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Neutropenia 
Management/Next Dose for Entinostat 
≤ Grade 1 
No change in dose 
Grade 2 
Hold* until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold until ≤ Grade 1.  Resume at one dose level lower** 
Grade 4 
Discontinue entinostat*** 
* For grade 2 neutropenia events occurring mid-cycle, treatment does not need to be held 
**For grade 3 neutropenia events occurring mid-cycle, treatment should be held, but dose 
reduction not required upon resuming.  If event persists to day 1 of next cycle, resuming at one 
dose level lower is required.  
*** Entinostat should be held for grade 4 events occurring mid-cycle and may resume at one 
dose level lower with GCSF support upon recovery to ≤ Grade 1.  
For neutropenia events occurring between days 2 and 21 of each cycle that improve by 
day 1 of subsequent cycle, dose reductions may be made at investigator discretion.  GCSF 
support should be considered on subsequent cycles.  
 
 
Thrombocytopenia 
Management/Next Dose for Entinostat 
≤ Grade 1 
No change in dose 
Grade 2 
Hold* until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold until ≤ Grade 1.  Resume at one dose level lower 
Grade 4 
Discontinue entinostat 
* For grade 2 thrombocytopenia events occurring mid-cycle, treatment does not need to be held 
 
For thrombocytopenia events occurring between days 2 and 21 of each cycle, dose 
reductions at next cycle Day 1 may be made at investigator discretion, unless required as 
above 
 
 
Other non-
hematologic AEs 
Management/Next Dose for Entinostat 
≤ Grade 2 
No change in dose 
Grade 3 
Hold until ≤ grade 1.  Resume at one dose level lower.  
Grade 4 
Discontinue entinostat 
 
 
7.3 
Atezolizumab 
 
7.3.1 General AE Management and Dose Modification Guidelines 
 
There will be no dose reduction for atezolizumab in this study.   
 
Atezolizumab will be given on day one of each cycle. If carboplatin and etoposide are held 
during induction, atezolizumab will also be held.  
 
If entinostat is held during induction or maintenance, atezolizumab may continue if the adverse 


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event is deemed attributable only to entinostat, such as a hematologic toxicity.  
 
If atezolizumab is held, carboplatin and etoposide may continue during induction. Entinostat may 
continue in either induction or maintenance regimen, unless the adverse event worsens and then 
entinostat should also be held. Entinostat may also be held at the investigator discretion for 
severe or life-threating events. 
 
Patients may temporarily suspend atezolizumab treatment for up to 84 days (12 weeks) beyond 
the scheduled date of delayed infusion if study drug-related toxicity requiring dose suspension is 
experienced.  If atezolizumab is held because of AEs for 84 days beyond the scheduled date of 
infusion, the patient will be discontinued from atezolizumab and will be followed for safety and 
efficacy as specified in this protocol.  If the AE resolves within 84 days and the patient is 
receiving corticosteroid therapy for the event, atezolizumab may be held for longer than 84 days 
(up to 4 weeks) in order to allow tapering of the steroid dose to ≤10 mg oral prednisone or 
equivalent. 
 
Dose interruptions for reasons other than toxicity, such as surgical procedures, may be allowed.  
The acceptable length of interruption will be at the discretion of the study PI in consultation with 
CTEP. 
 
Atezolizumab must be permanently discontinued if the patient experiences any of the 
following events, regardless of benefit: 
 
• Grade 4 pneumonitis 
• AST or ALT >5×ULN or total bilirubin >3×ULN  
• Grade 4 diarrhea or colitis 
• Grade 4 hypophysitis 
• Any grade myasthenic syndrome/myasthenia gravis, Guillain-Barré or 
meningoencephalitis 
• Grade 4 ocular inflammatory toxicity 
• Grade 4 pancreatitis or any grade of recurrent pancreatitis 
• Grade 4 rash 
• Any grade myocarditis 
 
Any toxicities associated or possibly associated with atezolizumab treatment should be managed 
according to standard medical practice.  Additional tests, such as autoimmune serology or 
biopsies, may be used to determine a possible immunogenic etiology.  Although most immune-
related adverse events (irAEs) observed with immunomodulatory agents have been mild and self 
limiting, such events should be recognized early and treated promptly to avoid potential major 
complications (Di Giacomo et al., 2010).  Discontinuation of atezolizumab may not have an 
immediate therapeutic effect, and there is no available antidote for atezolizumab.  In severe 
cases, immune-related toxicities may be acutely managed with topical corticosteroids, systemic 
corticosteroids, or other immunosuppressive agents.  The investigator should consider the 
benefit-risk balance prior to further administration of atezolizumab.   
 


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For detailed information regarding management of adverse events associated with atezolizumab, 
please refer to the most current version of the Atezolizumab Investigator’s Brochure and the 
FDA product label. 
 
The primary approach to grade 1 to 2 irAEs is supportive and symptomatic care with continued 
treatment with atezolizumab; for higher-grade irAEs, atezolizumab should be withheld and oral 
and/or parenteral steroids administered.  Recurrent grade 2 irAEs may also mandate withholding 
atezolizumab or the use of steroids.  Assessment of the benefit risk balance should be made by 
the investigator, with consideration of the totality of information as it pertains to the nature of the 
toxicity and the degree of clinical benefit a given patient may be experiencing prior to further 
administration of atezolizumab.  Atezolizumab should be permanently discontinued in patients 
with life threatening irAEs. 
 
Patients should be assessed clinically (including review of laboratory values) for toxicity prior to, 
during, and after each infusion.  If unmanageable toxicity due to atezolizumab occurs at any time 
during the study, treatment with atezolizumab should be discontinued. 
 
7.3.2 Systemic Immune Activation 
 
Systemic immune activation is a rare condition characterized by an excessive immune response. 
Given the mechanism of action of atezolizumab, systemic immune activation is considered a 
potential risk when given in combination with other immunomodulating agents.  Systemic 
immune activation should be included in the differential diagnosis for patients who, in the 
absence of an alternative etiology, develop a sepsis-like syndrome after administration of 
atezolizumab, and the initial evaluation should include the following: 
• CBC with peripheral smear 
• PT, PTT, fibrinogen, and D-dimer 
• Ferritin 
• Triglycerides 
• AST, ALT, and total bilirubin 
• LDH 
• Complete neurologic and abdominal examination (assess for hepatosplenomegaly) 
 
If systemic immune activation is still suspected after the initial evaluation, contact the Principal 
Investigator for additional recommendations. 
 
 
 


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8. 
PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational or commercial 
agents administered in this study can be found in Section 10.1. 
 
8.1 
CTEP IND Agents 
 
8.1.1 Entinostat (NSC 706995) 
 
Chemical name:  
pyridine-3-ylmethyl N-[4-[(2-
aminophenyl)carbamoyl]phenyl]methyl]carbamate  
 
Other names:  
MS-27-275, MS-275, SNDX-275 
 
Classification: 
Histone deacetylase inhibitor (HDACi)  
 
Molecular formula:  C21H20N4O3 
 
 
 
 
M.W.: 376.41 
 
Mode of Action: 
Histone deacetylases (HDACs) are a family of enzymes that regulate 
chromatin remodeling and gene transcription via the dynamic process of 
acetylation and deacetylation of core histones.  Entinostat inhibits histone 
deacetylases, changes chromatin configuration, and induces differentiation 
and apoptosis of cancer cells through an epigenetic mechanism. 
 
How Supplied: 
Entinostat is supplied by the Syndax Pharmaceuticals, Inc. and distributed 
by the Pharmaceutical Management Branch, DCTD, NCI as 1 mg (either 
pink to light red or light pink to orange), or 5 mg (yellow) film-coated 
tablets (round-biconvex). Tablets are produced using the polymorph B 
form of the drug.  
 
 
 
 
Each tablet also contains mannitol, sodium starch glycolate, 
hydroxypropyl cellulose, potassium bicarbonate, and magnesium stearate.  
The film coating is derived from an aqueous suspension consisting of one 
or more of the following ingredients (dependent on tablet strength): 
hypromellose, talc, polyethylene glycol, titanium dioxide, and ferric oxide 
pigments (red and yellow) as coloring.  Tablets are provided in bottles of 
12 tablets (1 mg) and 4 (5 mg).   
 
Storage: 
 
Store the bottles at up to 25°C (77°F); excursions are permitted from 15°C 
to 30°C (59°F to 86°F).   
 
 
 
 
If a storage temperature excursion is identified, promptly return Entinostat 
to the proper storage temperature and quarantine the supplies.  Provide a 
detailed report of the excursion (including documentation of temperature 
monitoring and duration of the excursion) to 
PMBAfterHours@mail.nih.gov for determination of suitability. 


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Stability: 
 
Shelf life stability studies of the intact bottles are on-going. 
 
Route of Administration: 
Oral, on an empty stomach, at least 2 hours after and 1 hour before 
a meal.  Entinostat tablets should not be split, crushed, or chewed. 
 
Potential Drug Interactions:  In vitro studies show that entinostat is not metabolized by CYP 
enzymes, but rather by UGT 1A4 to form a glucuronide metabolite. Data from in vitro 
experiments showed that, while entinostat inhibited cytochrome P-450 (CYP) enzymes 2C8 and 
3A4, the degree of the inhibition makes it unlikely that any in vivo systemic interactions would 
occur. Entinostat did not inhibit any tested UDP glucuronosyltransferase (UGT) enzymes. 
However, entinostat has the potential to induce CYP 1A2 and CYP 2C8. Finally, entinostat is a 
substrate for P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) transporters and 
does not inhibit either of these transport proteins. 
 
Results of pharmacokinetic studies evaluating the effect of proton pump inhibitors on entinostat 
suggest that entinostat absorption is not affected by acid reducing agents. 
 
Patient Care Implications:   
 
Entinostat may cause fatigue or malaise; advise patient to exercise caution while driving a 
vehicle or operating machinery.  
 
Administration of entinostat is contraindicated in patients with a history of allergy to entinostat 
or other medications that have a benzamide structure (eg, tiapride, remoxipride, clebropride).  
Careful monitoring of patients for signs of infection or reactivation of past infections is 
recommended, as reactivation of infection has been reported in patients treated with entinostat, in 
some cases without evidence of neutropenia. The clinical significance of this finding and the 
potential association with entinostat is unknown.  
 
Entinostat must not be used during pregnancy or while breast-feeding. Women and men 
participating in entinostat clinical studies must agree to use acceptable contraceptive methods, as 
indicated in the clinical study protocol, during treatment and for 3 months thereafter. 
 
Availability 
 
Entinostat is an investigational agent supplied to investigators by the Division of Cancer 
Treatment and Diagnosis (DCTD), NCI. 
 
Entinostat is provided to the NCI under a Collaborative Agreement between the Pharmaceutical 
Collaborator and the DCTD, NCI (see Section 13.5). 
 
8.1.2 Agent Ordering and Agent Accountability 
 
8.1.2.1 
NCI-supplied agents may be requested by eligible participating Investigators (or their 
authorized designee) at each participating institution.  The CTEP-assigned protocol 


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number must be used for ordering all CTEP-supplied investigational agents.  The 
eligible participating investigators at each participating institution must be registered 
with CTEP, DCTD through an annual submission of FDA Form 1572 (Statement of 
Investigator), NCI Biosketch, Agent Shipment Form, and Financial Disclosure Form 
(FDF).  If there are several participating investigators at one institution, CTEP-
supplied investigational agents for the study should be ordered under the name of one 
lead participating investigator at that institution. 
 
Sites may order initial agent supplies when a subject is being screened for enrollment 
onto the study. 
 
Submit agent requests through the PMB Online Agent Order Processing (OAOP) 
application.  Access to OAOP requires the establishment of a CTEP Identity and 
Access Management (IAM) account and the maintenance of an “active” account 
status, a “current” password, and active person registration status.  For questions 
about drug orders, transfers, returns, or accountability, call or email PMB any time.  
Refer to the PMB’s website for specific policies and guidelines related to agent 
management.   
 
8.1.2.2 
Agent Inventory Records – The investigator, or a responsible party designated by the 
investigator, must maintain a careful record of the receipt, dispensing and final 
disposition of all agents received from the PMB using the appropriate NCI 
Investigational Agent (Drug) Accountability Record (DARF) available on the CTEP 
forms page.  Store and maintain separate NCI Investigational Agent Accountability 
Records for each agent, strength, formulation and ordering investigator on this 
protocol. 
 
8.1.3 Investigator Brochure Availability 
 
The current version of the IB for entinostat will be accessible to site investigators and research 
staff through the PMB OAOP application.  Access to OAOP requires the establishment of a 
CTEP IAM account and the maintenance of an “active” account status, a “current” password and 
active person registration status.  Questions about IB access may be directed to the PMB IB 
Coordinator via email. 
 
8.1.4 Useful Links and Contacts 
• CTEP Forms, Templates, Documents:  http://ctep.cancer.gov/forms/ 
• NCI CTEP Investigator Registration:  RCRHelpDesk@nih.gov 
• PMB policies and guidelines: 
http://ctep.cancer.gov/branches/pmb/agent_management.htm  
• 
PMB Online Agent Order Processing (OAOP) application:  
https://ctepcore.nci.nih.gov/OAOP 
• CTEP Identity and Access Management (IAM) account: https://ctepcore.nci.nih.gov/iam/  
• CTEP IAM account help:  ctepreghelp@ctep.nci.nih.gov  
• IB Coordinator:  IBCoordinator@mail.nih.gov  
• PMB email:  PMBAfterHours@mail.nih.gov 


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• PMB phone and hours of service: (240) 276-6575 Monday through Friday between 8:30 
am and 4:30 pm (ET) 
 
8.2 
Commercial Agents 
 
8.2.1 Atezolizumab (NSC 783608) 
 
Other Names: Tecentriq™, MPDL3280A 
 
Classification: monoclonal antibody 
 
M.W.: 150 KD 
 
Mode of Action: anti-PD-L1 
 
Description:  Atezolizumab is a humanized IgG1 monoclonal antibody consisting of two heavy 
chains (448 amino acids) and two light chains (214 amino acids). Atezolizumab targets human 
PD-L1 and inhibits its interaction with its receptor PD-1. Atezolizumab also blocks the binding 
of PD-L1 to B7.1, an interaction that is reported to provide additional inhibitory signals to T cells 
(Butte et al., 2007).  
 
Preparation:  The prescribed dose of atezolizumab should be diluted in 0.9% NaCl to a 
concentration between 3.2 mg/mL and 16.8 mg/mL and infused through an intravenous line with or 
without a sterile, non-pyrogenic, low-protein binding in-line filter (pore size of 0.2 or 0.22 
micrometer).  The IV bag may be constructed of polyvinyl chloride (PVC), polyolefin (PO), or 
polyethylene (PE).  The prepared solution may be stored at 2°C-8°C for up to 24 hours or at 
ambient < 25°C (77°F) for 6 hours.  If the dose solution is stored at 2°C–8°C (36°F–46°F), it 
should be removed from refrigeration and allowed to reach room temperature prior to 
administration.  This time includes storage and time for administration for infusion. Do not shake or 
freeze infusion bags containing the dose solution. 
 
Storage: 2°C-8°C (36°F-46°F) Vial contents should not be frozen or shaken and should be 
protected from direct sunlight. 
 
Stability:  Refer to product label. 
 
CAUTION:  No preservative is used in atezolizumab; therefore, the vial is intended for single 
use only. Discard any unused portion of drug remaining in a vial.  
 
Route of Administration: IV infusion 
 
Method of Administration:  Atezolizumab is administered as an intravenous infusion over 60 
minutes. If the first infusion is tolerated, all subsequent infusions may be delivered over 30 
minutes. Do not administer atezolizumab as an intravenous push or bolus. No premedication is 
indicated for administration of Cycle 1 of atezolizumab. Patients who experience an infusion 


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related reaction with Cycle 1 of atezolizumab may receive premedication with antihistamines or 
antipyretics/analgesics (e.g. acetaminophen) for subsequent infusions. 
 
Potential Drug Interactions:  Cytochrome P450 enzymes as well as conjugation/glucuronidation 
reactions are not involved in the metabolism of atezolizumab. No drug interaction studies for 
atezolizumab have been conducted or are planned. There are no known interactions with other 
medicinal products or other form of interactions. 
 
Patient Care Implications: Female patients of childbearing potential should utilize contraception 
and take active measures to avoid pregnancy while undergoing atezolizumab treatment and for at 
least 150 days after the last dose of atezolizumab. 
 
Agent Ordering:  Commercially supplied.  
 
For more detailed information, please consult an atezolizumab package insert. 
 
8.2.2 Carboplatin 
 
Molecular Formula:  C6H12N2O4Pt 
 
M.W.:  371.25 
 
Description:  Crystalline powder 
 
How Supplied:  Carboplatin for injection is supplied as a sterile pyrogen-free powder and as a 
10 mg/mL aqueous solution in multi-dose vials.  Carboplatin is commercially available from 
commercial sources. 
 
Storage:  Refer to the package label for storage information. 
 
Preparation:  Consult the carboplatin package insert for detailed formulation and storage 
instructions. 
 
Administration:  IV infusion over 30-60 minutes. 
 
Agent Ordering:  Carboplatin is commercially available. 
 
For more detailed information, please consult a carboplatin package insert. 
 
8.2.3 Etoposide (NSC141540) 
 
Product Description:  Etoposide (etoposide) is a topoisomerase inhibitor.  The chemical name 
for etoposide is: 4'-Demethylepipodophyllotoxin 9-[4,6-O-(R)-ethylidene-β-Dglucopyranoside].  
Etoposide is a semi-synthetic derivative of podophyllotoxin. 
 
Solution preparation:  Etoposide injection is available as 20 mg/mL solution for injection.  


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79 
Etoposide should be diluted to a maximum concentration of 0.4 mg/mL in 5% Dextrose in Water 
or 0.9% Sodium Chloride.   
 
Store intact vials at 20°C to 25°C (68°F to 77°F); do not freeze.  Stability of diluted solutions are 
concentration dependent.  Precipitation may occur with concentrations >0.4 mg/mL.  Following 
dilution with 0.9% Sodium Chloride or 5% Dextrose in Water to concentrations of 0.2-0.4 
mg/mL, the drug is chemically stable for 96 and 24 hours at room temperature under normal 
room fluorescent light in both glass and plastic containers.  Sites may follow their institutional 
guidelines for the preparation, storage, and stability of etoposide.   
 
Route of Administration:  Do not give etoposide by bolus intravenous injection.  Etoposide 
solutions may be infused over 60 minutes.  Extravasation of etoposide may result in swelling, 
pain, cellulitis, and necrosis including skin necrosis.  Etoposide is a cytotoxic drug.  Follow 
applicable special handling and disposal procedures.  To minimize the risk of dermal exposure, 
use of gloves is recommended.  If dermal contact occurs, immediately and thoroughly wash areas 
of skin contact with soap and water and flush mucosa with water 
 
Agent Ordering:  Commercially Supplied. 
 
For more detailed information, please consult an etoposide package insert. 
 
 
 


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80 
9. 
STATISTICAL CONSIDERATIONS 
 
9.1 
Study Design/Endpoints 
 
This is a phase 1 trial to evaluate the safety and efficacy of various doses of entinostat combined 
with with atezolizumab, carboplatin, and etoposide therapy for patients with treatment naïve ES-
SCLC.  Four dose levels of entinostat are detailed in Figure 1. The Bayesian optimal interval 
(BOIN) design will be used to find the maximum tolerated dose (MTD) based on safety (Liu and 
Yuan, 2015; Yuan et al., 2016).  The target toxicity rate for the MTD is 20%.  Due to 
overlapping hematologic toxicities between chemotherapy and entinostat, it may be difficult to 
separate attributions specifically to entinostat, particularly for thrombocytopenia events.  Our 
DLT definitions will count these more extreme hematologic events at DLTs, although it is 
recognized that these occur in the setting of carboplatin and etoposide chemotherapy alone.  
Therefore, it is anticipated that a 20% DLT rate is a conservative estimate of the true DLTs 
directly related to entinostat.  Furthermore, small cell lung cancer is an aggressive malignancy 
with poor overall survival.  Additional toxicity is justified if there is potential for efficacy gains.  
Dose-limiting toxicities (DLT) will be determined by adverse events occurring during the first 
cycle of treatment. DLTs are defined in Section 6.2.  
 
The primary endpoints of the study are: 
• MTD of entinostat 
• Grade 3/4 adverse event rate as defined by CTCAE v5.0 
• Number of cycles received of the combination of entinostat, atezolizumab, carboplatin, 
and etoposide (maximum = 4) 
 
The secondary endpoint of the study is: 
• 9-month PFS rate, defined as the proportion of patients alive and without disease 
progression after 9 months from study enrollment 
 
9.1.1 Treatment allocation 
 
Participants will be enrolled and treated in cohorts of size 3.  Only DLTs that occur within the 
first cycle will be used for dose finding.  As shown in Figure 2, the BOIN design uses the 
following rule, optimized to minimize the probability of incorrect dose assignment, to guide dose 
escalation and de-escalation.   
 
The steps to implement the BOIN design are as follows:  1) Participants in the first cohort are 
treated at dose level 1; 2) To assign a dose to the next cohort of participants, conduct dose 
escalation and de-escalation according to the rule displayed in the table below; 3) Repeat step 2 
until the maximum sample size of 36 is reached, or stop the trial if the number of participants 
treated at the current dose reaches 12 and the decision according to the table below is to stay at 
the current dose. 
 
After the trial is completed, the MTD is determined based on isotonic regression as specified in 
Liu and Yuan (2015).  This computation is implemented by the shiny app “BOIN” available at 
http://www.trialdesign.org. Specifically, the MTD is the dose for which the isotonic estimate of 


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81 
the toxicity rate is closest to the target toxicity rate. If there are ties, the higher dose level will be 
selected when the isotonic estimate is lower than the target toxicity rate and the lower dose level 
will be selected when the isotonic estimate is greater than or equal to the target toxicity rate. 
 
At the conclusion of the trial, all available safety data will be reviewed.  If a significant number 
of clinically significant adverse events outside the definition of a DLT occurred at the MTD, the 
recommended phase 2 dose may be a lower dose level than the MTD.  Examples of clinically 
significant events that would be considered are events similar to DLTs that occurred in later 
cycles outside the DLT window, treatment discontinuation due to an adverse event attributed to 
entinostat, or patient withdrawal from the study due to intolerable adverse events.  
 
When using the table below, the following descriptions for decision types should be considered.  
“Eliminate” means eliminate the current and higher doses from the trial to prevent treating any 
future participants at these doses because they are overly toxic.  When a dose is eliminated, 
automatically de-escalate the dose to the next lower level. When the lowest dose is eliminated, 
stop the trial for safety. In this case, no dose should be selected as the MTD.  If none of the 
actions (i.e., escalation, de-escalation or elimination) is triggered, treat the new participants at the 
current dose.  If the current dose is the lowest dose and the rule indicates dose de-escalation, treat 
the new participants at the lowest dose unless the number of DLTs reaches the elimination 
boundary, at which point terminate the trial for safety.  If the current dose is the highest dose and 
the rule indicates dose escalation, treat the new participants at the highest dose. 
 
Escalation/De-escalation Rule 
Number of patients treated 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
Escalate if # of DLT <= 
0 
0 
0 
0 
0 
0 
1 
1 
1 
1 
1 
1 
Deescalate if # of DLT >= 
1 
1 
1 
1 
2 
2 
2 
2 
3 
3 
3 
3 
Eliminate if # of DLT >= 
NA NA 
2 
3 
3 
3 
4 
4 
4 
5 
5 
5 
 
 
 
 
 
 


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82 
Figure 2:Study Design 
 
Figure 3: Study Design 
 
 
9.1.2 Safety   
 
Dose elimination rules are included to provide guidance for doses with a high probability that the 
rate of toxicity is greater than the target toxicity rate of 20%.  For the purpose of overdose 
control, doses j and higher levels will be eliminated from further examination if Pr(pj> 0.20 | 
data) > 0.95 and at least 3 participants have been treated at dose level j, where pj is the true DLT 
rate of dose level j,j= 1,⋯, 3. This posterior probability is evaluated based on the beta-binomial 
model yj ∣ pj ∼binomial(pj) with pj ∼uniform(0,1), where yj is the number of participants 
experienced DLT at dose level j. When the lowest dose is eliminated, the trial will stop for 
safety. The probability cutoff 0.95 is chosen to be consistent with the common practice that when 
the target DLT rate <=1/6, a dose with 2/3 participants experienced DLT is eliminated. The 


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83 
above dose escalation/de-escalation and elimination rule can be equivalently presented in the 
dose escalation/de-escalation table in Section 9.1.1, which will be used to conduct the trial. 
 
9.1.3 Statistical properties 
 
Simulations were run to display the performance of the design of this trial.  For each of the 4 
scenarios considered, 10,000 simulated trials were run.  The following table reports the true DLT 
rate for each dose level, the percentage of simulated trials selecting each dose level, the 
percentage of participants treated at each dose level, the average number of participants per trial, 
and the percentage of trials stopping early due to safety concerns.  The results displayed in the 
table below allow for a maximum sample size of 36 participants with a reduced sample size if a 
trial ends due to observing 12 participants on a single dose level.   
 
Operating characteristics 
  
Dose 
level -1 
Dose 
level 1 
Dose 
level 2 
Dose 
level 3 
Average 
number of 
participants 
% of trials 
stopped 
early 
Scenario 1 
 
 
 
 
 
  
True DLT Rate 
0.03 
0.08 
0.12 
0.2 
 
  
Selection % 
2.89 
15.7 
32.7 
48.64 
23.7 
0.1 
% Pts Treated 
5.6 
27.5 
34.1 
32.8 
  
  
Scenario 2 
 
  
True DLT Rate 
0.05 
0.12 
0.2 
0.28 
 
  
Selection % 
7.41 
36.52 
38.13 
17.56 
23.7 
0.4 
% Pts Treated 
10.6 
37.7 
33.7 
18 
  
  
Scenario 3 
 
  
True DLT Rate 
0.12 
0.2 
0.28 
0.36 
 
  
Selection % 
29.55 
44.92 
18.6 
3.43 
22.3 
3.5 
% Pts Treated 
25.7 
43.7 
23 
7.6 
  
  
Scenario 4 
 
  
True DLT Rate 
0.2 
0.28 
0.36 
0.44 
 
  
Selection % 
51.73 
27.54 
5.17 
0.5 
19.4 
15.1 
% Pts Treated 
41.3 
42 
13.7 
2.9 
  
  
 
 
9.2 
Sample Size/Accrual Rate 
 
The maximum sample size is 36 participants and the trial will stop accruing participants once 12 
participants have been treated on a single dose level.  The maximum target sample size is based 
on obtaining sufficient information to assess the study aim of establishing the MTD.  Operating 
characteristics provided in the table in section 9.1.3 indicate that the sample size results in a high 
rate of simulated trials identifying the target dose level as the MTD across multiple dose-toxicity 
scenarios, highlighting the ability of study design to achieve the primary aim of determining the 
MTD.   


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84 
 
We anticipate accruing 2 patients per month and therefore expect to complete accrual within 18 
months. 
 
PLANNED ENROLLMENT REPORT 
DOMESTIC PLANNED ENROLLMENT REPORT (TREATMENT) 
Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
Female 
Male 
Female 
Male 
American Indian/ 
Alaska Native 
0 
0 
0 
0 
0 
Asian 
1 
1 
0 
0 
2 
Native Hawaiian or 
Other Pacific 
Islander 
0 
0 
0 
0 
0 
Black or African 
American 
3 
3 
0 
0 
0 
White 
12 
12 
1 
1 
26 
More Than One 
Race 
1 
1 
0 
0 
2 
Total 
17 
17 
1 
1 
36 
PHS 398 / PHS 2590 (Rev. 03/20 Approved Through 2/28/2023)  
OMB No. 0925-0001/0002 
 
 
9.3 
Analysis of Secondary Endpoints 
 
Adverse events and DLTs will be summarized by frequency and magnitude.  The rate of 
feasibility of administering entinostat concomitantly with atezolizumab, carboplatin, and 
etoposide as determined by the proportion of participants who receive 3 or more cycles of the 
combination, will be calculated with a 90% confidence interval.  The Kaplan Meier estimator 
will be used to estimate survival curves for all time to event endpoints including progression free 
survival (PFS) and overall survival (OS).  The 9 month PFS rate will be estimated with a 90% 
confidence interval.  Anti-tumor endpoints, including measures of tumor response and symptom 
relief, will be summarized using descriptive statistics. Tumor response will be measured using 
RESIST 1.1 criteria and reported as overall response rate (ORR) with a 95% confidence interval. 
Entinostat exposure will be determined for each patient using mixed effects pharmacokinetic 
modeling. Atezolizumab clearance, including a time-varying rate of change, will be determined 
for each patient using mixed effects pharmacokinetic modeling. Exposure-response assessments 
will be assess associations between entinostat exposure with the clinically significant toxicity, 
PFS and OS. Clearance-response will be assessed between baseline or time-varying 
atezolizumab clearance with the presence of cachexia, PFS and OS. Biomarker evaluations from 
exploratory objectives will be summarized using descriptive statistics. 
 
 
 
 


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85 
10. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of AEs (Section 10.1) and the characteristics of an observed AE (Sections 10.2 and 
10.3) will determine whether the event requires expedited reporting via the CTEP Adverse Event 
Reporting System (CTEP-AERS) in addition to routine reporting. 
 
10.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) 
 
10.1.1 CAEPRs for CTEP IND Agent 
 
10.1.1.1 
CAEPR for Entinostat 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
 for 
MS-275 (SNDX-275, entinostat, NSC 706995) 
 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI via AdEERS (except as noted below).  Refer to the 'CTEP, NCI Guidelines: Adverse 
Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for further 
clarification. Frequency is provided based on 221 patients. Below is the CAEPR for MS-275 (SNDX-275, 
entinostat). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required.  
 
Version 2.5, September 10, 20181 
 
 Adverse Events with Possible  
 Relationship to MS-275 (SNDX-275, entinostat) 
 (CTCAE 5.0 Term) 
[n= 221] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting (SPEER) 
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
Anemia 
 
 
 Anemia (Gr 3) 
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
Constipation 
 
 Constipation (Gr 2) 
 
Diarrhea 
 
 Diarrhea (Gr 3) 
 
Dyspepsia 
 
 Dyspepsia (Gr 2) 
Nausea 
 
 
 Nausea (Gr 3) 
Vomiting 
 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Edema limbs 
 
 Edema limbs (Gr 2) 


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86 
 
 Adverse Events with Possible  
 Relationship to MS-275 (SNDX-275, entinostat) 
 (CTCAE 5.0 Term) 
[n= 221] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting (SPEER) 
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
Fatigue 
 
 
 Fatigue (Gr 3) 
 
Fever 
 
 Fever (Gr 2) 
INFECTIONS AND INFESTATIONS 
  
 
Infection2 
 
 Infection2 (Gr 3) 
INVESTIGATIONS 
  
 
Alkaline phosphatase increased  
 Alkaline phosphatase increased  
(Gr 2) 
 
Lymphocyte count decreased 
 
 Lymphocyte count decreased (Gr 4) 
Neutrophil count decreased  
 
 Neutrophil count decreased (Gr 4) 
Platelet count decreased 
 
 
 Platelet count decreased (Gr 4) 
 
White blood cell decreased 
 
 White blood cell decreased (Gr 3) 
METABOLISM AND NUTRITION DISORDERS 
  
Anorexia 
 
 
 Anorexia (Gr 3) 
 
Dehydration 
 
 Dehydration (Gr 2) 
 
Hyperglycemia 
 
 Hyperglycemia (Gr 2) 
Hypoalbuminemia 
 
 
 Hypoalbuminemia (Gr 2) 
 
Hypocalcemia 
 
 Hypocalcemia (Gr 2) 
 
Hypokalemia 
 
 Hypokalemia (Gr 2) 
 
Hyponatremia 
 
 Hyponatremia (Gr 3) 
Hypophosphatemia 
 
 
 Hypophosphatemia (Gr 3) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Myalgia 
 
 Myalgia (Gr 2) 
NERVOUS SYSTEM DISORDERS 
  
 
Dysgeusia 
 
 Dysgeusia (Gr 2) 
Headache 
 
 
 Headache (Gr 2) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
 Dyspnea (Gr 3) 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
 
Erythema multiforme 
  
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
2Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATION SOC. 
 
3Gastrointestinal hemorrhage includes Anal hemorrhage, Cecal hemorrhage, Colonic hemorrhage, 
Duodenal hemorrhage, Esophageal hemorrhage, Esophageal varices hemorrhage, Gastric hemorrhage, 
Hemorrhoidal hemorrhage, Ileal hemorrhage, Intra-abdominal hemorrhage, Jejunal hemorrhage, Lower 
gastrointestinal hemorrhage, Oral hemorrhage, Pancreatic hemorrhage, Rectal hemorrhage, 
Retroperitoneal hemorrhage, and Upper gastrointestinal hemorrhage under the GASTROINTESTINAL 
DISORDERS SOC. 
 
 
 


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87 
Adverse events reported on MS-275 (SNDX-275, entinostat) trials, but for which there is 
insufficient evidence to suggest that there was a reasonable possibility that MS-275 (SNDX-275, 
entinostat) caused the adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Febrile neutropenia; Hemolysis; Leukocytosis 
CARDIAC DISORDERS - Atrial fibrillation; Atrioventricular block complete; Cardiac disorders - Other 
(transient right-side heart failure with worsening tricuspid regurgitation); Chest pain - cardiac; Conduction 
disorder; Heart failure; Left ventricular systolic dysfunction; Palpitations; Pericardial effusion; Pericarditis; 
Sinus tachycardia; Supraventricular tachycardia; Ventricular fibrillation 
EAR AND LABYRINTH DISORDERS - Hearing impaired 
EYE DISORDERS - Blurred vision 
GASTROINTESTINAL DISORDERS - Anal mucositis; Colitis; Dysphagia; Enterocolitis; Esophageal pain; 
Esophagitis; Flatulence; Gastrointestinal disorders - Other (hyperdefecation); Gastrointestinal 
hemorrhage3; Hemorrhoids; Mucositis oral; Pancreatitis; Periodontal disease; Rectal mucositis; Rectal 
pain; Small intestinal mucositis; Typhlitis; Visceral arterial ischemia 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema face; Generalized 
edema; Injection site reaction; Multi-organ failure; Non-cardiac chest pain; Pain 
IMMUNE SYSTEM DISORDERS - Allergic reaction; Anaphylaxis; Autoimmune disorder 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising 
INVESTIGATIONS - Activated partial thromboplastin time prolonged; Alanine aminotransferase 
increased; Aspartate aminotransferase increased; Blood bilirubin increased; CPK increased; Creatinine 
increased; GGT increased; INR increased; Investigations - Other (coagulopathy); Investigations - Other 
(vitamin D deficiency); Lipase increased; Serum amylase increased; Weight loss 
METABOLISM AND NUTRITION DISORDERS - Acidosis; Hypercalcemia; Hyperkalemia; 
Hypermagnesemia; Hypernatremia; Hypertriglyceridemia; Hyperuricemia; Hypoglycemia; 
Hypomagnesemia; Tumor lysis syndrome 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthralgia; Back pain; Bone pain; 
Chest wall pain; Generalized muscle weakness; Muscle cramp; Musculoskeletal and connective tissue 
disorder - Other (thorax pain); Myositis; Pain in extremity 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Tumor pain 
NERVOUS SYSTEM DISORDERS - Ataxia; Depressed level of consciousness; Dizziness; Dysphasia; 
Intracranial hemorrhage; Neuralgia; Olfactory nerve disorder; Peripheral motor neuropathy; Peripheral 
sensory neuropathy; Seizure; Syncope; Tremor 
PSYCHIATRIC DISORDERS - Anxiety; Confusion; Depression; Insomnia; Libido decreased 
RENAL AND URINARY DISORDERS - Acute kidney injury; Proteinuria; Renal and urinary disorders - 
Other (bladder distension); Renal calculi; Renal hemorrhage; Urinary frequency; Urinary retention 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Allergic rhinitis; Atelectasis; Epistaxis; 
Hypoxia; Laryngeal mucositis; Pharyngeal mucositis; Pleural effusion; Pleuritic pain; Pulmonary edema; 
Respiratory failure; Tracheal mucositis 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Hyperhidrosis; Nail loss; 
Photosensitivity; Pruritus; Purpura; Rash maculo-papular; Skin and subcutaneous tissue disorders - Other 
(hyperkeratotic lesions/squamous cell carcinoma); Urticaria 
SURGICAL AND MEDICAL PROCEDURES - Surgical and medical procedures - Other (packed RBC 
transfusion) 
VASCULAR DISORDERS - Flushing; Hypertension; Hypotension; Thromboembolic event 
 
Note: MS-275 (SNDX-275, entinostat) in combination with other agents could cause an exacerbation of 
any adverse event currently known to be caused by the other agent, or the combination may result in 
events never previously associated with either agent. 
 
 
 
 


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88 
10.1.2 Adverse Event Lists for Commercial Agents 
 
10.1.2.1 
CAEPR for Atezolizumab 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
for 
Atezolizumab (MPDL3280A, NSC 783608) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below). Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 
for further clarification. Frequency is provided based on 3097 patients. Below is the CAEPR for 
Atezolizumab (MPDL3280A). 
 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the AE 
in the SPEER. If this CAEPR is part of a combination protocol using multiple investigational agents and 
has an AE listed on different SPEERs, use the lower of the grades to determine if expedited reporting is 
required. 
 
  
 
Version 2.3, March 11, 20211  
 
 Adverse Events with Possible  
 Relationship to Atezolizumab (MPDL3280A) 
 (CTCAE 5.0 Term) 
[n= 3097] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
Anemia 
 
  
CARDIAC DISORDERS 
  
 
 
Heart failure2 
  
 
 
Myocarditis2 
  
 
 
Pericardial effusion2 
  
 
 
Pericardial tamponade2 
  
 
 
Pericarditis2 
  
ENDOCRINE DISORDERS 
  
 
 
Adrenal insufficiency2 
  
 
 
Endocrine disorders - Other 
(diabetes)2 
  
 
Hyperthyroidism2 
 
  
 
 
Hypophysitis2 
  
 
Hypothyroidism2 
 
  
EYE DISORDERS 
  
 
 
Eye disorders - Other (ocular 
inflammatory toxicity)2 
  
 
 
Uveitis2 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
 
Colitis2 
  


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89 
 
 Adverse Events with Possible  
 Relationship to Atezolizumab (MPDL3280A) 
 (CTCAE 5.0 Term) 
[n= 3097] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
Diarrhea 
 
 Diarrhea (Gr 2) 
 
Dysphagia 
 
  
 
Nausea 
 
 Nausea (Gr 2) 
 
 
Pancreatitis2 
  
 
Vomiting 
 
 Vomiting (Gr 2) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
Fatigue 
 
 
 Fatigue (Gr 2) 
 
Fever3 
 
  
 
Flu like symptoms3 
 
  
HEPATOBILIARY DISORDERS 
  
 
 
Hepatic failure2 
  
 
 
Hepatobiliary disorders - 
Other (hepatitis)2 
  
IMMUNE SYSTEM DISORDERS 
  
 
Allergic reaction3 
 
  
 
 
Anaphylaxis3 
  
 
 
Cytokine release syndrome3   
 
 
Immune system disorders - 
Other (systemic immune 
activation)2 
  
INFECTIONS AND INFESTATIONS 
  
Infection4 
 
 
  
INJURY, POISONING AND PROCEDURAL COMPLICATIONS 
  
 
Infusion related reaction3 
 
  
INVESTIGATIONS 
  
 
Alanine aminotransferase 
increased2 
 
  
 
Alkaline phosphatase increased2  
  
 
Aspartate aminotransferase 
increased2 
 
  
 
Blood bilirubin increased2 
 
  
 
 
Creatinine increased 
  
 
GGT increased2 
 
  
 
Lipase increased* 
 
  
 
 
Platelet count decreased 
  
 
Serum amylase increased* 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
 Anorexia (Gr 2) 
 
 
Hyperglycemia2 
  
 
Hypokalemia 
 
  
 
Hyponatremia 
 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia2 
 
  
 
Back pain 
 
  
 
 
Generalized muscle 
weakness 
  
 
Myalgia 
 
  
 
 
Myositis2 
  


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
90 
 
 Adverse Events with Possible  
 Relationship to Atezolizumab (MPDL3280A) 
 (CTCAE 5.0 Term) 
[n= 3097] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
NERVOUS SYSTEM DISORDERS 
  
 
 
Ataxia2 
  
 
 
Encephalopathy2 
  
 
 
Nervous system disorders - 
Other (encephalitis non-
infective)2 
  
 
 
Guillain-Barre syndrome2 
  
 
 
Nervous system disorders - 
Other (meningitis non-
infective)2 
  
 
 
Myasthenia gravis2 
  
 
 
Paresthesia2 
  
 
 
Peripheral motor neuropathy2   
 
 
Peripheral sensory 
neuropathy2 
  
RENAL AND URINARY DISORDERS 
  
 
 
Acute kidney injury 
  
 
 
Renal and urinary disorders - 
Other (nephritis)2 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
  
 
Hypoxia 
 
  
 
Nasal congestion 
 
 Nasal congestion (Gr 2) 
 
 
Pleural effusion2 
  
 
 
Pneumonitis2 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
 
Bullous dermatitis2 
  
 
 
Erythema multiforme2 
  
 
Pruritus 
 
  
 
Rash acneiform 
 
  
 
Rash maculo-papular 
 
  
 
 
Skin and subcutaneous tissue 
disorders - Other (drug 
reaction with eosinophilia and 
systemic symptoms 
[DRESS])2 
  
 
Skin and subcutaneous tissue 
disorders - Other (lichen planus)2 
 
  
 
 
Skin and subcutaneous tissue 
disorders - Other 
(exanthematous pustulosis)2 
  
 
 
Stevens-Johnson syndrome2   
 
 
Toxic epidermal necrolysis2 
  
 
 
*Denotes adverse events that are <3%. 
 
1This table will be updated as the toxicity profile of the agent is revised. Updates will be distributed to all 


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91 
Principal Investigators at the time of revision. The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
2Atezolizumab, being a member of a class of agents involved in the inhibition of “immune checkpoints,” 
may result in severe and possibly fatal immune-mediated adverse events probably due to T-cell activation 
and proliferation. Immune-mediated adverse reactions have been reported in patients receiving 
atezolizumab. Adverse events potentially related to atezolizumab may be manifestations of immune-
mediated adverse events. In clinical trials, most immune-mediated adverse reactions were reversible and 
managed with interruptions of atezolizumab, administration of corticosteroids and supportive care. 
 
3Infusion reactions, including high-grade hypersensitivity reactions, anaphylaxis, and cytokine release 
syndrome, which have been observed following administration of atezolizumab, may manifest as fever, 
chills, shakes, itching, rash, hypertension or hypotension, or difficulty breathing during and immediately 
after administration of atezolizumab. 
 
4Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. 
 
Adverse events reported on atezolizumab (MPDL3280A) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that atezolizumab (MPDL3280A) 
caused the adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(pancytopenia); Febrile neutropenia 
CARDIAC DISORDERS - Cardiac arrest; Ventricular tachycardia 
GASTROINTESTINAL DISORDERS - Constipation; Dry mouth; Ileus 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema limbs; Malaise; 
Multi-organ failure 
HEPATOBILIARY DISORDERS - Portal vein thrombosis 
INVESTIGATIONS - Lymphocyte count decreased; Neutrophil count decreased; Weight loss; White blood 
cell decreased 
METABOLISM AND NUTRITION DISORDERS - Hypophosphatemia; Tumor lysis syndrome 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Bone pain; Muscle cramp: Pain in 
extremity 
NERVOUS SYSTEM DISORDERS - Headache 
PSYCHIATRIC DISORDERS - Confusion; Insomnia; Suicide attempt 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Breast pain 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchopulmonary hemorrhage; 
Pulmonary hypertension; Respiratory failure 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Dry skin2; Hyperhidrosis 
VASCULAR DISORDERS - Hypertension; Hypotension; Thromboembolic event 
 
Note: Atezolizumab (MPDL3280A) in combination with other agents could cause an exacerbation of any 
adverse event currently known to be caused by the other agent, or the combination may result in events 
never previously associated with either agent. 
 
10.1.2.2 
Adverse Event List for Carboplatin 
 
The most common adverse reactions for carboplatin are included below.  See a carboplatin 
package insert for more information. 
 
Myelosuppression, nausea, vomiting, diarrhea, weight loss, constipation, gastrointestinal pain, 
electrolyte imbalances, hypomagnesemia, hypocalcemia, hyponatremia, hyperuremia elevated 


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92 
alkaline phosphatase, AST, and total bilirubin, peripheral neuropathies (mild paresthesias, 
clinical ototoxicity and other sensory abnormalities are rare), renal tubular damage, renal 
insufficiency, impotence, sterility, amenorrhea, gynecomastia anaphylactoid and urticarial 
reactions (acute), flushing, rash, pruritis and rarely hypotension or bronchospasm, alopecia, pain, 
asthenia and mucosal side effects, decreased serum electrolytes values (sodium, magnesium, 
calcium and potassium). 
 
10.1.2.3 
Adverse Event List for Etoposide 
 
The most serious adverse reactions to etoposide are myelosuppression, secondary leukemia, and 
hypersensitivity reactions.  Other adverse reactions that have been observed include:  nausea, 
vomiting, abdominal pain, constipation, dysphagia, fever, transient cortical blindness, optic 
neuritis, interstitial pneumonitis/pulmonary fibrosis, pigmentation, radiation recall dermatitis, 
Stevens-Johnson syndrome, toxic epidermal necrolysis, seizure, aftertaste, hepatotoxicity, and 
extravasation.  Transient hypotension and other anaphylactic-like symptoms are associated with 
rapid infusion.  Please refer to the etoposide package insert for additional information. 
 
10.2 
Adverse Event Characteristics  
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
5.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 5.0.  A copy of the CTCAE version 5.0 can be 
downloaded from the CTEP website 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 10.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER. 
- 
Other AEs for the protocol that do not require expedited reporting are outlined in 
Section 10.3.4. 
 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
10.3 
Expedited Adverse Event Reporting 
 
10.3.1 Rave-CTEP-AERS Integration. 
 
The Rave Cancer Therapy Evaluation Program Adverse Event Reporting System (CTEP-
AERS) integration enables evaluation of post-baseline AEs entered in Rave to determine 


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93 
whether they require expedited reporting, and facilitates entry in CTEP-AERS for those 
AEs requiring expedited reporting.    
 
All AEs that occur after baseline are collected in Medidata Rave using the Adverse Event 
form, which is available for entry at each treatment or reporting period, and used to 
collect AEs that start during the period or persist from the previous reporting period.  
CRA will enter AEs that occur prior to the start of treatment on a baseline form that is not 
included in the Rave-CTEP-AERS integration.  AEs that occur prior to enrollment must 
begin and end on the baseline Adverse Event form and should not be included on the 
standard Adverse Events form that is available at treatment unless there has been an 
increase in grade. 
 
Prior to sending AEs through the rules evaluation process, site staff should verify the 
following on the Adverse Event form in Rave: 
 
• The reporting period (course/cycle) is correct, and 
• AEs are recorded and complete (no missing fields) and the form is query-free. 
 
The CRA reports AEs in Rave at the time the Investigator learns of the event.  If the CRA 
modifies an AE, it must be re-submitted for rules evaluation. 
 
Upon completion of AE entry in Medidata Rave, the CRA submits the AE for rules 
evaluation by completing the Expedited Reporting Evaluation form.  Both NCI and 
protocol-specific reporting rules evaluate the AEs submitted for expedited reporting.  A 
report is initiated in CTEP-AERS using information entered in Medidata Rave for AEs 
that meet reporting requirements.  The CRA completes the report by accessing CTEP-
AERS via a direct link on the Medidata Rave Expedited Reporting Evaluation form. 
 
In the rare occurrence that Internet connectivity is lost, a 24-hour notification is to be 
made to CTEP by telephone at 301-897-7497.  Once internet connectivity is restored, the 
24-hour notification that was phoned in must be entered immediately into CTEP-AERS 
using the direct link from Medidata Rave. 
 
Additional information about the CTEP-AERS integration is available on the CTSU 
website: 
 
• Study specific documents:  Protocols > Documents > Education and Promotion, 
and   
• Expedited Safety Reporting Rules Evaluation user guide:  Resources > CTSU 
Operations Information > User Guides & Help Topics. 
 
NCI requirements for SAE reporting are available on the CTEP website:  
 
• NCI Guidelines for Investigators:  Adverse Event Reporting Requirements is 
available at 
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguid


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94 
elines.pdf. 
 
10.3.2 Distribution of Adverse Event Reports 
 
CTEP-AERS is programmed for automatic electronic distribution of reports to the following 
individuals:  Principal Investigator and Adverse Event Coordinator(s) (if applicable) of the 
Corresponding Organization or Lead Organization, the local treating physician, and the Reporter 
and Submitter.  CTEP-AERS provides a copy feature for other e-mail recipients.  
 
10.3.3 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports. 
 
Note:  A death on study requires both routine and expedited reporting, regardless of 
causality as long as the death occurred within 30 days after the last administration of the 
investigational agent.  Attribution to treatment or other cause must be provided. 
 
Death due to progressive disease should be reported as Grade 5 “Disease progression” in the 
system organ class (SOC) “General disorders and administration site conditions.”  Evidence that 
the death was a manifestation of underlying disease (e.g., radiological changes suggesting tumor 
growth or progression: clinical deterioration associated with a disease process) should be 
submitted.  
 
Phase 1 and Early Phase 2 Studies:  Expedited Reporting Requirements for Adverse 
Events that Occur on Studies under an IND/IDE within 30 Days of the Last Administration 
of the Investigational Agent/Intervention 1, 2 
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) 
NOTE:  Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not 
they are considered related to the investigational agent(s)/intervention (21 CFR 312.64) 
An adverse event is considered serious if it results in ANY of the following outcomes:   
1) 
Death 
2) 
A life-threatening adverse event  
3) 
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 
hours  
4) 
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
5) 
A congenital anomaly/birth defect.  
6) 
Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment, they may jeopardize the patient or 
subject and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition. (FDA, 21 CFR 312.32; ICH E2A and ICH E6). 
 
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via electronic 
submission within the timeframes detailed in the table below. 
Hospitalization 
Grade 1 and Grade 2 Timeframes 
Grade 3-5 
Timeframes 
Resulting in 
Hospitalization  
≥ 24 hrs 
10 Calendar Days 
24-Hour 5 Calendar 
Days 


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95 
Not resulting in 
Hospitalization  
≥ 24 hrs 
Not required 
NOTE:  Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific 
Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR. 
Expedited AE reporting timelines are defined as: 
o 
“24-Hour; 5 Calendar Days” - The AE must initially be submitted electronically within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. 
o 
“10 Calendar Days” - A complete expedited report on the AE must be submitted electronically within 10 
calendar days of learning of the AE. 
1Serious adverse events that occur more than 30 days after the last administration of investigational 
agent/intervention and have an attribution of possible, probable, or definite require reporting as follows:  
Expedited 24-hour notification followed by complete report within 5 calendar days for: 
• 
All Grade 3, 4, and Grade 5 AEs 
Expedited 10 calendar day reports for: 
• 
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization 
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, 
rounded UP to the nearest whole day, after the agent/intervention was last administered.  Footnote “1” above 
applies after this reporting period. 
Effective Date:  May 5, 2011 
 
10.3.4 Additional Protocol-Specific Expedited Adverse Event Reporting Exclusions 
 
For this protocol only, grade 3 laboratory AEs that do not meet criteria for DLT or result in a 
change study treatment do not require expedited reporting via CTEP-AERS.  However, they still 
must be reported through the routine reporting mechanism (Section 10.4). 
 
10.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 
 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents.  AEs are reported in a routine manner at scheduled times 
during the trial using Medidata Rave.  For this trial the Adverse Event CRF is used for routine 
AE reporting in Rave. 
 
10.5 
Pregnancy 
 
Although not an adverse event in and of itself, pregnancy as well as its outcome must be 
documented via CTEP-AERS.  In addition, the Pregnancy Information Form included within 
the NCI Guidelines for Adverse Event Reporting Requirements must be completed and 
submitted to CTEP.  Any pregnancy occurring in a patient or patient’s partner from the time of 
consent to 150 days (5 months) after the last dose of study treatment must be reported and then 
followed for outcome.  Newborn infants should be followed until 30 days old.  Please see the 
“NCI Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD (CTEP 


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96 
and CIP) and DCP INDs and IDEs” (at 
http://ctep.cancer.gov/protocolDevelopment/adverse_effects.htm) for more details on how to 
report pregnancy and its outcome to CTEP.  
 
10.6 
Secondary Malignancy 
 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy). A secondary 
malignancy is not considered a metastasis of the initial neoplasm. 
 
CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported expeditiously via CTEP-AERS.  Three options are available to 
describe the event:  
 
• Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia [AML])  
• Myelodysplastic syndrome (MDS)  
• Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol.  
 
10.7 
Second Malignancy 
 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy).  Second malignancies require ONLY routine AE 
reporting unless otherwise specified. 
 


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97 
 
11. STUDY CALENDAR 
 
Baseline evaluations (i.e. physical exam, vital signs, weight, performance status, laboratory tests, including pregnancy test, EKG (as 
indicated)) are to be conducted within 2 weeks prior to study registration.  Radiologic evaluations must be done <4 weeks prior to 
study registration.  In the event that the patient’s condition is deteriorating, the physical exam and laboratory evaluations should be 
repeated within 48 hours prior to initiation of the next cycle of therapy.  All in-clinic treatments and assessments can be carried out ±2 
days of the time points indicated below during induction to allow for holidays, inclement weather, and other unexpected conflicts.  In 
the maintenance phase, a window of ±3 days is allowed for Day 1 of each cycle. 
 
 
Induction (Cycles 1-4) 
Maintenance  
(Cycles 5-17) 
D1 
End of study treatment (at least 30 days 
after last entinostat dose) 
Follow-upa 
 
Pre- 
Study 
C1 
D1 
C1 
D8 
C1 
D15 
C2D1 
C3D1 
C4D1 
Entinostat 
 
A 
A 
A 
A 
A 
A 
A 
 
 
Atezolizumab 
 
B 
 
 
B 
B 
B 
B 
Bj 
Bj 
Carboplatin, Etoposide 
 
C 
 
 
C 
C 
C 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
Concurrent meds 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Height 
X 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
 
 
X 
X 
X 
X 
X 
 
Performance status 
X 
 
 
 
 
 
 
 
 
 
CBC w/diff, plts 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Comprehensive Chemistry 
Panelb 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
PT/INR 
x 
 
 
 
 
 
 
 
 
 


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98 
 
Induction (Cycles 1-4) 
Maintenance  
(Cycles 5-17) 
D1 
End of study treatment (at least 30 days 
after last entinostat dose) 
Follow-upa 
 
Pre- 
Study 
C1 
D1 
C1 
D8 
C1 
D15 
C2D1 
C3D1 
C4D1 
TSH, T3, T4n 
X 
X 
 
 
X 
 
X 
Xi  
Xi  
 
EKG (as indicated) 
X 
 
 
 
 
 
 
 
 
 
Adverse event evaluation 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
Tumor measurements (RECIST 
assessments) 
X 
 
 
 
 
X 
 
Xe 
Xf 
Xf 
Radiologic evaluation 
Xg 
 
 
 
 
Xg 
 
Xg 
Xg 
Xg 
Overall Survivalh 
 
 
 
 
 
 
 
 
 
X 
Pregnancy testc 
X 
 
 
 
 
 
 
 
 
 
Archival tumor submission 
X 
 
 
 
 
 
 
 
 
 
Tumor biopsyd 
X 
 
 
 
 
 
 
 
 
Xk 
Blood in cfDNA Streck tube for 
ctDNA 
 
X 
 
 
 
 
 
 
 
Xk 
Flow cytometry, ELIspot 
 
X 
 
 
X 
X 
X 
 
 
Xk 
Entinostat PKl 
 
x 
x 
x 
x 
 
 
 
 
 
Atezolizumab PKm 
 
x 
 
 
x 
x 
x 
x 
 
 
A: 
Entinostat:  Dose as assigned; Days 1, 8, and 15 of each cycle 
B: 
Atezolizumab: Dose as assigned; Day 1 of each cycle 
C:      Carboplatin, etoposide: Dose as assigned; Carboplatin Day 1, Etoposide Days 1-3, cycles 1-4. For patients that cannot tolerate carboplatin and etoposide, discontinue induction cycles and 
follow the Maintenance regimen. 
a: 
Follow-up assessments will be conducted for up to 5 years from the date of registration. Patients that discontinue study treatment for reasons other than disease progression will follow the 
imaging schedule per footnotes f and g. Patients that discontinue study treatment for disease progression will be followed every 3 months for the first 2 years and then every 6 months for 
years 3 -5 from the date of registration. 
b: 
Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, potassium, total protein, SGOT [AST], SGPT [ALT], sodium. 
c: 
Pregnancy test for women of childbearing potential. 
d:      Tissue biopsy is not required at screening if archival tissue is available.  Tissue biopsy at progression (off study) is optional. PT/INR may be required per institutional requirements for biopsies. 


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99 
 
Induction (Cycles 1-4) 
Maintenance  
(Cycles 5-17) 
D1 
End of study treatment (at least 30 days 
after last entinostat dose) 
Follow-upa 
 
Pre- 
Study 
C1 
D1 
C1 
D8 
C1 
D15 
C2D1 
C3D1 
C4D1 
e: 
Tumor measurements are repeated every 6 weeks (+/- 1 week) for year 1.   
f: 
Tumor measurements are repeated every 3 months (+/- 2 weeks) for year 2, then every 6 months (+/- 1 month) thereafter.  Documentation (radiologic) must be provided for patients 
removed from study for progressive disease. 
g: 
CT Chest/Abd/Pelvis are performed within 4 weeks of study registration and then every 6 weeks(+/- 1 week) for year 1, every 3 months (+/- 2 weeks) for year 2, then every 6 months (+/- 1 
month) thereafter until progression. Patients who discontinue study treatment for reasons other than disease progression will to continue radiographic evaluations per this schedule during 
Follow-Up until disease progression is documented. For pts with untreated brain mets, brain MRI is performed within 4 weeks of study enrollment and then subsequently at same schedule as 
CT imaging; otherwise as clinically indicated. 
h: 
If participant is no longer coming to the study site, study staff will call or email the participant to check overall survival every 3 months for years 1-2, then every 6 months (+/- 1 month) until 5 
years from registration. 
i: 
Day 1 of every even cycle. 
j: 
May continue per investigator/patient discretion as standard of care. Labs, vitals, performance status should be done as routine standard of care and are not indicated on this table. End of 
treatment visit may occur on a day when standard of care atezolizumab is administered or a separate day. 
k:       Tumor biopsy (optional), blood collection in cfDNA Streck tube for ctDNA, Flow cytometry, and ELIspot are to be performed at the time of progression.  Refer to Sections 5.1 and 5.5. 
l:        Entinostat PK on Cycles 1-2, Day 1: prior to entinostat, ~0.5 hr post dose, and ~2 hrs post dose; Cycles 1-2, Day 2: prior to etoposide infusion; Cycle 1, Day 8 and 15: prior to entinostat. 
m:      Atezolizumab PK on Day 1 of Cycles 1 and 2: prior to atezolizumab and after the end of the atezolizumab infusion at the same time as the ~2 hr post entinostat PK. On Day 1 of Cycles 3, 4, 6, 
and 8: prior to atezolizumab and ~0.5 hr after completion of atezolizumab infusion. 
n:       Free or total T3/T4 may be performed per institutional standards. 
 


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100 
11.1 
Management of Study Patients During Local Epidemic or Pandemic 
 
In the event of ongoing or worsening COVID-19 outbreaks locally or regionally (or other 
widespread viral illnesses that strain health systems and require modification of normal 
operations), efforts to reduce visits and exposure for patients will be permissible, where 
permitted by law, institutional policy, and NCI requirements.  All efforts should be made to 
follow the study protocol and study calendar without deviation.  When this is not feasible or safe, 
the following modifications can be considered.  These modifications should be used to make it 
feasible for patients remain on study instead of withdrawing. 
• All labs and visits are required to be maintained per the study calendar.   
• Excluding screening and cycle 1 day 1, outside facilities may be used for laboratory 
assessments  
• Excluding screening and cycle 1 day 1, remote visits (telehealth) may be used in place of 
in person visits. Video telemedicine visits are strongly preferred over telephone only 
encounters to accurately assess adverse events.  
• Days 2-3 of etoposide may be administered as oral dose of 200 mg/m2 PO daily. (Cycles 
1-4, day 1 carboplatin and etoposide will need to be administered at study facility as per 
study protocol)  
• For patients in the maintenance phase, atezolizumab may be given every 4 weeks per 
FDA labeled dosing schedule of 1680 mg every 4 weeks.   
• Local infusion facilities not part of the study facilities may be used for maintenance 
atezolizumab.  
• Entinostat can be shipped directly to the patient up to two bottles at a time.   
 


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101 
12. MEASUREMENT OF EFFECT 
 
Although the clinical benefit of these drugs has not yet been established, the intent of offering 
this treatment is to provide a possible therapeutic benefit, and thus the patient will be carefully 
monitored for tumor response and symptom relief in addition to safety and tolerability.  Patients 
with measurable disease will be assessed by standard criteria.  For the purposes of this study, 
patients should be re-evaluated every 6 weeks during year 1, every 3 months during year 2, and 
every 6 months thereafter.  In addition to a baseline scan, confirmatory scans will also be 
obtained 6 weeks following initial documentation of an objective response. 
 
12.1 
Antitumor Effect – Solid Tumors 
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) [Eur J Ca 45:228-247, 2009].  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria. 
 
12.1.1 Definitions 
 
Evaluable for Toxicity.  All patients will be evaluable for toxicity from the time of their first 
treatment with entinostat. 
 
Evaluable for Objective Response.  Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will 
be considered evaluable for response.  These patients will have their response classified 
according to the definitions stated below.  (Note:  Patients who exhibit objective disease 
progression prior to the end of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Patients who have lesions present at baseline that are 
evaluable but do not meet the definitions of measurable disease, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 
disease.  The response assessment is based on the presence, absence, or unequivocal progression 
of the lesions.  
 
12.1.2 Disease Parameters 
 
Measurable Disease.  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as ≥20 mm (≥2 cm) by chest x-ray or as 
≥10 mm (≥1 cm) with CT scan, MRI, or calipers by clinical exam.  All tumor measurements 
must be recorded in millimeters (or decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area might or might not be 
considered measurable.   
 
Malignant Lymph Nodes.  To be considered pathologically enlarged and measurable, a lymph 


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102 
node must be ≥15 mm (≥1.5 cm) in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm [0.5 cm]).  At baseline and in follow-up, 
only the short axis will be measured and followed. 
 
Non-Measurable Disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm [<1 cm] or pathological lymph nodes with ≥10 to <15 mm [≥1 to <1.5 cm] 
short axis), are considered non-measurable disease.  Bone lesions, leptomeningeal disease, 
ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, 
if they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
 
Target Lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline.  Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements.  It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be selected.  A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 
lesions will be calculated and reported as the baseline sum diameters.  If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum.  The baseline sum diameters 
will be used as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-Target Lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up.  
 
12.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment. 
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam. 


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Clinical Lesions.  Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and ≥10 mm (≥1 cm) diameter as assessed using 
calipers (e.g., skin nodules).  In the case of skin lesions, documentation by color photography, 
including a ruler to estimate the size of the lesion, is recommended.  
 
Chest X-Ray.  Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 
defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI.  This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm (0.5 cm) or less.  If CT scans have slice 
thickness greater than 5 mm (0.5 cm), the minimum size for a measurable lesion should be twice 
the slice thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which greatly 
impact image quality, lesion conspicuity, and measurement.  Furthermore, the availability of 
MRI is variable globally.  As with CT, if an MRI is performed, the technical specifications of the 
scanning sequences used should be optimized for the evaluation of the type and site of disease.  
Furthermore, as with CT, the modality used at follow-up should be the same as was used at 
baseline and the lesions should be measured/assessed on the same pulse sequence.  It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all 
scanners, body parts, and diseases.  Ideally, the same type of scanner should be used and the 
image acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT.  At present, the low dose or attenuation correction CT portion of a combined PET-CT 
is not always of optimal diagnostic CT quality for use with RECIST measurements.  However, if 
the site can document that the CT performed as part of a PET-CT is of identical diagnostic 
quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be 
used for RECIST measurements and can be used interchangeably with conventional CT in 
accurately measuring cancer lesions over time.  Note, however, that the PET portion of the CT 
introduces additional data which may bias an investigator if it is not routinely or serially 
performed.   
 
Ultrasound.  Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement.  Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 
guaranteed that the same technique and measurements will be taken from one assessment to the 
next.  If new lesions are identified by ultrasound in the course of the study, confirmation by CT 
or MRI is advised.  If there is concern about radiation exposure at CT, MRI may be used instead 
of CT in selected instances. 
 
Endoscopy, Laparoscopy.  The utilization of these techniques for objective tumor evaluation is 
not advised.  However, such techniques may be useful to confirm complete pathological 
response when biopsies are obtained or to determine relapse in trials where recurrence following 


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complete response (CR) or surgical resection is an endpoint. 
 
Tumor Markers.  Tumor markers alone cannot be used to assess response.  If markers are 
initially above the upper normal limit, they must normalize for a patient to be considered in 
complete clinical response.  Specific guidelines for both CA-125 response (in recurrent ovarian 
cancer) and PSA response (in recurrent prostate cancer) have been published [JNCI 96:487-488, 
2004; J Clin Oncol 17, 3461-3467, 1999; J Clin Oncol 26:1148-1159, 2008].  In addition, the 
Gynecologic Cancer Intergroup has developed CA-125 progression criteria which are to be 
integrated with objective tumor assessment for use in first-line trials in ovarian cancer [JNCI 
92:1534-1535, 2000]. 
 
Cytology, Histology.  These techniques can be used to differentiate between partial responses 
(PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as 
germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease. 
 
FDG-PET.  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease).  New lesions on the basis of 
FDG-PET imaging can be identified according to the following algorithm:  
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion. 
b. No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD.  If the 
positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan).  If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not PD. 
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in 
cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring.  The use of FDG-PET in this circumstance should be prospectively described in 
the protocol and supported by disease-specific medical literature for the indication.  
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity. 
 
Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image. 
 
 
 


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12.1.4 Response Criteria 
 
12.1.4.1 
Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm (<1 cm). 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study).  In addition to the relative increase of 20%, the sum must also demonstrate an 
absolute increase of at least 5 mm (0.5 cm).  (Note:  the appearance of one or more new lesions is 
also considered progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum diameters while on study. 
 
12.1.4.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm [<1 cm] short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions.  Unequivocal progression should not normally trump 
target lesion status.  It must be representative of overall disease status change, not a single lesion 
increase. 
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the 
treating physician should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or Principal Investigator). 
 
12.1.4.3 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).  The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria. 
 


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For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
CR 
CR 
No 
CR 
≥4 wks. Confirmation** 
CR 
Non-CR/Non-
PD 
No 
PR 
≥4 wks. Confirmation** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not 
evaluated 
No 
SD 
Documented at least once ≥4 
wks. from baseline** 
PD 
Any 
Yes or No 
PD 
no prior SD, PR or CR 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
**    Only for non-randomized trials with response as primary endpoint. 
Note:  Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.”  Every effort should be made to document the 
objective progression even after discontinuation of treatment. 
 
For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
 
‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign this 
category when no lesions can be measured is not advised 
 
12.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented. 
 


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Duration of stable disease:  Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements.  
 
12.1.6 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first. 
 
 
 


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13. STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 10 
(Adverse Events: List and Reporting Requirements). 
 
13.1 
Study Oversight 
 
This protocol is monitored at several levels, as described in this section.  The Protocol Principal 
Investigator is responsible for monitoring the conduct and progress of the clinical trial, including 
the ongoing review of accrual, patient-specific clinical and laboratory data, and routine and 
serious adverse events; reporting of expedited adverse events; and accumulation of reported 
adverse events from other trials testing the same drug(s).  The Protocol Principal Investigator and 
statistician have access to the data at all times through the CTMS web-based reporting portal.   
 
For the Phase 1 portion of this study, all decisions regarding dose escalation/expansion/de-
escalation require sign-off by the Protocol Principal Investigator through the CTMS/IWRS.  In 
addition, for the Phase 1 portion, the Protocol Principal Investigator will have at least monthly, 
or more frequently, conference calls with the Study Investigators and the CTEP Medical 
Officer(s) to review accrual, progress, and adverse events and unanticipated problems.  
 
All Study Investigators at participating sites who register/enroll patients on a given protocol are 
responsible for timely submission of data via Medidata Rave and timely reporting of adverse 
events for that particular study.  This includes timely review of data collected on the electronic 
CRFs submitted via Medidata Rave. 
 
All studies are also reviewed in accordance with the enrolling institution’s data safety monitoring 
plan. 
 
13.2 
Data Reporting 
 
Medidata Rave is a clinical data management system being used for data collection for this 
trial/study.  Access to the trial in Rave is controlled through the CTEP-IAM system and role 
assignments.   
Requirements  to access Rave via iMedidata: 
 
• 
A valid account, and  
• 
Assigned a  Rave roles on the LPO or PO roster at the enrolling site of:  Rave CRA, Rave 
Read Only, Rave CRA (LabAdmin), Rave SLA, or Rave Investigator.   
Rave role requirements: 
o Rave CRA or Rave CRA (Lab Admin) role, must have a minimum of an 
Associate Plus (AP) registration type, 
o Rave Investigator role, must be registered as an Non-Physician Investigator 
(NPIVR) or Investigator (IVR), and 
o Rave Read Only role, site staff must have at a minimum an Associates (A) 
registration type. 


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109 
• 
Refer to https://ctep.cancer.gov/investigatorResources/default.htm for registration types 
and documentation required. 
 
If the study has a DTL, individuals requiring write access to Rave must also be assigned the 
appropriate Rave tasks on the DTL. 
 
Upon initial site registration approval for the study in Regulatory Support System (RSS), all 
persons with Rave roles assigned on the appropriate roster will be sent a study invitation e-mail 
from iMedidata.  To accept the invitation, site staff must log in to the Select Login 
(https://login.imedidata.com/selectlogin) using their CTEP-IAM username and password, and 
click on the accept link in the upper right-corner of the iMedidata page.  Site staff will not be 
able to access the study in Rave until all required Medidata and study specific trainings are 
completed.  Trainings will be in the form of electronic learnings (eLearnings), and can be 
accessed by clicking on the link in the upper right pane of the iMedidata screen.  If an eLearning 
is required and has not yet been taken, the link to the eLearning will appear under the study name 
in iMedidata instead of the Rave EDC link; once the successful completion of the eLearning has 
been recorded, access to the study in Rave will be granted, and a Rave EDC link will display 
under the study name.  
 
Site staff that have not previously activated their iMedidata/Rave account at the time of initial 
site registration approval for the study in RSS will receive a separate invitation from iMedidata 
to activate their account.  Account activation instructions are located on the CTSU website in the 
Data Management section under the Rave resource materials (Medidata Account Activation and 
Study Invitation Acceptance).  Additional information on iMedidata/Rave is available on the 
CTSU members’ website in the Data Management > Rave section at www.ctsu.org/RAVE/ or by 
contacting the CTSU Help Desk at 1-888-823-5923 or by e-mail at ctsucontact@westat.com.   
 
13.2.1 Method 
 
This study will be monitored by the Clinical Trials Monitoring Service (CTMS).  Data will be 
submitted to CTMS at least once every two weeks via Medidata Rave (or other modality if 
approved by CTEP).  Information on CTMS reporting is available at 
http://www.theradex.com/clinicalTechnologies/?National-Cancer-Institute-NCI-11.  On-site 
audits will be conducted three times annually (one annual site visit and two data audits).  For 
CTMS monitored studies, after users have activated their accounts, please contact the Theradex 
Help Desk at (609) 619-7862 or by email at CTMSSupport@theradex.com for additional support 
with Rave and completion of CRFs. 
 
13.2.2 Responsibility for Data Submission 
 
For ETCTN trials, it is the responsibility of the PI(s) at the site to ensure that all investigators at 
the ETCTN Sites understand the procedures for data submission for each ETCTN protocol and 
that protocol specified data are submitted accurately and in a timely manner to the CTMS via the 
electronic data capture system, Medidata Rave.   
 
Data are to be submitted via Medidata Rave to CTMS on a real-time basis, but no less than once 


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110 
every 2 weeks.  The timeliness of data submissions and timeliness in resolving data queries will 
be tracked by CTMS.  Metrics for timeliness will be followed and assessed on a quarterly basis.  
For the purpose of Institutional Performance Monitoring, data will be considered delinquent if it 
is greater than 4 weeks past due. 
 
Data from Medidata Rave and CTEP-AERS is reviewed by the CTMS on an ongoing basis as 
data is received.  Queries will be issued by CTMS directly within Rave.  The queries will appear 
on the Task Summary Tab within Rave for the CRA at the ETCTN to resolve.  Monthly web-
based reports are posted for review by the Drug Monitors in the IDB, CTEP.  Onsite audits will 
be conducted by the CTMS to ensure compliance with regulatory requirements, GCP, and NCI 
policies and procedures with the overarching goal of ensuring the integrity of data generated 
from NCI-sponsored clinical trials, as described in the ETCTN Program Guidelines, which may 
be found on the CTEP 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm)  and 
CTSU websites. 
 
CTMS will utilize a core set of eCRFs that are Cancer Data Standards Registry and Repository 
(caDSR) compliant (http://cbiit.nci.nih.gov/ncip/biomedical-informatics-
resources/interoperability-and-semantics/metadata-and-models).  Customized eCRFs will be 
included when appropriate to meet unique study requirements.  The PI is encouraged to review 
the eCRFs, working closely with CTMS to ensure prospectively that all required items are 
appropriately captured in the eCRFs prior to study activation.  CTMS will prepare the eCRFs 
with built-in edit checks to the extent possible to promote data integrity. 
 
CDUS data submissions for ETCTN trials activated after March 1, 2014, will be carried out by 
the CTMS contractor, Theradex.  CDUS submissions are performed by Theradex on a monthly 
basis.  The trial’s lead institution is responsible for timely submission to CTMS via Rave, as 
above. 
 
Further information on data submission procedures can be found in the ETCTN Program 
Guidelines 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm). 
 
13.3 
Data Quality Portal 
 
The Data Quality Portal (DQP) provides a central location for site staff to manage 
unanswered queries and form delinquencies, monitor data quality and timeliness, 
generate reports, and review metrics.  
 
The DQP is located on the CTSU members’ website under Data Management.  The Rave 
Home section displays a table providing summary counts of Total Delinquencies and 
Total Queries.  DQP Queries, DQP Delinquent Forms, and the DQP Reports modules are 
available to access details and reports of unanswered queries, delinquent forms, and 
timeliness reports.  Review the DQP modules on a regular basis to manage specified 
queries and delinquent forms. 
 


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111 
The DQP is accessible by site staff that are rostered to a site and have access to the CTSU 
website.  Staff that have Rave study access can access the Rave study data using a direct 
link on the DQP. 
 
To learn more about DQP use and access, click on the Help icon displayed on the Rave 
Home, DQP Queries, and DQP Delinquent Forms modules. 
 
Note:  Some Rave protocols may not have delinquent form details or reports specified on 
the DQP.  A protocol must have the Calendar functionality implemented in Rave by the 
Lead Protocol Organization (LPO) for delinquent form details and reports to be available 
on the DQP.  Site staff should contact the LPO Data Manager for their protocol regarding 
questions about Rave Calendaring functionality.  
13.4 
CTEP Multicenter Guidelines 
 
N/A 
 
13.5 
Collaborative Agreements Language 
 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI 
under a Collaborative Agreement (CRADA, CTA, CSA) between the Pharmaceutical 
Company(ies) (hereinafter referred to as “Collaborator(s)”) and the NCI Division of Cancer 
Treatment and Diagnosis.  Therefore, the following obligations/guidelines, in addition to the 
provisions in the “Intellectual Property Option to Collaborator”  
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained within the 
terms of award, apply to the use of the Agent(s) in this study: 
 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can 
Agent(s) be transferred or licensed to any party not participating in the clinical study.  
Collaborator(s) data for Agent(s) are confidential and proprietary to Collaborator(s) and shall 
be maintained as such by the investigators.  The protocol documents for studies utilizing 
Agents contain confidential information and should not be shared or distributed without the 
permission of the NCI.  If a copy of this protocol is requested by a patient or patient’s family 
member participating on the study, the individual should sign a confidentiality agreement.  A 
suitable model agreement can be downloaded from: http://ctep.cancer.gov. 
 
2. For a clinical protocol where there is an investigational Agent used in combination with 
(an)other Agent(s), each the subject of different Collaborative Agreements, the access to and 
use of data by each Collaborator shall be as follows (data pertaining to such combination use 
shall hereinafter be referred to as "Multi-Party Data”): 
 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
 


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112 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator 
to develop, obtain regulatory approval or commercialize its own Agent. 
 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must 
agree in writing prior to the commencement of the trials that it will use the Multi-Party 
Data solely for development, regulatory approval, and commercialization of its own 
Agent. 
 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
will be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used and 
disclosed consistent with all applicable federal statutes and regulations for the protection of 
human subjects, including, if applicable, the Standards for Privacy of Individually 
Identifiable Health Information set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
 
5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-
Cooperative Group studies for immediate delivery to Collaborator(s) for advisory review and 
comment prior to submission for publication.  Collaborator(s) will have 30 days from the 
date of receipt for review.  Collaborator shall have the right to request that publication be 
delayed for up to an additional 30 days in order to ensure that Collaborator’s confidential and 
proprietary data, in addition to Collaborator(s)’s intellectual property rights, are protected.  
Copies of abstracts must be provided to CTEP for forwarding to Collaborator(s) for courtesy 
review as soon as possible and preferably at least three (3) days prior to submission, but in 
any case, prior to presentation at the meeting or publication in the proceedings.  Press 
releases and other media presentations must also be forwarded to CTEP prior to release.  
Copies of any manuscript, abstract and/or press release/ media presentation should be sent to: 
 
Email:  ncicteppubs@mail.nih.gov 
 
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No publication, 
manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/ 
proprietary information. 
 
 


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113 
13.6 
Incidental/Secondary Findings Disclosure Procedure 
 
No incidental or secondary findings are expected in this study, however, it is possible that an 
incidental germline mutation may be detected that may affect the care of a participant. In this 
case, if the participant indicated on the consent form that he/she would like to be informed of 
incidental findings, then the site would be contacted with this information. The treating physician 
will inform the participant and, based on institutional policy and physician judgment, others, 
such as a genetic counselor or social worker, may be present. If confirmatory testing is required 
to confirm the finding, the patient will have the option to undergo confirmatory testing according 
to standard clinical care. 
 
 
 
 


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14. REFERENCES 
 
An, N., H. Wang, W. Jia, et al.  (2019).  The prognostic role of circulating CD8+ T cell 
proliferation in patients with untreated extensive stage small cell lung cancer.  J Transl Med.  
17(1):402 
 
Antonia, S.J., J.A. Lopez-Martin, J. Bendell, et al.  (2016).  Nivolumab alone and nivolumab 
plus ipilimumab in recurrent small-cell lung cancer (CheckMate 032): a multicentre, open-label, 
phase 1/2 trial.  Lancet Oncol.  17(7): 883-895. 
 
Baverel, P. G., Dubois, V. F. S., Jin, C. Y., Zheng, Y., Song, X., Jin, X., Mukhopadhyay, P., 
Gupta, A., Dennis, P. A., Ben, Y., Vicini, P., Roskos, L., & Narwal, R. (2018a). Population 
pharmacokinetics of durvalumab in cancer patients and association with longitudinal biomarkers 
of disease status. Clinical Pharmacology and Therapeutics, 103(4), 631-642. 
 
Butte, M.J., M.E. Keir, T.B. Phamduy et al.  (2007).  Programmed death-1 ligand 1 interacts 
specifically with the B7-1 costimulatory molecule to inhibit T cell responses.  Immunity  27(1): 
111-122. 
 
Carboplatin Package Insert. (2011). Carboplatin Injection. Teva Pharmaceutical Industries, Petah 
Tikva, Israel. 
 
Coss, C. C., Clinton, S. K., & Phelps, M. A. (2018). Cachectic cancer patients: Immune to check-
point inhibitor therapy? Clinical Cancer Research, 24(23), 5787-5789. 
 
Desnoyer, A., Broutin, S., Delahousse, J., Maritaz, C., Blondel, L., Mir, O., Chaput, N., & Paci, 
A. (2020). Pharmacokinetic/pharmacodynamic relationship of therapeutic monoclonal antibodies 
used in oncology: Part 2, immune checkpoint inhibitor antibodies. European Journal of Cancer 
(1990), 128, 119-128. 
 
Doyle, A., W.J. Martin, K. Funa, et al.  (1985).  Markedly decreased expression of class I 
histocompatibility antigens, protein, and mRNA in human small-cell lung cancer. J Exp Med.  
161(5):1135–51. 
 
Entinostat Investigator’s Brochure, 2018, Entinostat (SNDX-275), Version 17.0, 08 May 2018, 
Syndax Pharmaceuticals, Waltham, MA. 
 
Food and Drug Administration. (2016a). U.S. food and drug administration center for drug 
evaluation research, BLA 761041 clinical pharmacology review - atezolizumab. 
https://www.accessdata.fda.gov/drugsatfda_docs/nda/2016/761041Orig1s000OtherR.pdf 
 
Food and Drug Administration. (2016b). U.S. food and drug administration center for drug 
evaluation research, NDA/BLA multi-disciplinary review and evaluation {BLA 761097} 
{libtayo™/cemiplimab}. 
https://www.accessdata.fda.gov/drugsatfda_docs/nda/2018/761097Orig1s000MultidisciplineR.p
df 


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115 
 
Gay, C., L. Diao, C. Stewart, et al.  (2019).  ASCL1, NEUROD1, and POU2F3 Drive Distinct 
Subtypes of Small Cell Lung Cancer with Unique Therapeutic Vulnerabilities.  WCLC.  
abst:OA03.06. 
 
Gojo, I., A. Jiemjit, J.B. Trepel, et al.  (2007).  Phase 1 and pharmacologic study of MS-275, a 
histone deacetylase inhibitor, in adults with refractory and relapsed acute leukemias.  Blood.  
109(7):2781–2790.  
 
Govindan, R., N. Page, D. Morgensztern, et al.  (2006).  Changing epidemiology of small-cell 
lung cancer in the United States over the last 30 years: analysis of the surveillance, 
epidemiologic, and end results database.  J Clin Oncol.  24(28):4539-4544. 
 
Hanoteau, A., J.M. Newton, R. Kruper, et al.  (2019).  Tumor microenvironment modulation 
enhances immunologic benefit of chemoradiotherapy.  J Immunother Cancer.  15;7(1):10. 
 
Harvey RD, Morgan ET. Cancer, inflammation, and therapy: effects on cytochrome p450-
mediated drug metabolism and implications for novel immunotherapeutic agents. Clin 
Pharmacol Ther 2014; 96: 449-457 
 
Hellmann, M., S. Antonia, S. Ponce, et al.  (2017).  MA09.05 Nivolumab Alone or with 
Ipilimumab in Recurrent Small Cell Lung Cancer (SCLC): 2-Year Survival and Updated 
Analyses from the Checkmate 032 Trial.  Journal of Thoracic Oncology.  12(1): S393-S394. 
 
Hellmann, M.D., M.K. Callahan, M.M. Awad, et al.  (2018a).  Tumor Mutational Burden and 
Efficacy of Nivolumab Monotherapy and in Combination with Ipilimumab in Small-Cell Lung 
Cancer.  Cancer Cell.  33(5): 853-861 e4. 
 
Hellmann, M., P. Janne, M. Opyrchal, et al.  (2018b).  OA05.01 Efficacy/Safety of Entinostat 
(ENT) and Pembrolizumab (PEMBRO) in NSCLC Patients Previously Treated with Anti-PD-
(L)1 Therapy.  Journal of Thoracic Oncology.  13(10):S330. 
 
Hermann, G., P. Heffeter, T. Falta, et al.  (2013).  In vitro studies focusing on kinetic aspects of 
intracellular chemistry by LC-ICP-MS.  Metallomics.  5:636-647. 
 
Horn, L., A.S. Mansfield, A. Szczęsna, et al.  (2018).  First-Line Atezolizumab plus 
Chemotherapy in Extensive-Stage Small-Cell Lung Cancer.  N Engl J Med. 379(23):2220-2229. 
 
Investigator’s Brochure, Atezolizumab (MPDL3280A). Version 15, July 2019. 
 
Jia, D., A. Augert, D-W. Kim, et al.  (2018).  Crebbp Loss Drives Small Cell Lung Cancer and 
Increases Sensitivity to HDAC Inhibition.  Cancer Discov.  8(11):1422-1437. 
 
Kim, K., A.D. Skora, Z. Li, et al.  (2014).  Eradication of metastatic mouse cancers resistant to 
immune checkpoint blockade by suppression of myeloid-derived cells.  Proc Natl Acad Sci U S 
A. 111(32):11774-11779. 


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116 
 
Liu, S. and Y. Yuan.  (2015).  Bayesian Optimal Interval Designs for Phase I Clinical Trials.  
Journal of the Royal Statistical Society: Series C.  64,507-523. 
 
Melief, C.J.M., M.J.P. Welters, I. Vergote, et al.  (2020).  Strong vaccine responses during 
chemotherapy are associated with prolonged cancer survival.  Sci Transl Med.  18;12(535). 
 
Mir, O., Broutin, S., Desnoyer, A., Delahousse, J., Chaput, N., & Paci, A. (2020). 
Pharmacokinetics/ pharmacodynamic (PK/PD) relationship of therapeutic monoclonal antibodies 
used in oncology: What's new? European Journal of Cancer (1990), 128, 103-106. 
 
Owonikoko, T.K., B. Dwivedi, Z. Chen, et al.  (2020).  YAP1 positive small-cell lung cancer 
subtype is associated with the T-cell inflamed gene expression profile and confers good 
prognosis and long term survival.  ASCO Annual Meeting.  abst:9019. 
 
Reed, E., M. Dabholkar, B. Chabner, et al.  (1996).  Platinum analogues cancer chemotherapy. 
Lippincott-Raven Publishers, Philadelphia: 357. 
 
Rudin, C.M., J.T. Poirier, L.A. Byers, et al.  (2019).  Molecular Subtypes of Small Cell Lung 
Cancer: A Synthesis of Human and Mouse Model Data.  Nat Rev Cancer.  19(5):289-297. 
 
Saida, Y., S. Wantanbe, T. Tanaka, et al.  (2015).  Critical Roles of Chemoresistant Effector and 
Regulatory T Cells in Antitumor Immunity After Lymphodepleting Chemotherapy.  J Immunol.  
15;195(2):726-35. 
 
Sanghavi, K., Zhang, J., Zhao, X., Feng, Y., Statkevich, P., Sheng, J., Roy, A., & Vezina, H. E. 
(2019). Population pharmacokinetics of ipilimumab in combination with nivolumab in patients 
with advanced solid tumors. CPT: Pharmacometrics and Systems Pharmacology, 9(1), 29-39. 
 
Suzuki, R., X. Wei, P.K. Allen, et al.  (2019).  Prognostic significance of total lymphocyte count, 
neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in limited stage SCLC.  Clin 
Lung Cancer.  20(2):117-123. 
 
Terranova-Barberio, M., S. Thomas, N. Ali, et al.  (2017).  HDAC inhibition potentiates 
immunotherapy in triple negative breast cancer.  Oncotarget.  8(69):114156-114172. 
 
Tomita Y., M. Lee, S. Lee, et al.  (2016).  The interplay of epigenetic therapy and immunity in 
locally recurrent or metastatic estrogen receptor-positive breast cancer: Correlative analysis of 
ENCORE 301, a randomized, placebo-controlled phase II trial of exemestane with or without 
entinostat.  Oncoimmunology.  5(11):e1219008. 
 
Turner, D. C., Kondic, A. G., Anderson, K. M., Robinson, A. G., Garon, E. B., Riess, J. W., Jain, 
L., Mayawala, K., Kang, J., Ebbinghaus, S. W., Sinha, V., de Alwis, D. P., & Stone, J. A. (2018). 
Pembrolizumab Exposure–Response assessments challenged by association of cancer cachexia 
and catabolic clearance. Clinical Cancer Research, 24(23), 5841-5849. 
 


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117 
Van Meir, H., R.A. Nout, M.J.P. Welters, et al.  (2016).  Impact of (chemo)radiotherapy on 
immune cell composition and function in cervical cancer patients.  Oncoimmunology.  
23;6(2):e1267095. 
 
Wilkins, J. J., Brockhaus, B., Dai, H., Vugmeyster, Y., White, J. T., Brar, S., Bello, C. L., 
Neuteboom, B., Wade, J. R., Girard, P., & Khandelwal, A. (2019). Time‐Varying clearance and 
impact of disease state on the pharmacokinetics of avelumab in merkel cell carcinoma and 
urothelial carcinoma. CPT: Pharmacometrics and Systems Pharmacology, 8(6), 415-427. 
 
Xu, A., K.K. Bhanumathy, J. Wu, et al.  (2016).  IL-15 signaling promotes adoptive effector T 
cell survival and memory formation in irradiation-induced lymphopenia.  Cell Biosci.  6;6:30. 
 
Yuan, Y., K.R Hess, S.G. Hilsenbeck, et al.  (2016).  Bayesian optimal interval design: a simple 
and well-performing design for phase I oncology trials.  Clinical Cancer Research.  22(17),4291-
4301. 
 
Zheng, Y., Narwal, R., Jin, C., Baverel, P. G., Jin, X., Gupta, A., Ben, Y., Wang, B., 
Mukhopadhyay, P., Higgs, B. W., & Roskos, L. (2018). Population modeling of tumor kinetics 
and overall survival to identify prognostic and predictive biomarkers of efficacy for durvalumab 
in patients with urothelial carcinoma. Clinical Pharmacology & Therapeutics, 103(4), 643-652. 
 
Zheng, H., W. Zhao, C. Yan, et al.  (2016).  HDAC Inhibitors Enhance T-Cell Chemokine 
Expression and Augment Response to PD-1 Immunotherapy in Lung Adenocarcinoma.  Clin 
Cancer Res.  22(16): p. 4119-32. 
 
 
 


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118 
APPENDIX A 
PERFORMANCE STATUS CRITERIA 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 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. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 


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119 
APPENDIX B 
FORMULA TO ESTIMATE RENAL FUNCTION USING SERUM 
CREATININE 
 
Formulas to estimate renal function using serum creatinine provided by the NCI’s Investigational 
Drug Steering Committee (IDSC) Pharmacological Task Force in table below. 
 
1. Estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology 
Collaboration (CKD-EPI) (Levey et al., 2009). 
 
Formulae: 
 
Race and 
Sex 
Serum Creatinine (SCr), 
µmol/L (mg/dL) 
Equation 
Black 
 
 
Female 
≤62 (≤0.7) 
GFR = 166 × (SCr/0.7)−0.329 × (0.993)Age 
 
>62 (>0.7) 
GFR = 166 × (SCr/0.7)−1.209 × (0.993)Age 
Male 
≤80 (≤0.9) 
GFR = 163 × (SCr/0.9)−0.411 × (0.993)Age 
 
>80 (>0.9) 
GFR = 163 × (SCr/0.9)−1.209 × (0.993)Age 
 
 
 
White or 
other 
 
 
Female 
≤62 (≤0.7) 
GFR = 144 × (SCr/0.7)−0.329 × (0.993)Age 
 
>62 (>0.7) 
GFR = 144 × (SCr/0.7)−1.209 × (0.993)Age 
Male 
≤80 (≤0.9) 
GFR = 141 × (SCr/0.9)−0.411 × (0.993)Age 
 
>80 (>0.9) 
GFR = 141 × (SCr/0.9)−1.209 × (0.993)Age 
 
SCr in mg/dL; Output is in mL/min/1.73 m2 and needs no further conversions. 
 
2. eGFR using the Modification of Diet in Renal Disease (MDRD) Study (Levey et al., 2006). 
 
175 x SCr–1.154 × age–0.203 × 0.742 (if female) × 1.212 (if black) 
Output is in mL/min/1.73 m2 and needs no further conversions. 
3. Estimated creatinine clearance (ClCr) by the Cockcroft-Gault (C-G) equation (Cockcroft and 
Gault, 1976). 
 
 
Followed by conversion to a value normalized to 1.73 m2 with the patient’s body surface area 
(BSA). 
 
References 
1. Levey, A.S., L.A. Stevens, C.H. Schmid, et al.  (2009).  A new equation to estimate 
glomerular filtration rate.  Ann Inter Med.  150:604-612. 
2. Levey, A.S., J. Coresh, T. Greene, et al.  (2006).  Using standardized serum creatinine 
values in the modification of diet in renal disease study equation for estimating 
glomerular filtration rate.  Ann Intern Med.  145:247-254. 
3. Cockcroft, D.W. and M.H. Gault.  (1976).  Prediction of creatinine clearance from serum 
creatinine.  Nephron.  16:31-41. 
 


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120 
APPENDIX C 
PATIENT DRUG INTERACTIONS HANDOUT AND WALLET 
CARD 
 
Information for Patients, Their Caregivers and Non-Study Healthcare Team on Possible 
Interactions with Other Drugs and Herbal Supplements  
 
Patient 
Name: 
      
Diagnosis:        
Trial #: 
10399 
Study 
Doctor: 
      
Study 
Doctor 
Phone #:  
      
Study 
Drug(s): 
Entinostat, 
Atezolizumab, 
Carboplatin, 
Etoposide 
 
 
 
Please show this paper to all your healthcare providers (doctors, physician assistants, nurse practitioners, 
pharmacists), and tell them you are taking part in a clinical trial sponsored by the National Cancer 
Institute.  
 
These are the things that your healthcare providers need to know: 
Entinostat interacts with certain specific enzymes in your liver or other tissues like the gut and 
certain transport proteins that help move drugs in and out of cells. 
 
 
Explanation 
CYP 
isoenzymes  
The enzymes in question are UGT 1A4, CYP 1A2,2C8 and CYP 3A4.  Entinostat is 
broken down by UGT 1A4 and may be affected by other drugs that inhibit or induce 
this enzyme.   
Entinostat has the potential to increase the metabolism rate of other drugs broken 
down by CYP 1A2 and 2C8.  Entinostat inhibits the breakdown of drugs by CYP 2C8 
in the lab.  Entinostat is not an inhibitor of CYP3A4. 
Protein 
transporters  
The proteins in question are P-glycoprotein (P-gp) and breast cancer resistance protein 
(BCRP).  Entinostat is moved in and out of cells/organs by these transport proteins..  
 
 
 
These are the things that you need to know: 
The study drug entinostat, may interact with other drugs which can cause side effects. For this reason, it is 
very important to tell your doctors about all your medicines, including: (a) medicines you are taking 
before this clinical trial, (b) medicines you start or stop taking during this study, (c) medicines you buy 
without a prescription (over-the-counter remedy), (d) herbals or supplements (e.g. St. John’s Wort). It is 
helpful to bring your medication bottles or an updated medication list with you.  
 
Before you enroll onto the clinical trial, your study doctor will work with your regular health care 
providers to review any medicines and herbal supplements that are considered strong inducers/inhibitors 
of UGT 1A4, P-gp and BCRP, or substrates of CYP 1A2 and 2C8.  
 


NCI Protocol #:  10399 
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121 
• Please be very careful!  Over-the-counter drugs (including herbal supplements) may contain 
ingredients that could interact with your study drug.  Speak to your doctors or pharmacist to 
determine if there could be any side effects.  
 
• There is no drug-drug interaction between entinostat and acid reducing agents (i.e. omeprazole) 
 
• Your regular health care provider should check a frequently updated medical reference or call your 
study doctor before prescribing any new medicine or discontinuing any medicine.   
 
 
 
Version Aug2019 
 
(Next page: Patient Drug Interaction Wallet Card) 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
122 
TEMPLATE A: PATIENT DRUG INTERACTION WALLET CARD  
 
 
EMERGENCY INFORMATION 
 
dRUG INTERACTIONS  
Show this card to all of your 
healthcare providers. Keep it 
with you in case you go to the 
emergency room. 
Tell your doctors before you start 
or stop any medicines. 
Check with your doctor or 
pharmacist if you need to use an 
over-the-counter medicine or 
herbal supplement! 
Carry this card with you at all times   
Entinostat interacts with specific enzymes in your liver or other tissues like 
the gut, transport proteins that help move drugs in and out of cells and 
must be used very carefully with other medicines. 
Patient Name:       
Use caution and avoid the 
following drugs if possible:  
 
Not applicable  
 
Your healthcare providers should be aware of any medicines that are 
strong inducers/inhibitors of UGT 1A4, P-gp and BCRP, or substrates of CYP 
1A2 and 2C8. 
Diagnosis:       
Study Doctor:       
Study Doctor Phone #:       
NCI Trial #: 10399 
Before prescribing new medicines, your health care provider should check 
a frequently-updated medical reference for a list of drugs to avoid or 
contact your study doctor. 
Study Drug(S): Entinostat, Atezolizumab, 
Carboplatin, Etoposide 
 
             Version Aug2019 
 
For more information: 1-800-4-CANCER 
For more information: 1-800-4-CANCER 
For more information: 1-800-4-CANCER 
For more information: 1-800-4-CANCER 
cancer.gov | clinicaltrials.gov 
cancer.gov | clinicaltrials.gov 
cancer.gov | clinicaltrials.gov 
cancer.gov | clinicaltrials.gov 
 
 
 
 
 
Folding 


NCI Protocol #:  10399 
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123 
APPENDIX D 
PRE-BIOPSY ASSESSMENT 
 
A pre-biopsy lesion assessment can increase trial safety and efficiency.  By agreement between 
all investigators, an attempt at biopsy will be made if the clinical trial team determines that a 
biopsy poses minimal relative risk, provides potential clinical gain to the participant, and will 
likely yield sufficient tissue for analysis.   
 
Pre-biopsy assessments will be reported and tracked through a trial-specific CRF within the 
CTEP Medidata Rave system.  Additional information can be found in the Investigational 
Radiology SOP available at:   
https://ctep.cancer.gov/initiativesPrograms/docs/ETCTN_IR_Research_Biopsy_SOP.pdf.  
 
Individual Patient Pre-Biopsy Assessment.  IR co-investigators are encouraged to apply this 
pre-biopsy scoring and correlation system to assist in the determination of biopsy 
appropriateness. 
 
• IR co-investigators assign a subjective score of 1-3 based on likelihood of success due to 
lesion characteristics.  
 
1.  Biopsy should not be done  
A. Due to safety concerns 
B. Due to lack of suitable lesion for biopsy 
 
2.  Uncertainty about success  
A. Due to access path to lesion 
B. Due to lesion characteristics  
 
3.  Likely successful  
 
• Lesion characteristics to be considered 
• Size (small) (<2 cm) 
• Location/path to lesion 
• Morphologic features (necrosis, sub-solid, sclerosis, ill-defined/infiltrative) 
• PET (+/-), avidity  
• Organ/site (sclerotic bone is low yield; fine needle aspiration to be used) 
 


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124 
APPENDIX E 
TISSUE BIOPSY VERIFICATION 
 
A copy of the diagnostic pathology report must be shipped with archival tissue specimens sent to 
the EET Biobank. If the diagnostic pathology report is available at the time of shipment of a fresh 
biopsy sample, it should be shipped with the tissue.  
 
If the corresponding pathology report is not available for the biopsy, then a copy of the 
radiology report or operative report from the biopsy procedure and the diagnostic 
pathology report must be sent to the EET Biobank. A completed copy of this appendix 
(i.e., Tissue Biopsy Verification) must also be submitted to the EET Biobank. 
 
Note: If this information is not provided with the biopsy specimen, then it will not be accepted 
by the EET Biobank. 
 
 
 
Please have the Clinician* responsible for signing out this patient’s case complete the following: 
 
ETCTN Universal Patient ID:  
 
 
ETCTN Patient Study ID:   
 
 
Date of Procedure (mm/dd/yyyy):   
 
 
Tissue Type (circle one): 
Primary 
 
Time point (circle one):  Baseline 
Disease Progression 
 
Site Tissue Taken From:   
 
 
Diagnosis:   
 
 
I agree that this tissue may be released for research purposes only and that the release of this 
tissue will not have any impact on the patient’s care. 
 
 
 
Clinician Signature 
Date 
 
 
 
Clinician Printed Name 
 
*Note: For the purposes of this form, Clinician could include the Nurse Practitioner, Registered Nurse, Pathologist, 
Radiologist, Interventional Radiologist, Surgeon, Oncologist, Internist, or other medical professional responsible for 
the patient’s care.  
 
Version: 1 
Effective Date: 9/2019 


NCI Protocol #:  10399 
Version Date:  August 17, 2021 
 
125 
APPENDIX F 
MEDICATION DIARY 
 
PATIENT’S MEDICATION DIARY – Entinostat 
 
     Today’s date _______________________________ 
Cycle ___________________ ___________________ 
     Patient Initials_________________________  
Patient Study ID _____________________________________ 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form for each cycle. 
2. 
You will take your dose of entinostat on the same day each week.  You will take (circle dose) two (2) 1 mg tablets OR three 
(3) 1 mg tablets OR one (1) 5 mg tablet every week.  Take on an empty stomach, at least 1 hour before and 2 hours after a 
meal.  You should swallow the tablets whole.  Do not split, crush or chew the tablet(s). 
3.     If you forget to take a dose or vomit after taking your dose, do not make it up. Wait and take it the next week. 
4. 
Record the date, the time, and the number of tablets of the size tablet(s) you took in the shaded areas for Days 1, 8 and 15.  
You will not take entinostat on the shaded days. 
5. 
If you have any comments or notice any side effects, please record them in the Comments column for that day.   
6. 
Please return the forms to your physician when you go for your next appointment. 
 
Day 
 
Date 
What time was 
dose taken? 
# of tablets taken 
Comments 
1 mg 
5 mg 
1 
 
 
 
 
 
2 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
3 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
4 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
5 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
6 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
7 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
8 
 
 
 
 
 
9 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
10 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
11 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
12 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
13 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
14 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
15 
 
 
 
 
 
16 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
17 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
18 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
19 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
20 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
21 
XX 
XX 
XX 
XX 
Do not take entinostat on this day 
Physician’s Office will complete this section: 
1. 
Date patient started protocol treatment____________________________________________________________________ 
2. 
Date patient was removed from study_____________________________________________________________________ 
3. 
Patient’s planned total weekly dose________________________________________________________________________ 
4. 
Total dose taken this cycle ___________________________________________________________ 
5. 
Physician/Nurse/Data Manager’s Signature/Date 
________________________________________________________________ 
 
    Patient’s initials/date:__________________________________________________________________________________ 
 
 
CTEP-assigned Protocol #_10399__ 
 
Local Protocol # ___________________