Conditions: Breast Cancer
Keywords: Breast Cancer
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 20
Healthy volunteers: no

Brief summary:
This research study is studying a combination of drugs as a possible treatment for metastatic breast cancer.

The interventions involved in this study are:

* Pembrolizumab
* Trastuzumab emtansine (also called T-DM1)

Detailed description:
This research study is a Phase I clinical trial, which tests the safety of an investigational intervention and also tries to define the appropriate dose of the investigational intervention to use for further studies. "Investigational" means that the intervention is being studied. It also means that the FDA (U.S. Food and Drug Administration) has not approved the combination of Pembrolizumab and T-DM1 for use in patients, including people with your type of cancer.

This study will determine what amount (or dose) of Pembrolizumab and of T-DM1 is safe for people to take and what effects, good or bad, this combination may have on participants and their disease.

The FDA has not approved Pembrolizumab for this specific disease but it has been approved in the United Sates for the treatment of other types of cancer.

The FDA has approved Trastuzumab emtansine (T-DM1) as a treatment option for this type of breast cancer

The combination of Pembrolizumab and T-DM1 is investigational. It is thought that together these drugs to help get the immune system to attack tumor cells and kill cancer cells that have the HER2 protein. However, it is not known if giving the two study drugs at the same time will have a better anti-cancer effect than giving each treatment on its own.

Arms:
arm 1: * Pembrolizumab will be administered intravenousely in clinic on day 1 of each 3-week cycle
* Pembrolizumab will be administered prior to T-DM1 administration
* Pembrolizumab will be given at a predetermine dose
* T-DM1 will be administered intravenousely in clinic on day 1 of each 3-week cycle
* T-DM1 will be given at a predetermine dose

Interventions: intervention 1: T-DM1 intervention 2: Pembrolizumab
Intervention descriptions: intervention 1: -T-DM1 will be administered intravenousely in clinic on day 1 of each 3-week cycle intervention 2: -Pembrolizumab will be administered intravenousely in clinic on day 1 of each 3-week cycle

Protocol document:
Prot_SAP_000.pdf: 


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SCHEMA 
 
 
 
Dose De-Escalation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recommended Phase 2 Dose Expansion 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients: 
HER2-
positive 
metastatic 
breast 
cancer 
Dose de-
escalation 
(6 participants) 
Treatment with 
pembrolizumab 
+ T-DM1 
RP2D 
Dose de-
escalate and 
Recruit 6 more 
participants 
≥2 
DLTs 
RP2D
Stop 
No 
Yes 
≥2 DLTs 
≤ 1 DLT 
Number of participants: 6-12 
Cycle Length: 21 days (3 weeks) 
Biopsy at baseline and 6 weeks are optional during dose de-escalation 
Tumor assessments completed every 6 weeks for the first 6 months and then every 9 weeks. 
6 Week Optional 
Fresh Tissue 
Biopsy 
Number of participants: 15 
Cycle Length: 21 days 
Biopsy at baseline is required and biopsy at 6 weeks post-treatment initiation is optional 
Tumor assessments completed every 6 weeks for the first 6 months and then every 9 weeks. 
Patients: 
HER2-
positive 
metastatic 
breast 
cancer 
Baseline 
Required Fresh 
Tissue Biopsy 
Treatment with 
pembrolizumab 
+ T-DM1 


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TABLE OF CONTENTS 
 
SCHEMA .........................................................................................................................................2 
1. OBJECTIVES ...........................................................................................................................6 
1.1 Study Design ...............................................................................................................6 
1.2 Primary Objectives......................................................................................................6 
1.3 Secondary Objectives..................................................................................................6 
2. BACKGROUND ......................................................................................................................7 
2.1 Study Disease: Metastatic HER2-Positive Breast Cancer ..........................................7 
2.2 Pembrolizumab ...........................................................................................................7 
2.3 T-DM1 ......................................................................................................................11 
2.4 Rationale ...................................................................................................................13 
2.5 Correlative Studies Background ...............................................................................13 
3. PARTICIPANT SELECTION ................................................................................................15 
3.1 Eligibility Criteria .....................................................................................................15 
3.2 Exclusion Criteria .....................................................................................................17 
3.3 Inclusion of Women and Minorities .........................................................................19 
4. REGISTRATION PROCEDURES ........................................................................................19 
4.1 General Guidelines for DF/HCC Institutions ...........................................................19 
4.2 Registration Process for DF/HCC Institutions ..........................................................19 
4.3 General Guidelines for Other Investigative Sites .....................................................19 
4.4 Registration Process for Other Investigative Sites....................................................20 
5. TREATMENT PLAN .............................................................................................................20 
5.1 Treatment Regimen ...................................................................................................20 
5.2 Pre-Treatment Criteria ..............................................................................................21 
5.3 Agent Administration................................................................................................22 
5.4 Definition of Dose-Limiting Toxicity (DLT) ...........................................................23 
5.5 General Concomitant Medication and Supportive Care Guidelines .........................24 
5.6 Criteria for Taking a Participant Off Protocol Therapy ............................................27 
5.7 Duration of Follow Up ..............................................................................................30 
5.8 Criteria for Taking a Participant Off Study ..............................................................30 
6. DOSING DELAYS/DOSE MODIFICATIONS  ...................................................................31 
6.1 Management of toxicities attributable to pembrolizumab ........................................31 
6.2 Management of toxicities attributable to T-DM1 .....................................................35 
6.3 Management of toxicities attributable to both pembrolizumab and T-DM1 ............39 


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7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS .................................41 
7.1 Expected Toxicities ...................................................................................................42 
7.2 Adverse Event Characteristics ..................................................................................45 
7.3 Expedited Adverse Event Reporting .........................................................................46 
7.4 Expedited Reporting to the Food and Drug Administration (FDA) .........................46 
7.5 Expedited Reporting to Hospital Risk Management ................................................46 
7.6 Expedited Reporting to 
..................................................................................46 
7.7 Routine Adverse Event Reporting ............................................................................49 
8. PHARMACEUTICAL INFORMATION ...............................................................................49 
8.1 Pembrolizumab .........................................................................................................49 
8.2 T-DM1 ......................................................................................................................51 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES .............................................53 
9.1 Summary table: research tissue and blood specimen collection ...............................53 
9.2 Fresh Tissue Collection.............................................................................................54 
9.3 Procedures for obtaining blood specimens for study ................................................56 
9.4 Sites Performing Correlative Studies ........................................................................58 
9.5 Blood and tissue banking ..........................................................................................58 
9.6 Hypotheses for correlative objectives .......................................................................58 
9.7 Planned assays for correlative objectives .................................................................59 
10. STUDY CALENDAR ..........................................................................................................63 
11. MEASUREMENT OF EFFECT...........................................................................................64 
11.1 Antitumor Effect – Solid Tumors ...........................................................................64 
11.2 Antitumor Effect – Hematologic Tumors ...............................................................72 
11.3 Other Response Parameters: Immune-Related Response Criteria 
(irRECIST) .............................................................................................................72 
12. DATA REPORTING / REGULATORY REQUIREMENTS ..............................................75 
12.1 Data Reporting ........................................................................................................75 
12.2 Data Safety Monitoring...........................................................................................75 
12.3 Multicenter Guidelines............................................................................................76 
12.4 Collaborative Agreements Language ......................................................................76 
13. STATISTICAL CONSIDERATIONS..................................................................................76 
13.1 Study Design/Endpoints..........................................................................................76 
13.2 Sample Size, Accrual Rate and Study Duration .....................................................78 
13.3 Stratification Factors ...............................................................................................78 
13.4 Interim Monitoring Plan .........................................................................................78 
13.5 Analysis of Primary Endpoints ...............................................................................78 
13.6 Analysis of Secondary Endpoints ...........................................................................78 
13.7 Reporting and Exclusions .......................................................................................79 
14. PUBLICATION PLAN ........................................................................................................79 


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REFERENCES ..............................................................................................................................80 
APPENDIX A PERFORMANCE STATUS CRITERIA ...........................................................87 
APPENDIX B New York Heart Association (NYHA) Classifications ......................................88 
APPENDIX C Strong CYP3A Inducers/Inhibitors ....................................................................89 
APPENDIX D Guidelines for Liver Biopsy ...............................................................................90 
 APPENDIX E Guidelines for collecting research biopsy tissue ...............................................91 
 
 
 


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1. OBJECTIVES 
 
 
1.1 
Study Design 
 
This is a phase Ib, open label study assessing the safety and tolerability of pembrolizumab in 
combination with T-DM1.  The population to be studied consists of patients with metastatic 
HER2-positive (HER2+) breast cancer previously treated with a taxane and trastuzumab.  The 
study will be conducted as a dose de-escalation study, as the common toxicities of the two agents 
are not overlapping.  Once the recommended phase 2 dose (RP2D) is declared, 15 additional 
eligible patients with metastatic HER2+ breast cancer will be entered into an expansion cohort. 
 
1.2 
Primary Objectives 
 
To evaluate the safety and tolerability of pembrolizumab in combination with 
trastuzumab-DM1 (T-DM1) in patients with metastatic HER2+ breast cancer. 
 
1.3 
Secondary Objectives 
 
Efficacy objectives: 
1. To explore the activity of pembrolizumab in combination with T-DM1, as defined by 
objective response rate, in patients with metastatic HER2+ breast cancer 
2. To explore the activity of pembrolizumab in combination with T-DM1, as defined by 
progression free survival (PFS), duration of response, disease control rate (defined as 
partial responses + complete responses + stable disease at 18 weeks), and overall survival 
(OS) in patients with metastatic HER2+ breast cancer 
 
Correlative science objectives: 
1. To characterize a broad array of immune markers in metastatic HER2-positive breast 
tumors (characterization will be based on histology, protein expression, mRNA 
expression, and genomic analysis) 
To explore how different immunosuppressive and/or immune-stimulating immune 
marker profiles at baseline correlate with disease response to therapy (response assessed 
by RECIST 1.1 and immune-related RECIST (irRECIST)) 
2. To characterize changes in immune marker profile in peripheral blood mononuclear cells 
(PBMCs) from baseline to over the course of trial therapy 
3. To explore whether induction of changes in the immunosuppressive and/or immune-
stimulating immune marker profile in PBMCs at baseline compared to on-therapy 
correlates with disease response to therapy (response assessed by RECIST 1.1 and 
irRECIST) 
4. To investigate whether there is an immune marker in circulating PBMCs that corresponds 
to tumor infiltrating lymphocyte (TIL) percentage in baseline tumor 
5. In the cohort of patients who have re-biopsy at week 6 of treatment: To characterize 
changes in a broad array of immune markers from baseline (as characterized in aim (1)) 
to 6 weeks on trial therapy, and explore changes in the tumor microenvironment that 
correlate with disease response to therapy. 


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6. To characterize the structure and function of the gut microbiome in patients with breast 
cancer prior to starting this clinical trial. 
7. To determine whether pre-treatment characteristics of the structure and function of the 
gut microbiome in patients with breast cancer is associated with efficacy of 
pembrolizumab plus T-DM1. 
8. To characterize changes in the structure and function of the gut microbiome of patients 
with breast cancer after two cycles of therapy compared to baseline.  
9. To determine whether changes in the overall diversity of the gut microbiome, estimated 
by the Shannon Index, of patients with breast cancer after two cycles of therapy regimens 
is associated with efficacy of pembrolizumab plus T-DM1. 
10. To determine if the abundance and functional profile of specific gut bacteria are 
associated with objective response to pembrolizumab plus T-DM1. 
11. To evaluate the functional pathways that may play a role as a predictive biomarker of 
response to pembrolizumab plus T-DM1. 
12. To explore whether the number and/or type of mutations identified using a next 
generation sequencing (NGS) panel is correlated with patient outcomes (PFS, ORR, and 
OS). This will be performed on DFCI participants only.  
 
 
2. BACKGROUND 
 
2.1 
Study Disease: Metastatic HER2-Positive Breast Cancer 
 
HER2, also known as neu and c-erbB-2, is an oncogene encoding a tyrosine kinase growth factor 
receptor in the family of the epidermal growth factor receptor (EGFR), and is amplified in 
approximately 20% of all human breast cancers.  It is an independent predictor of time to relapse 
and overall survival in multivariable models, and is a marker of poor prognosis.1  The functional 
significance of HER2 amplification in breast cancer prompted development of trastuzumab, a 
monocloncal anti-HER2 antibody.  Addition of trastuzumab to standard chemotherapy produces 
an overall survival benefit in HER2-amplified metastatic breast cancer.2  Similarly, trastuzumab 
plus chemotherapy is superior to chemotherapy alone in multiple large, randomized trials of 
adjuvant therapy in HER2-positive disease.3-6 
 
However, despite significant gains in understanding the biology of HER2-driven cancers and 
developing highly effective second-generation HER2-targeted agents such as pertuzumab and T-
DM1, in the metastatic setting acquired resistance to HER2-directed therapies occurs in virtually 
all patients.  Several mechanisms of resistance have been suggested, including impaired receptor-
antibody binding, truncated HER2 protein, and signaling via alternate pathways or through 
constitutive activation of the PI3K signaling pathway.7-11  Further therapeutic approaches are 
therefore needed.  As described in more detail below, there is evidence that supports using the 
anti-tumor immune response as a therapeutic target in HER2+ breast cancer, especially 
concurrent with antibody-based therapy. 
 
2.2 
Pembrolizumab 
 
 


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The PD-1 pathway in cancer 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades.  Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in 
various malignancies.  In particular, the presence of CD8+ T-cells and the ratio of CD8+ effector 
T-cells / FoxP3+ regulatory T-cells seems to correlate with improved prognosis and long-term 
survival in many solid tumors. 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune 
control.  The normal function of PD-1, expressed on the cell surface of activated T-cells under 
healthy conditions, is to down-modulate unwanted or excessive immune responses, including 
autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig superfamily member related 
to CD28 and CTLA-4 which has been shown to negatively regulate antigen receptor signaling 
upon engagement of its ligands (PD-L1 and/or PD-L2).  The structure of murine PD-1 has been 
resolved.  PD-1 and family members are type I transmembrane glycoproteins containing an Ig 
Variable-type (V-type) domain responsible for ligand binding and a cytoplasmic tail which is 
responsible for the binding of signaling molecules.  The cytoplasmic tail of PD-1 contains 2 
tyrosine-based signaling motifs, an immunoreceptor tyrosine-based inhibition motif (ITIM) and 
an immunoreceptor tyrosine-based switch motif (ITSM).  Following T-cell stimulation, PD-1 
recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif within its cytoplasmic 
tail, leading to the dephosphorylation of effector molecules such as CD3ζ, PKCθ and ZAP70 
which are involved in the CD3 T-cell signaling cascade.  The mechanism by which PD-1 down 
modulates T-cell responses is similar to, but distinct from that of CTLA-4 as both molecules 
regulate an overlapping set of signaling proteins.  PD-1 was shown to be expressed on activated 
lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer 
cells.  Expression has also been shown during thymic development on CD4-CD8- (double 
negative) T-cells as well as subsets of macrophages and dendritic cells.  The ligands for PD-1 
(PD-L1 and PD-L2) are constitutively expressed or can be induced in a variety of cell types, 
including non-hematopoietic tissues as well as in various tumors.  Both ligands are type I 
transmembrane receptors containing both IgV- and IgC-like domains in the extracellular region 
and contain short cytoplasmic regions with no known signaling motifs.  Binding of either PD-1 
ligand to PD-1 inhibits T-cell activation triggered through the T-cell receptor.  PD-L1 is 
expressed at low levels on various non-hematopoietic tissues, most notably on vascular 
endothelium, whereas PD-L2 protein is only detectably expressed on antigen-presenting cells 
found in lymphoid tissue or chronic inflammatory environments.  PD-L2 is thought to control 
immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen unwarranted T-
cell function in peripheral tissues.  Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor.  PD-1 
has been suggested to regulate tumor-specific T-cell expansion in subjects with melanoma 
(MEL).  This suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune 
evasion and should be considered as an attractive target for therapeutic intervention. 
 
Pembrolizumab 
Pembrolizumab is a potent and highly selective humanized monoclonal antibody (mAb) of the 
IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-
L1 and PD-L2.  KeytrudaTM (pembrolizumab; MK-3475) has recently been approved in the 


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United Stated for the treatment of patients with unresectable or metastatic melanoma and disease 
progression following ipilumumab and, if BRAF V600 mutation positive, a BRAF inhibitor. 
Please refer to the Full Prescribing Information for pembrolizumab for complete safety 
information: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/.   
 
Clinical data are derived from an ongoing, first-in-human phase I study (PN001, NCT01295827) 
to evaluate the safety and clinical activity of pembrolizumab as a monotherapy, sponsored by 
.  There are five parts to this study (Parts A-D and F) (Investigator’s 
Brochure, 2014). 
 
Part A was a 3+3 dose escalation study in subjects with solid tumors to evaluate safety, 
tolerability, pharmacokinetics (PK), and pharmacodynamics, and to determine a maximum 
tolerated dose (MTD) or preliminary recommended phase 2 doses (RP2Ds).  Doses were 1, 3, 
and 10 mg/kg every 2 weeks (Q2W); doses of either 2 mg/kg or 10 mg/kg were also 
administered every 3 weeks (Q3W).  All 3 dose levels were well tolerated and no dose-limiting 
toxicities (DLTs) were observed; therefore, the MTD was not determined.  The RP2D was 
determined by the sponsor based on safety, PK, and pharmacodynamic measurements, along 
with the strength of antitumor activity signals observed. 
 
Pharmacokinetics 
The half-life (t1/2) of pembrolizumab is approximately 4 weeks and there is no indication of dose 
dependency or half-life in the three dose groups (1,3, and 10 mg/kg) (Investigator’s Brochure, 
2014).  The long t1/2 supports a dosing interval of every 2 or 3 weeks. 
 
There was a dose-related increase in exposure from 1 to 10 mg/kg.  Serum concentrations of 
pembrolizumab were lower by a factor of approximately 5 in patients receiving 2 mg/kg Q3W 
than in those receiving 10 mg/kg Q3W.  Steady-state trough concentrations were 20% greater in 
the patients receiving 10 mg/kg Q2W than in those receiving the same dose Q3W. 
 
A population pharmacokinetic analysis has been performed using serum concentration time data 
from 476 patients. Within the resulting population PK model, clearance and volume parameters 
of pembrolizumab were found to be dependent on body weight. The relationship between 
clearance and body weight, with an allometric exponent of 0.59, is within the range observed for 
other antibodies and would support both body weight normalized dosing or a fixed dose across 
all body weights.  pembrolizumab has been found to have a wide therapeutic range based on the 
melanoma indication.  The population PK evaluation revealed that there was no significant 
impact of tumor burden on exposure. In addition, exposure was similar between the NSCLC and 
melanoma indications. Therefore, there are no anticipated changes in exposure between different 
indication settings. 
 
The rationale for further exploration of 2 mg/kg and comparable doses of pembrolizumab in 
solid tumors is based on: 1) similar efficacy and safety of pembrolizumab when dosed at either 2 
mg/kg or 10 mg/kg Q3W in melanoma patients, 2) the flat exposure-response relationships of 
pembrolizumab for both efficacy and safety in the dose ranges of 2 mg/kg Q3W to 10 mg/kg 
Q3W, 3) the lack of effect of tumor burden or indication on distribution behavior of 
pembrolizumab (as assessed by the population PK model) and 4) the assumption that the 


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dynamics of pembrolizumab target engagement will not vary meaningfully with tumor type. 
 
The choice of the 200 mg Q3W as an appropriate dose for the switch to fixed dosing is based on 
simulations performed using the population PK model of pembrolizumab showing that the fixed 
dose of 200 mg every 3 weeks will provide exposures that 1) are optimally consistent with those 
obtained with the 2 mg/kg dose every 3 weeks, 2) will maintain individual patient exposures in the 
exposure range established in melanoma as associated with maximal efficacy response and 3) will 
maintain individual patients exposure in the exposure range established in melanoma that are well 
tolerated and safe.  
A fixed dose regimen will simplify the dosing regimen to be more convenient for physicians and 
to reduce potential for dosing errors.  A fixed dosing scheme will also reduce complexity in the 
logistical chain at treatment facilities and reduce wastage. 
 
Anti-Drug Antibodies (ADA) Data 
The occurrence of ADA has been observed in less than 1% of the patients screened, indicating a 
low potential of pembrolizumab to elicit the formation of ADA.  No impact of ADA on 
pembrolizumab exposure has been observed. 
 
Efficacy 
When treated with pembrolizumab monotherapy, the overall response rate (ORR) for ipilimumab 
(IPI)-treated patients with melanoma was 25%/27% according to the Response Evaluation 
Criteria in Solid Tumors (RECIST)/investigator-assessed immune-related response criteria 
(irRC), respectively (Investigator’s Brochure, 2014).  The ORR for IPI-naïve patients with 
melanoma was 39%/43% by RECIST/investigator-assessed irRC, respectively.  The majority of 
responses were seen in patients with melanoma by 16 weeks of therapy; however, some 
responses have been reported after 24 weeks or more of therapy with pembrolizumab.  
Responses can be delayed, and in some patients, a RECIST-defined progression followed by 
response has been observed. 
 
The preliminary ORR for 38 patients with non-small cell lung cancer was 21%/24% by 
RECIST/investigator-assessed irRC, respectively (Investigator’s Brochure, 2014). 
 
Pharmacodynamics/Biomarkers 
Pharmacodynamic data (IL-2 release assay) has suggested that peripheral target engagement is 
durable (>21 days).   
 
PD-L1 is being investigated as a predictive biomarker for pembrolizumab treatment.  At the 15th 
World Conference on Lung Cancer, Garon et al presented preliminary data on a subset of 
patients suggesting that higher levels of tumor PD-L1 expression are associated with increased 
clinical activity.12  ORR by RECIST 1.1 occurred in 4 out of 7 patients with higher levels of PD-
L1 expression (57%, 95% CI 18-90%) versus 2 out of 22 patients with lower levels of PD-L1 
expression (9%, 95% CI 1-29%).  These data are extremely preliminarily, and PD-L1 is not 
being used for patient selection. 
 
Biomarkers to evaluate immune modulation and markers in the tumor microenvironment, such as 


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T-cell infiltration, the baseline expression of markers of T-cell suppression FoxP3 or the 
immunoregulatory enzyme incoleamine 2,3-dioxygenase (IDO) in tumor biopsies, were 
associated with a high response rate in patients with advanced melanoma.13,14 
 
Safety data 
The most frequent treatment-related adverse events (AEs) were fatigue, nausea, cough, pruritis, 
diarrhea, and rash (Investigator’s Brochure, 2014).  Most AEs were not considered serious.  The 
most commonly-reported immune-related AEs were rash, pruritis, vitiligo, hypothyroidism, 
arthralgia, diarrhea, and pneumonitis. 
 
Important identified risks include: pneumonitis, thyroid disorders (hypothyroidism and 
hyperthyroidism), colitis, diarrhea, hepatitis, nephritis, uveitis, rash/pruritis, and neuropathy. 
 
 
2.3 
T-DM1 
 
T-DM1 mechanism of action 
T-DM1 is a promising anti-HER2 agent, with proven efficacy in the metastatic setting.  T-DM1 
is composed of: trastuzumab, a humanized monoclonal antibody that binds to domain IV on the 
juxtamembrane region of the extracellular domain (ECD) of HER2 and inhibits tumor growth in 
vitro and in vivo via several mechanisms;15-17 DM1, a potent anti-microtubule agent derived from 
maytansine; and SMCC, a thioether linker molecule used to conjugate DM1 to trastuzumab.  T-
DM1 retains all of the modes of action of trastuzumab, which include a binding affinity to the 
HER2 ECD that is comparable to trastuzumab, inhibition of HER2-ECD shedding, inhibition of 
the HER2-activated PI3K/Akt signaling pathway, and mediation of antibody-dependent cell-
mediated cytotoxicity (ADCC).18  Linkage of a cytotoxic agent to highly specific monoclonal 
antibodies targeting tumor-specific and/or overexpressed tumor-associated antigens focuses the 
delivery of such agents to tumor cells, which creates a more favorable therapeutic window than 
could be achieved by their administration as free drugs, and may facilitate combinations with 
different agents.  After binding to HER2, T-DM1 undergoes receptor-mediated internalization, 
followed by intracellular release of DM1 and subsequent cytotoxicity.  Activation of cytotoxicity 
of the conjugate requires that it be internalized into the cell after binding to HER2.  The non-
internalized conjugate remains inactive, thus limiting the systemic toxicity. 
 
T-DM1 clinical efficacy data 
In multiple clinical phase II and III studies, T-DM1 as a single agent has demonstrated robust 
and clinically meaningful activity, as well as favorable toxicity in patients with HER2+ 
metastatic breast cancer (MBC).  Two phase II studies—TDM4258g and TDM4374g—evaluated 
the safety and efficacy of T-DM1 administered at a dose of 3.6 mg/kg (maximum tolerated dose 
[MTD] in Phase I) every 3 weeks until progressive disease (PD) or unacceptable toxicity in 
HER2+ MBC who had progressed on previous HER2-directed therapy and conventional 
chemotherapy.19,20  Patients enrolled onto study TDM4374g were specifically required to have 
received an antrhacycline, trastuzumab, a taxane, lapatinib, and capecitabine in the neoadjuvant, 
adjuvant, locally advanced or metastatic setting.  Additionally, patients must have been treated 
with two or more HER2-directed regimens in the locally advanced or metastatic setting, and 
must have progressed on their most recent treatment. 


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The clinical activity of T-DM1 was similar in the two studies.  In Study TDM4258g, on the basis 
of the final analysis approximately 12 months after the last patient was enrolled, the overall 
response rate (ORR) in efficacy evaluable patients was 38.9% (95% confidence interval [CI], 
29.7%, 48.5%) by investigator and 26.9% (95% CI, 19.2%, and 35.8%) by independent review. 
The clinical benefit rate (CBR) (defined as complete response [CR], partial response [PR], or 
stable disease for > 6 months) was 46.3% by investigator assessment (95% CI, 36.7%, 56.2%) 
and 40.7% by independent review (95% CI, 31.8%, 50.6%). The median progression-free 
survival (PFS) was 4.6 months by both the investigators and the independent review facility 
(IRF) assessment. In Study TDM4374g, on the basis of clinical data collected through 1 January 
2010, approximately 9 months after the last patient had enrolled, the ORR among all treated 
patients was 34.5% (95% CI, 26.1%, 43.9%) by IRF assessment and 32.7% (95% CI, 24.1%, 
42.1%) by investigator assessment.  The CBR was 48.2% (95% CI, 38.8%, 57.9%) by IRF 
assessment and 46.4% (95% CI, 37.1%, 56.1%) by investigator assessment.  The median 
duration of response was not reached (95% CI, 4.6 months, not reached) by IRF assessment and 
9.7 months (95% CI, 6.6 months, not reached) by investigator assessment. In this study 
population, there was a median PFS of 6.9 months (95% CI:  4.2, 9.5) as assessed by the IRF and 
5.5 months (95% CI:  4.1, 7.5) by investigator review. 
 
The safety profile of T-DM1 was also similar between the two studies.  In Study TDM4258g, the 
five most common adverse events (AEs) were fatigue (65.2%), nausea (50.9%), headache 
(40.2%), epistaxis (35.7%), and pyrexia (34.8%).  Most of these events were Grade 1−2. The 
three most common Grade 3−4 AEs observed in this trial were hypokalemia (8.9%), 
thrombocytopenia (TCP) (8.0%), and fatigue (4.5%).  In Study TDM4374g, a total of 49 patients 
(44.5%) experienced at least one Grade ≥ 3 AE. The three most common Grade ≥ 3 adverse 
events (by Medical Dictionary for Regulatory Activities [MedDRA] preferred terms) were TCP 
(7.3%), fatigue (4.5%), and cellulitis (3.6%).  Serious adverse events (SAEs) were reported in 25 
patients (22.7%). No single SAE was reported in more than 4 patients. No Grade ≥ 3 left 
ventricular systolic dysfunction (LVSD) events (symptomatic congestive heart failure [CHF] 
and/or left ventricular ejection fraction [LVEF] of < 40%) were reported in either study.  
 
In the randomized phase III EMILIA study, T-DM1 monotherapy proved superior to the 
approved regimen lapatinib/capecitabine in patients who had progressed on prior trastuzumab 
and taxane.21  Median PFS was 9.6 months in the T-DM1 arm compared with 6.4 months in the 
capecitabine and lapatinib arm (HR = 0.65, 95% CI; 0.55 to 0.77; p <0.001), and median overall 
survival (OS) at the second interim analysis crossed the stopping boundary for efficacy (30.9 
months vs. 25.1; HR = 0.68, 95% CI; 0.55 to 0.85; p <0.001). Overall, fewer Grade ≥ 3 adverse 
events were observed in the T-DM1 arm (40.8%) than in the lapatinib arm (57%). The most 
common Grade ≥ 3 adverse events with T-DM1 were thrombocytopenia (12.9%), elevated AST 
(4.3%) and ALT (2.9%), anemia (2.7%) and fatigue (2.4%).  Based on the EMILIA data, T-DM1 
was recently approved by the Food and Drug Administration (FDA) for patients with advanced 
HER2+ breast cancer that has progressed on trastuzumab-based therapy, with superior overall 
survival (OS) and a better adverse event profile compared to the lapatinib/capecitabine 
combination. 
 


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T-DM1 will be used in this protocol as per standard FDA indications for the single agent.  Please 
refer to the Full Prescribing Information for T-DM1 for complete safety information: 
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/.   
 
2.4 
Rationale 
 
Accumulating evidence suggests that the immune system plays an important role in control of 
HER2+ breast cancer, and works with HER2-targeted therapies to do so.  High levels of immune 
infiltrates are observed in HER2-overexpressing breast cancers.  Recent studies suggest that 
monoclonal antibodies such as trastuzumab may stimulate adaptive anti-tumor immunity.  Two 
studies in mice demonstrated that anti-HER2 antibody therapy required adaptive CD8-dependent 
immunity to mediate its optimal effect.22,23  It is thought that trastuzumab activates toll-like 
receptor signaling, priming the release of interferon (IFN) and priming IFN-producing CD8+ T 
cells.  In addition, more recent data suggested that each 10% increase in tumor-infiltrating 
lymphocytes (TILs) was associated with a significant decrease in distant recurrence in patients 
receiving adjuvant trastuzumab,24 further suggesting the importance of antitumor immunity in 
the HER2+ subset of breast cancer.  In HER2+ breast cancer patients, therefore, combining 
cytotoxic chemotherapy (which provokes tumor antigen recognition) with anti-HER2 
monoclonal antibodies (which stimulate adaptive immunity) and checkpoint inhibitors (which 
enhance adaptive antitumor immune responses by preventing T cell exhaustion) is an attractive, 
rational approach for maximizing the antitumor immune response to advance the treatment of 
HER2-positive breast cancer. 
 
Trastuzumab emtansine (T-DM1), as described above, is a novel antibody-drug conjugate (ADC) 
composed of trastuzumab (a humanized antibody directed against the extracellular region of 
HER2), DM1 (an anti-microtubule cytotoxic agent), and a linker molecule.  Pembrolizumab is a 
checkpoint inhibitor with promising clinical data in melanoma and non-small cell lung cancer, as 
discussed above, as well as preliminary efficacy data in triple negative breast cancer.25  The 
combination of pembrolizumab with T-DM1 has the potential to concurrently: (1) stimulate 
tumor antigen recognition through use of a cytotoxic; (2) simulate adaptive immunity and ADCC 
through use of anti-HER2 antibody therapy; and (3) enhance the anti-tumor autoimmune 
response with an anti-PD-1 antibody.  The proposed study will explore the safety and efficacy of 
this combination in women with advanced HER2+ breast cancer. 
 
2.5 
Correlative Studies Background 
 
2.5.1 
Blood and Tissue Analysis  
There is growing evidence that signatures of tumor-associated immunologic activity are seen in 
breast cancer and are significant prognostic predictors, particularly in triple negative breast 
cancer (TNBC) and HER2-positive breast cancer.  Many different groups have demonstrated that 
the amount of tumor-infiltrating lymphocytes (TILs) in a tumor specimen, commonly assessed 
simply by histological evaluation of a standard hematoxylin and eosin-stained slide by a trained 
pathologist, is a significant predictor of both response to therapy and overall disease outcomes in 
the neoadjuvant and adjuvant settings.26-31  Recently, more in-depth methods of immunologic 
profiling are being explored in breast cancer, for example mRNA expression of immune-


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activating and immunosuppressive factors, and these additional immune profiles also appear to 
have prognostic significance.27 
 
However, the development of immune signatures in breast cancer that go beyond simple 
histology is at a very early stage.  Additionally, much of the work done in this area has been in 
the adjuvant and neoadjuvant settings, with less known about the immunologic profile of 
metastatic disease.  Given the promise of immune-based therapies in other solid malignancies 
such as melanoma and non-small cell lung cancer, with preliminary data demonstrating activity 
of immune checkpoint inhibition in advanced breast cancer patients,25,32 there is a great need to 
better characterize the immune profile of breast tumors across multiple disease subtypes, and at 
different points in the course of therapy.  The bulk of our correlative science in this trial focuses 
on characterizing a broad array of immune markers in metastatic HER2-positive breast cancer, 
investigating whether those markers predict disease response to therapy, and exploring how 
markers change from the start T-DM1 plus pembrolizumab treatment to the time of development 
of progressive disease. 
 
In melanoma, the solid malignancy currently at the forefront of understanding the anti-tumor 
immune response, investigation into expression of immune mediators in the peripheral blood is 
at an early phase.33  As a correlative study to this trial, we will characterize the immune marker 
profile of peripheral blood mononuclear cells (PBMCs) in enrolled breast cancer patients.  
Additionally, given the demonstrated clinical significance of TILs in breast cancer specimens, 
we will investigate whether there is a peripheral marker whose level corresponds to TIL 
percentage.  Lastly, we will evaluate whether there is a correlation between changes in PBMC 
immune profiles over the course of treatment, and disease response to therapy.  Evidence of a 
correlation would be of significant interest as it would suggest the potential presence of a 
predictive biomarker in the peripheral blood.  
 
2.5.2 
Microbiome Analysis 
 
 
The gut microbiota has been recognized as a modulator of immune system development44. 
Healthy individuals have microbial populations in their intestinal tract that vary markedly in 
composition45,46.  The diversity of intestinal microbiota represents a significant challenge to the 
host’s immune defenses, which must balance immune tolerance of beneficial microbes with 
inflammatory responses against pathogens.  Alterations in the gut microbiota and their resulting 
interactions with intestinal epithelieum and the host immune system are associated with many 
disease, including cancer47.  Recently, two preclinical studies provided to immune checkpoint 
inhibitors (ICI), raising the possibility that stool microbiota could be used as biomarker 
predictors of efficacy to immunotherapy48,49.  Interestingly, postmenopausal women with breast 
cancer have altered composition and low diversity of their gut microbiota compared to healthy 
controls50. 
 
Identification of biomarkers that predict response to ICI-based therapies can spare de novo 
resistant patients from the unnecessary risks of immune-related adverse events.  In addition, the 
identification of bacterial species associated with response could open new strategies to 


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maximize the clinical benefit of cancer immunotherapy through the modulation of gut 
microbiota. 
 
This correlative project is made possible by collaboration with the BWH/Harvard Cohorts 
Biorepository and Microbiome Dx. Further details can be found in Section 9.   
 
2.5.3 
Tumor Genomic Profile 
 
In addition to the immune microenvironment, intrinsic tumor factors may be associated with 
response to immune checkpoint inhibitors. Although some of the mechanisms related to de novo 
or acquired resistance to ICI have been recently described, including loss of function in beta-2- 
microglobulin or defects in the interferon signaling pathway[Gao et al., 2016, Zaretsky et al., 
2016], the knowledge of immune resistance remains largely unknown. Several gene/pathways 
have been described as possible candidates of having an immunosuppressive role in different 
advanced solid tumor, including MYC amplification[Casey et al., 2016], activation in WNT-β-
catenin pathway[Spranger et al., 2015], activation in MAPK pathway, loss of PTEN[Li et al., 
2016, Peng et al., 2016, George et al., 2017]. On the other hand, few possible biomarkers of 
response to ICI have emerged, including mutational load[Snyder et al., 2014, Rizvi et al., 2015], 
tumor aneuploidy[Davoli et al., 2017], mismatch repair defects[Le et al., 2015], and BRCA2 
mutation[Hugo et al., 2016]. Notably, there is no data on genomic mechanisms of de novo 
resistance to anti-PD-1 therapy in patients with breast cancer. 
Therefore, as a correlative study to this trial, we will to explore whether the number and/or 
type of mutations identified using a next generation sequencing (NGS) panel – OncoPanel - is 
correlated with patient outcomes (PFS, ORR, and OS). This tool is a cancer genomic assay to 
detect somatic mutations, copy number variations and structural variants in tumor DNA extracted 
from fresh, frozen or formalin-fixed paraffin-embedded samples. The OncoPanel assay surveys 
exonic DNA sequences of 447 cancer genes and 191 regions across 60 genes for rearrangement 
detection. DNA is isolated from tissue containing at least 20% tumor nuclei and analyzed by 
massively parallel sequencing using a solution-phase Agilent SureSelect hybrid capture kit and an 
Illumina HiSeq 2500 sequencer. The targeted NGS assay (OncoPanel) will be performed at the 
Center for Advanced Molecular Diagnostics (Department of Pathology, Brigham and Women's 
Hospital). This assay has been extensively validated and is used as a CLIA-approved clinical 
molecular test in our institution without any additional sequencing assays to validate the findings 
[Wagle et al., 2012].  
 
 
3. PARTICIPANT SELECTION 
 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have histologically or cytologically confirmed invasive breast cancer, with 
stage IV disease.  Patients without pathologic or cytologic confirmation of metastatic 
disease should have unequivocal evidence of metastasis from physical examination or 
radiologic evaluation. 
 


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3.1.2 Either the primary tumor and/or the metastasis must have been tested for ER, PR and 
HER2.  Patient must have HER2+ breast cancer per ASCO CAP guidelines 2013. 
 
3.1.3 Prior chemotherapy:  
• History of prior therapy with trastuzumab and a taxane, separately or in 
combination, is required.   
• Patients must have either received one line of prior therapy for metastatic breast 
cancer, or have developed a disease recurrence during or within 6 months after 
completing adjuvant therapy.   
• No prior treatment with T-DM1 is allowed.   
• Last dose of chemotherapy must be at least 21 days prior to registration. 
 
3.1.4 Prior biologic therapy:  
• Patients must have discontinued all biologic or investigational therapy at least 21 
days before registration.  
 
3.1.5 Prior radiation therapy:  
• Patients may have received prior radiation therapy in either the metastatic or 
early-stage setting.   
• Radiation therapy must be completed at least 14 days prior to registration. 
 
3.1.6 In the dose de-escalation cohort: Subjects must have evaluable disease. 
In the expansion cohort: Subjects must have at least one lesion that is not within a 
previously radiated field that is measurable on computerized tomography (CT) or 
magnetic resonance imaging (MRI) scan per RECIST version 1.1.  Bone lesions are not 
considered measurable by definition. 
 
3.1.7 Age is ≥18 years. 
 
3.1.8 ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A) 
 
 
3.1.9 Participants must have normal organ and marrow function as defined below: 
 
− 
absolute neutrophil count 
≥1,500/μl 
− 
platelets 
≥100,000/μl 
− 
hemoglobin 
≥9 g/dL 
− 
total bilirubin 
≤1.5mg/dL (≤2.0 in patients with known Gilberts 
syndrome) 
− 
AST(SGOT)/ALT(SGPT) 
≤2.5 × institutional ULN.  ≤5.0 × institutional ULN for 
patients with documented liver metastases. 
− 
albumin  
 
 
 
 
>2.5mg/dL 
− 
serum creatinine 
≤1.5mg/dL or calculated GFR ≥60 mL/min 
− 
INR/PT  
 
 
 
≤1.5 times ULN unless participant is receiving 
anticoagulant therapy, as long as PT or PTT is within 


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therapeutic range of intended use of anticoagulants 
− 
aPTT/PTT  
 
 
≤1.5 times ULN unless participant is receiving 
anticoagulant therapy, as long as PT or PTT is within 
therapeutic range of intended use of anticoagulants 
 
3.1.10 Participants enrolling in the dose expansion must have tissue that is amenable to biopsy 
and be willing to undergo a fresh tissue biopsy at baseline.  Participants who undergo an 
attempted research biopsy procedure for the purpose of this protocol, and in whom 
inadequate tissue is obtained, are not required to undergo a repeat biopsy in order to 
continue on protocol. 
 
3.1.11  The effects of pembrolizumab on the developing human fetus are unknown.  For this 
reason and because tratuzumab, a component of T-DM1, is known to be teratogenic, 
women of child-bearing potential (as defined in Section 5.5.2) and men of childbearing 
potential must agree to use adequate contraception (as defined in Section 5.5.2) starting 
with the first dose of study therapy, for the duration of study participation, and for an 
additional 120 days after the last dose of study medication.  Note: abstinence is 
acceptable if this is the usual lifestyle and preferred contraception for the subject.   
• Should a woman become pregnant or suspect she is pregnant while she or her 
partner is participating in this study, the treating physician and principal 
investigator should be informed immediately.   
• While on the study, women should not breast-feed.   
• Subjects of childbearing potential are defined as those who have not been 
surgically sterilized and/or have had a menstrual period in the past year 
 
3.1.12 Female subject of child-bearing potential, as defined above, must have a negative urine or 
serum pregnancy within 7 days prior to receiving the first dose of study medication.  If a 
urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be 
required. 
 
3.1.13 Patients on bisphosphonates may continue receiving bisphosphonate therapy during study 
treatment. 
 
3.1.14 Left ventricular ejection fraction (LVEF) must be ≥ 50 as assessed by echocardiogram or 
MUGA documented within 28 days prior to first dose of study drug. 
 
3.1.15 Ability to understand and the willingness to sign a written informed consent document. 
 
3.2 
Exclusion Criteria 
 
3.2.1 The subject has received another investigational agent within 21 days of the first dose of 
study drug. 
 
3.2.2 The subject has received prior pembrolizumab or any other anti-PD-1 , anti-PD-L1, or 
anti-PD-L2 therapy, or has participated in any prior studies involving pembrolizumab. 
 


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3.2.3 Pre-existing neuropathy greater than or equal to grade 2. 
 
3.2.4 Hypersensitivity to pembrolizumab or T-DM1 or any of their excipients. 
 
3.2.5 The subject has any history or evidence of active, non-infectious pneumonitis or 
interstitial lung disease. 
 
3.2.6 Known brain metastases that are untreated, symptomatic, or require therapy to control 
symptoms. Participants with previously diagnosed brain metastases are eligible if they 
have completed treatment at least one month prior to trial therapy initiation, are 
neurologically stable with an absence of new neurological symptoms for at least 4 weeks 
prior to study entry, and have recovered from effects of radiotherapy or surgery.  Any 
corticosteroid use for brain metastases must have been discontinued without the 
subsequent appearance of symptoms for ≥2 weeks before the first study drug.  Treatment 
for brain metastases may include whole brain radiotherapy, radiosurgery, or a 
combination as deemed appropriate by the treating physician. 
 
3.2.7 Known carcinomatous meningitis. 
 
3.2.8 The subject has an uncontrolled intercurrent illness including, but not limited to, 
uncontrolled hypertension, unstable angina pectoris, uncontrolled cardiac arrhythmia, 
congestive heart failure (New York Heart Association Class III or IV; see Appendix B), 
active ischemic heart disease, myocardial infarction within the previous six months, 
uncontrolled diabetes mellitus, chronic liver or renal disease, or severe malnutrition. 
 
3.2.9 Concurrent use of potent CYP3A4 inhibitors (see Appendix C), such as ketoconazole and 
erythromycin, should be avoided during the study treatment with T-DM1. 
 
3.2.10 Active infection requiring intravenous antibiotics at cycle 1 day 1. 
 
3.2.11 Individuals with a history of a second malignancy are ineligible except for the following 
circumstances.  Individuals with a history of other malignancies are eligible if they have 
been disease-free for at least 5 years and are deemed by the investigator to be at low risk 
for recurrence of that malignancy. Individuals with the following cancers are eligible if 
diagnosed and treated within the past 5 years: cervical cancer in situ, and non-melanoma 
cancer of the skin.  Patients with other cancers diagnosed within the past 5 years and felt 
to be at low risk of recurrence should be discussed with the study sponsor to determine 
eligibility. 
 
3.2.12 The subject has a medical condition that requires chronic systemic steroid therapy or any 
other form of immunosuppressive medication including disease modifiying agents.  
Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid replacement 
therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic 
treatment. 
 


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3.2.13 The subject has an active autoimmune disease or a documented history of autoimmune 
disease or syndrome that requires systemic steroids or immunosuppressive agents. 
 
3.2.14 The participant is positive for Hepatitis B surface antigen, or Hepatitis C RNA.   
3.2.15 Known HIV-positive participants.  HIV-positive patients on combination antiretroviral 
therapy are ineligible because of the potential for pharmacokinetic interactions with 
pembrolizumab.  In addition, these participants are at increased risk of lethal infections 
with bone marrow suppressive therapy, i.e. nab-paclitaxel.  Appropriate studies will be 
undertaken in participants receiving combination antiretroviral therapy when indicated. 
 
3.2.16 The subject has received a live vaccine within 28 days of planned start of study therapy.  
Note: seasonal influenza vaccines for infection are generally inactivated flu vaccines and 
are allowed; however intranasal influenza vaccines (i.e. Flu-Mist ®) are live attenuated 
vaccines, and are not allowed. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial. 
 
4. REGISTRATION PROCEDURES 
 
4.1 
General Guidelines for DF/HCC Institutions 
 
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 
registration will be denied. 
 
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 
 
Following registration, participants may begin protocol therapy. Issues that would cause 
treatment delays should be discussed with the Overall Principal Investigator (PI). If a participant 
does not receive protocol therapy following registration, the participant’s registration on the 
study must be canceled. Registration cancellations must be made in OnCore as soon as possible.  
 
4.2 
Registration Process for DF/HCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.   
 
4.3 
General Guidelines for Other Investigative Sites 
 
N/A 
 


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4.4 
Registration Process for Other Investigative Sites 
 
N/A 
 
5. TREATMENT PLAN 
 
 
5.1 
Treatment Regimen 
The study will be conducted as a dose de-escalation study, as the common toxicities of the two 
agents are not overlapping.  Each cycle will be 21 days in length.  Six patients will be entered at 
dose level 1 (Table 1), consisting of T-DM1 3.6 mg/kg IV every 21 days, in combination with 
pembrolizumab 200 mg IV every 21 days.  If one or fewer dose limiting toxicities (DLTs) are 
noted within the first six patients, this dose level will be declared the RP2D.  If two or more 
DLTs are found in the first 6 patients, then 6 additional patients will be entered at dose level -1 
(Table 1).  If one or fewer DLTs are noted at dose level -1, then this will be declared the RP2D.  
If two or more DLTs are noted at dose level -1, enrollment will be stopped.  No dose changes 
will be explored for pembrolizumab as its toxicity has not been found to be dose-dependent in 
other clinical contexts. 
 
The DLT period is defined as 21 days from the first dose of therapy (i.e. the first cycle of 
therapy).  All six patients enrolled to the dose level must complete the DLT period before 
additional patients can be enrolled. 
 
Once the RP2D is declared, 15 eligible patients with metastatic HER2+ breast cancer will be 
entered into an expansion cohort. 
 
Treatment will be administered on an outpatient basis.  Reported adverse events and potential 
risks are described in Section 7.1.  Appropriate dose modifications are described in Section 6.  
Details of the regimen are described in Table 2.  No investigational or commercial agents other 
than those described below may be administered with the intent to treat the participant’s 
malignancy. 
 
Table 1: Dosing levels for dose de-escalation 
Dose De-Escalation Schedule 
Dose Level 
Dose 
Pembrolizumab 
(mg) 
T-DM1 
(mg/kg) 
Level 1: starting dose 
200 
3.6 
Level -1 
200 
3.0 
 
Table 2: Regimen description 
Regimen Description 
Agent 
Premedications
Dose 
Route 
Schedule 
Cycle 


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; Precautions 
Length 
Pembrolizumab 
Not routinely 
necessary unless 
prior infusion 
reaction. 
 
200 mg, at 
a final 
concentrati
on of 1 
mg/mL to 
10 mg/mL 
in NS or 
D5 
IV over 
approximately 
30 minutes 
(range: 25-40 
minutes).   
Day 1 
21 days  
(3 weeks) 
 
 
 
T-DM1 
Not routinely 
necessary unless 
prior infusion 
reaction. 
Per Table 
1* 
IV over 
approximately 
90 minutes 
(cycle 1) and 30 
minutes 
(subsequent  
cycles). 
 
Start T-DM1 
infusion after 
pembrolizumab 
infusion is 
complete. 
Day 1 
*Doses as appropriate for assigned dose level 
 
 
 
 
5.2 
Pre-Treatment Criteria 
 
5.2.1 
Cycle 1, Day 1 and Subsequent Cycles, Day 1 
 
Eligibility criteria do not need to be re-met at cycle 1 day 1.   
 
 
 
Criteria to treat at cycle 1 day 1: 
• Absolute neutrophil count >1500/μl 
• Platelets >100,000/μl 
• ALT and AST <2.5 x ULN in a patient with no documented liver metastases; 
ALT and AST <5.0 x ULN in a patient with documented liver metastases 
• Total bilirubin <1.5 x ULN (2.0 x ULN in a patient with well documented 
Gilbert’s syndrome) 
 


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5.3 
Agent Administration 
 
5.3.1 
Pembrolizumab 
 
Pembrolizumab will be administered by trained medical personnel at the investigational site.  
Treatment compliance will be monitored through documentation of study treatment 
administration in the subject’s medical record. 
 
Pembrolizumab will be administered in clinic on day 1 of each 3-week cycle (+/- 3 days).  It will 
be administered as a 30 minute IV infusion.  Sites should make every effort to target infusion 
timing to be as close to 30 minutes as possible.  However, given the variability of infusion 
pumps from site to site, a window of -5 minutes and +10 minutes is permitted (i.e., infusion time 
is 30 minutes: -5 min/+10 min). 
 
Pembrolizumab should be administered prior to T-DM1 administration.  There should be no 
overlap in timing of the two administrations; however, there is no required observation period 
prior to beginning T-DM1 administration. 
 
5.3.2 
T-DM1 
 
T-DM1 administration 
T-DM1 will be used as per the FDA label.  T-DM1 will be administered by trained medical 
personnel at the investigational site.  Treatment compliance will be monitored through 
documentation of study treatment administration in the subject’s medical record. 
 
T-DM1 will be administered in clinic on day 1 of each 3-week cycle (+/- 3 days).  The total 
Criteria to treat at day 1 of subsequent cycles: 
• Absolute neutrophil count >1000/μl 
• Platelets >75,000/μl 
• ALT and AST <3.0 x ULN in a patient with no documented liver metastases; 
ALT and AST <5.0 x ULN in a patient with documented liver metastases 
• Total bilirubin <1.5 x ULN (2.0 x ULN in a patient with well documented 
Gilbert’s syndrome) 
 


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dose of T-DM1 will be calculated according to institutional standards. 
 
The first infusion of T-DM1 will be administered over 90 minutes (+/- 10 minutes).  
Infusions may be slowed or interrupted for patients experiencing infusion-associated symptoms. 
Following the initial dose, patients will be observed for at least 60 minutes for fever, chills, or 
other infusion-associated symptoms.  Subsequent doses of T-DM1 may be administered over 
30 minutes (+/- 10 minutes) with a 30-minute post-infusion observation if the first infusion was 
well tolerated. Local health authority guidelines must be followed with regard to further 
observation and monitoring, if applicable.  Dose modifications for T-DM1 toxicity management 
are listed in Section 6, and Section 6, Table 6. 
 
Premedication for nausea and infusion reactions are not commonly required but may be given at 
the investigator’s discretion. 
 
 
5.4 
Definition of Dose-Limiting Toxicity (DLT)  
 
Dose-limiting toxicity is defined as any of the following events occurring within 21 days (1 
cycle) after the first dose of therapy, if judged by the investigator to be possibly, probably, or 
definitely related to study drug administration: 
 
• Death 
• Asymptomatic grade 4 hematologic toxicity lasting ≥14 days unless deemed by the 
investigator to be clinically insignificant 
• Grade 4 thrombocytopenia of any duration 
• ≥ Grade 3 Febrile neutropenia  
• ≥ Grade 3 Thrombocytopenia if associated with bleeding 
• ≥ Grade 3 elevation in AST or ALT associated with a grade 2 elevation in bilirubin that is 
at least possibly related to study drug (Hy’s Law)  
• ≥ Grade 3 non-hematologic laboratory value if: 
o Medical intervention is required to treat the patient, or 
o The abnormality leads to hospitalization, or 
o The abnormality persists >7 days 
 Excluding: 
 Alkaline phosphatase <10.0x ULN in a patient with grade 2 alkaline 
phosphatase elevation at baseline as a result of bone metastasis  
 Any laboratory values deemed by the investigator to be clinically 
insignificant 
• ≥ Grade 3 pneumonitis of any duration 
• ≥ Grade 3 Fatigue lasting >5 days 
• > Grade 3 other non-laboratory toxicity lasting >3 days despite optimal supportive care, 
excluding the following: 
o Alopecia of any grade 
 
DLTs will be assessed during the DLT assessment window (lasting for 1 cycle, or 21 days after 


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initiation of study therapy).  The dose de-escalation plan is described in Section 5.1. 
 
Management and dose modifications associated with the above adverse events are outlined in 
Section 6. 
 
Number of Participants with DLT 
at a Given Dose Level 
Escalation Decision Rule 
0 -1 out of 6 
Declared as RP2D 
>2 out of 6  
6 additional patients will be enrolled at dose level -1.  
• If 1 or fewer experience DLT at dose level -1, this 
will be declared as the RP2D. 
• If 2 or more of the group at dose level -1 experience 
DLT, enrollment will be stopped. 
 
5.5 
General Concomitant Medication and Supportive Care Guidelines 
 
5.5.1 
Concomitant Medication Guidelines 
 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial.  If there is a clinical indication for one of these or other medications or 
vaccinations specifically prohibited during the trial, discontinuation from trial therapy or 
vaccination may be required.  The investigator should discuss any questions regarding this with 
the Principle Investigator.  
 
Acceptable Concomitant Medications 
All treatments that the investigator considers necessary for a subject’s welfare may be 
administered at the discretion of the investigator in keeping with the community standards of 
medical care. 
Prohibited Concomitant Medications 
Participants should discontinue the following therapies 21 days prior to enrollment and must 
remain off them during protocol therapy: 
• Antineoplastic systemic chemotherapy or biological therapy  
• Immunotherapy not specified in this protocol 
• Chemotherapy not specified in this protocol 
• Biologic or targeted agents not specified in this protocol 
• Investigational agents other than pembrolizumab 
Participants should have completed radiation therapy 14 days prior to enrollment, if radiation 
therapy to a symptomatic solitary lesion or to the brain is required while on protocol therapy it 
may be allowed at the principle investigator’s discretion.   


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Participants are prohibited from receiving the following therapies during the Screening and 
Treatment Phase of this trial: 
• Any systemically active oral, injected, or implanted hormonal method of contraception 
except for progesterone coated intrauterine devices (IUDs) that had been previously 
implanted. 
• Estrogen replacement therapy. 
• Live vaccines within 28 days prior to the first dose of trial treatment and while 
participating in the trial.  Examples of live vaccines include, but are not limited to, the 
following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and 
typhoid vaccine.  
• Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
adverse event of suspected immunologic etiology.  The use of physiologic doses of 
corticosteroids may be approved after consultation with the Sponsor. 
 
Subjects who, in the assessment by the investigator, require the use of any of the aforementioned 
treatments for clinical management should be removed from the trial.  Subjects may receive 
other medications that the investigator deems to be medically necessary. 
Concomitant use of strong CYP3A4 inhibitors (e.g., ketoconazole and itraconazole; see 
Appendix C) with T-DM1 should be avoided. An alternate medication with no or minimal 
potential to inhibit CYP3A4/5 should be considered. If a strong CYP3A4/5 inhibitor is co-
administered with T-DM1, patients should be closely monitored for adverse reactions. 
There are no prohibited therapies during the Post-Treatment Follow-up Phase. 
5.5.2 
Contraception 
 
Pembrolizumab may have adverse effects on a fetus in utero.  Furthermore, it is not known if 
pembrolizumab has transient adverse effects on the composition of sperm.   
 
For this trial, male subjects will be considered to be of non-reproductive potential if they have 
azoospermia (whether due to having had a vasectomy or due to an underlying medical 
condition).   
 
Female subjects will be considered of non-reproductive potential if they are either:  
(1) postmenopausal (defined as at least 12 months with no menses without an 
alternative medical cause; in women < 45 years of age not using hormonal 
contraception or hormonal replacement therapy a high follicle stimulating 
hormone (FSH) level in the postmenopausal range is required to confirm a post-
menopausal state in women not using hormonal contraception or hormonal 
replacement therapy. In the absence of 12 months of amenorrhea, a FSH 
measurement is insufficient.);  


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OR  
(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy 
or bilateral tubal ligation/occlusion, at least 6 weeks prior to screening;  
OR  
(3) have a congenital or acquired condition that prevents childbearing. 
 
Female and male subjects of reproductive potential must agree to practice abstinence (if it is 
consistently employed as the subject’s preferred and usual lifestyle; however, periodic abstinence 
(e.g., calendar, ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are not 
acceptable) from heterosexual activity or use acceptable contraception (as defined below) during 
heterosexual activity while receiving protocol therapy and up to 120 days after the last dose of 
study. 
 
Acceptable methods of contraception are‡: 
  
Single method (one of the following is acceptable): 
• 
intrauterine device (IUD) 
• 
vasectomy of a female subject’s male partner  
• 
contraceptive rod implanted into the skin 
  
Combination method (requires use of two of the following): 
• 
diaphragm with spermicide (cannot be used in conjunction with cervical 
cap/spermicide) 
• 
cervical cap with spermicide (nulliparous women only)   
• 
contraceptive sponge (nulliparous women only)  
• 
male condom or female condom (cannot be used together) 
• 
hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin-
only pill), contraceptive skin patch, vaginal contraceptive ring, or subcutaneous 
contraceptive injection 
  
‡If a contraceptive method listed above is restricted by local regulations/guidelines, then 
it does not qualify as an acceptable method of contraception for subjects participating at 
sites in this country/region. 
 
Subjects should be informed that taking the study medication may involve unknown risks to the 
fetus (unborn baby) if pregnancy were to occur during the study.  In order to participate in the 
study subjects of childbearing potential must adhere to the contraception requirement (described 
above) from the day of study medication initiation (or 14 days prior to the initiation of study 
medication for oral contraception) and up to 120 days after the last dose of protocol therapy.  If 
there is any question that a subject of childbearing potential will not reliably comply with the 
requirements for contraception, that subject should not be entered into the study. 
 
5.5.3 
Supportive Care Guidelines – general medications 
 
The following treatments are permitted throughout the duration of the study treatment phase and 
during follow-up: 


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• Standard therapies for pre-existing medical conditions unless listed as prohibited therapy 
below. Any medication intended solely for supportive care (e.g., analgesics, anti-
diarrheal, anti-depressants) may be used at the investigator’s discretion. Patients on anti-
coagulant treatment should have their platelet count monitored closely during treatment 
with T-DM1. Antiemetics and anti-diarrheal medications should not be administered 
prophylactically before initial treatment with study drugs.  At the discretion of the 
investigator, prophylactic antiemetic and anti-diarrheal medication(s) may be used as per 
standard clinical practice before subsequent doses of study drugs. 
• Hematopoietic growth factors (e.g., G-CSF, granulocyte macrophage colony stimulating 
factor) may be used at investigator’s discretion for the primary prophylaxis and/or 
management of treatment-emergent neutropenia and/or for secondary prophylaxis as per 
NCCN/European Society for Medical Oncology guidelines 34,35 or local standard practice. 
However, treatment with granulocyte-colony stimulating factors will not permitted in 
cycle 1 unless the patient has febrile neutropenia and the physician considers its use as 
clinically indicated. It will be left to the treating physician choice from cycle 2.  
• Bisphosphonate or denosumab therapy to be used in accordance with the approved 
labeled indication and/or nationally recognized treatment guidelines.  Participants already 
receiving bisphosphonate/denosumab at the time of study entry can continue the 
treatment. Participants with new bone metastases documented as part of study screening 
procedures may begin a bisphosphonate after study registration but before initiation of 
protocol therapy. 
• Anticoagulants - Anticoagulation with heparin, heparin derivatives, and/or warfarin may 
be given at the discretion of the treating physician. Coagulation parameters should be 
checked at least once monthly, or more frequently at discretion of treating physician.  
• Pain medications administered per standard clinical practice are acceptable while the 
patient is enrolled in the study. 
 
Patients who experience toxicities should be treated symptomatically as clinically indicated.  
Medications that are considered necessary for the subject’s welfare and that are not expected to 
interfere with the evaluation of study treatment or be restricted may be given at the discretion of 
the investigator.  Ancillary treatments will be given as medically indicated. 
 
5.6 
Criteria for Taking a Participant Off Protocol Therapy 
 
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue 
until one of the following criteria applies: 
 
• 
Disease progression – in any subject who showed first radiologic evidence of 
progressive disease (PD) by RECIST 1.1 (see Section 11.1.4) and is deemed 
clinically stable, it is at the discretion of the investigator to continue treating the 
subject until progression is confirmed at least 4 weeks from the date of the first 
radiologic evidence of PD.  Further details are described below. 
 


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• 
Participants who have attained a confirmed complete response (CR) that have been 
treated for at least 24 weeks with pembrolizumab and had at least two treatments with 
pembrolizumab beyond the date when the initial CR was declared.  Concurrent 
discontinuation of T-DM1 is at the discretion of the investigator.  Subjects who then 
experience radiographic disease progression may be eligible for up to one year of 
additional treatment with pembrolizumab via the Second Course Phase (see below) at 
the discretion of the investigator if no systemic cancer treatment other than T-DM1 
was administered since the last dose of pembrolizumab, the subject meets the safety 
parameters listed in the Inclusion/Exclusion criteria, and the trial is open.  Subjects 
will resume therapy at the same dose and schedule as at the time of initial 
discontinuation. 
 
• 
Intercurrent illness that prevents further administration of treatment 
 
• 
Unacceptable adverse event(s) 
 
• 
Participant demonstrates an inability or unwillingness to comply with the medication 
regimen and/or documentation requirements 
 
• 
Participant decides to withdraw from the protocol therapy 
 
• 
General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator 
 
 
Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF) and recorded in the clinical trials management system 
(OnCore). Alternative care options will be discussed with the participant. 
 
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify the Overall PI, Sara Tolaney, MD MPH at
  
 
Confirmation of Progressive Disease 
 
Pembrolizumab, like other immunotherapeutic agents, may produce antitumor effects by 
potentiating endogenous cancer-specific immune responses. The response patterns seen with 
such an approach may extend beyond the typical time course of image responses seen with 
cytotoxic agents, and can manifest as a clinical response after an initial increase in tumor burden 
or even the appearance of new lesions. 
 
For any subject who showed first radiologic evidence of progressive disease (PD) by RECIST 
1.1 (see Section 11.1.4) and is deemed clinically stable, it is at the discretion of the investigator 
to continue treating the subject until progression is confirmed at least 4 weeks from the date of 
the first radiologic evidence of PD. If progression is confirmed, the subject will be discontinued 
from study treatment. Otherwise, the subject will continue treatment and radiographic scans. Any 


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subject who had initial radiologic progression and is deemed clinically unstable should be 
discontinued from both study drugs and no subsequent scan for confirmation is required. 
 
Further details are as below: 
 
For purposes of PFS assessment on this trial, in addition to radiographic assessment of tumor 
response or progression, the investigator should taking into account the clinical 
condition/stability of subjects. 
 
Clinically stable is defined by the following criteria: 
o Absence of signs and symptoms (including worsening of laboratory values) 
indicating disease progression 
o No decline in ECOG performance status 
o Absence of rapid progression of disease 
o Absence of progressive tumor(s) at critical anatomical sites (eg, cord 
compression) requiring urgent alternative medical intervention 
 
Any subject who showed first radiologic evidence of progressive disease and is deemed 
Clinically unstable should be discontinued from both study drugs and is not required to have 
repeat imaging for confirmation.  
 
For a clinically stable subject with first radiologic evidence of progressive disease 
(ie,unconfirmed progression of disease), it is at the discretion of the investigator to continue 
treating the subject with the assigned treatment per protocol until progression of disease is 
confirmed on a subsequent scan at least 4 weeks later. If progression is not confirmed on the 
subsequent scan, the subject should continue to receive study treatment and have radiographic 
scans performed every 6 weeks if the patient has been on study for less than 24 weeks, or every 9 
weeks for patients who have been on study greater than 24 weeks to monitor disease status. If 
radiologic progression is confirmed by subsequent scans, then the subject will be discontinued 
from study treatment. Exceptions may be considered to continue treatment in the presence of 
clinically stable or improved condition only after consultation with the principal investigator. 
 
 
Second Course Phase (Retreatment Period) 
 
Subjects who stop pembrolizumab for CR as described may be eligible for up to one year of 
additional pembrolizumab therapy if they progress after stopping study treatment.  This 
retreatment is termed the Second Course Phase of this study and is only available if the study 
remains open and the subject meets the following conditions: 
 
• Stopped initial treatment with pembrolizumab after attaining an investigator-determined 
confirmed CR according to RECIST 1.1, and: 
 was treated for at least 24 weeks with pembrolizumab before discontinuing 
therapy 


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 received at least two treatments with pembrolizumab beyond the date when the 
initial CR was declared 
AND 
 
• experienced an investigator-determined confirmed radiographic disease progression after 
stopping their initial treatment with pembrolizumab 
• did not receive any anti-cancer treatment other than T-DM1 since the last dose of 
pembrolizumab 
• meets all other study inclusion/exclusion criteria, as per Section 3. 
Subjects who restart treatment will be retreated at the same dose and dose interval as when they 
last received pembrolizumab.  Treatment will be administered for up to one additional year. 
Visit requirements are as outlined for subjects on the initial treatment phase of the trial, in the 
expansion cohort.  Resumption of T-DM1 concurrent with pembrolizumab is at the discretion of 
the investigator. 
 
 
5.7 
Duration of Follow Up 
 
All participants will be followed for overall survival.   
Follow-up for vital status will be accomplished by annual review of the medical record, 
records/phone calls to outside providers or phone calls to the patient until death is documented. 
 
In patients who come off trial for a reason other than progressive disease, scans should be 
performed every 6 weeks (if the patient is within 24 weeks of initiation of study treatment) or 
every 9 weeks (if the patient is greater than 24 weeks from initiation of study treatment) to 
evaluate for disease progression. 
 
Participants removed from protocol therapy for unacceptable adverse event(s) will be followed 
until resolution or stabilization of the adverse event. 
 
5.8 
Criteria for Taking a Participant Off Study 
 
Participants will be removed from study when any of the following criteria apply: 
• Lost to follow-up 
• Withdrawal of consent for data submission 
• Death 
 
The reason for taking a participant off study, and the date the participant was removed, must be 
documented in the case report form (CRF) and in OnCore.  
 
 


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6. DOSING DELAYS/DOSE MODIFICATIONS  
 
Dose delays and modifications will be made as indicated in the following table(s). The 
descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 will be utilized for dose delays and dose modifications. A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP website 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
If there are dosing delays for any reason, all study assessments are to be delayed in the same 
fashion, such that scans and other assessments occur in conjunction with cycles of treatment. 
 
6.1 
Management of toxicities attributable to pembrolizumab 
 
There are two types of uncommon toxicity that have been previously described in patients on 
both single agent pembrolizumab and single agent T-DM1: (1) hepatotoxicity, specifically 
manifesting as elevated AST, ALT, or total bilirubin; and (2) pneumonitis.  Dose modifications 
for these toxicities are addressed separately in Section 6.3.  
 
For toxicities likely attributable to pembrolizumab alone, concurrent holding of T-DM1 is at the 
discretion of the treating physician. 
 
Adverse events (both non-serious and serious) associated with pembrolizumab exposure may 
represent an immunologic etiology.  These adverse events may occur shortly after the first dose or 
several months after the last dose of treatment.  Pembrolizumab must be withheld for drug-related 
toxicities and severe or life-threatening AEs as per Table 4 below. 
 
 




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Type 1 diabetes 
mellitus (T1DM) 
or 
Hyperglycemia 
 
Newly onset 
T1DM or  
Grade 3 or 4 
hyperglycemia 
associated 
with evidence 
of β-cell 
failure 
Withhold 
• Initiate insulin 
replacement therapy for 
participants with T1DM  
• Administer anti-
hyperglycemic in 
participants with 
hyperglycemia  
 
• 
Monitor participants for 
hyperglycemia or other signs 
and symptoms of diabetes. 
Hypophysitis 
Grade 2 
Withhold 
• Administer 
corticosteroids and 
initiate hormonal 
replacements as 
clinically indicated.   
 
• 
Monitor for signs and symptoms 
of hypophysitis (including 
hypopituitarism and adrenal 
insufficiency)  
Grade 3 or 4  
Withhold or 
permanently 
discontinue1  
Hyperthyroidism  Grade 2 
Continue  
• Treat with non-selective 
beta-blockers (eg, 
propranolol) or 
thionamides as 
appropriate  
• 
Monitor for signs and symptoms 
of thyroid disorders.  
 
Grade 3 or 4  
Withhold or  
permanently 
discontinue1 
Hypothyroidism 
Grade 2-4 
Continue  
• Initiate thyroid 
replacement hormones 
(eg, levothyroxine or 
liothyroinine) per 
standard of care 
• 
Monitor for signs and symptoms 
of thyroid disorders.  
 
Nephritis and 
Renal 
dysfunction 
Grade 2 
Withhold  
• Administer 
corticosteroids 
(prednisone 1-2 mg/kg 
or equivalent) followed 
by taper. 
• 
Monitor changes of renal 
function 
 
Grade 3 or 4  
Permanently 
discontinue 
Myocarditis 
Grade 1 or 2 
Withhold 
• Based on severity of AE 
administer 
corticosteroids 
• 
Ensure adequate evaluation to 
confirm etiology and/or exclude 
other cause 
 
Grade 3 or 4 
Permanently 
discontinue 
Infusion 
Reaction2 
Grade 3 or 4 
Permanently 
discontinue 
• See Table 5 
• 
See Table 5 
All other 
immune-related 
AEs 
Intolerable/ 
persistent 
Grade 2 
Withhold 
• Based on type and 
severity of AE 
administer 
corticosteroids  
• 
Ensure adequate evaluation to 
confirm etiology and/or exclude 
other causes 
 
Grade 3 
Withhold or 
discontinue based 
on the type of 
event.  Events that 
require 
discontinuation 
include and not 
limited to:  
Gullain-Barre 
Syndrome, 
encephalitis 
Grade 4 or 
recurrent 
Grade 3  
Permanently 
discontinue 






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Event 
Grade 
Action to Be Taken  
Infusion-Related Reactions 
 
 
Infusion-related 
symptoms 
Grades 1−2   
Decrease infusion rate by 50% or interrupt infusion for 
patients who experience any other infusion-related 
symptoms (e.g., chills, fever). 
When symptoms have completely resolved, infusion 
may be restarted at ≤ 50% of prior rate and increased in 
50% increments every 30 minutes as tolerated.  
Infusions may be restarted at the full rate at the next 
cycle, with appropriate monitoring. In the event of a 
true hypersensitivity reaction (in which the severity of 
reaction increases with subsequent infusions) to T-
DM1 treatment, the respective agent must be 
permanently discontinued, and pembrolizumab must be 
discontinued as well. 
 
Supportive care with oxygen, β-agonists, 
antihistamines, antipyretics, or corticosteroids may be 
used as appropriate at the investigator's discretion. 
Premedication with corticosteroids, antihistamines, and 
antipyretics may be used before subsequent infusions at 
the investigator’s discretion. 
Patients should be monitored until complete resolution 
of symptoms. 
 
Grade ≥ 3 
allergic/hyperse
nsitivity 
reaction   
 
Stop infusion; discontinue all study treatment 
permanently. 
 
Supportive care with oxygen, β-agonists, 
antihistamines, antipyretics, or corticosteroids may be 
used, as appropriate, at the investigator's discretion. 
Patients should be monitored until complete resolution 
of symptoms. 
Paresthesias/ Dysesthesias 
(Persistent for > 7 Days or 
Caused the Next Cycle to be 
Delayed) 
Grade 1 or 2 
No dose modification 
Grade 3 or 4 
Withhold all study therapy dose until 
neuropathy < Grade 3 
 
Reduce T-DM1 one dose level. 
 
Discontinue all study therapy if event does not resolve 
to Grade < 3 within 42 days. 
Ejection fraction decreased  Asymptomatic 
decrease in LVEF 
See Figure 1 for dose modifications 
Grade 3 or 4 
Discontinue all study treatment.   
Heart Failure  
Grade 3 or 4 
Discontinue all study treatment.   
Heart Failure Accompanied 
by LVEF <45% 
Grade 2-4 
Discontinue all study treatment.   


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Nodular regenerative 
hyperplasia (NRH) 
 
For any clinical signs of liver dysfunction, discontinue 
T-DM1 and pembrolizumab and have the patient 
evaluated by a hepatologist.  If there are signs of portal 
hypertension (e.g., ascites and/or varices) and a 
cirrhosis-like pattern is seen on CT scan of the liver, 
the possibility of NRH should be considered.  For liver 
biopsy guidelines, please see Appendix D.  All protocol 
treatment should be discontinued in the event of a 
diagnosis of NRH. 
 
Neutropenia 
Grade 3 
Hold all study treatment until recovered to >1000K/uL. 
Assess ANC weekly or as medically indicated until 
recovery.  Resume treatment without dose reduction.   
Grade 4 
Hold all study treatment until recovered to >1000K/uL. 
Assess ANC weekly or as medically indicated until 
recovery.  Reduce T-DM1 one dose level.   
Thrombocytopenia 
Grade 2 or 3 on 
day of 
scheduled 
treatment 
Hold all study treatment until recovered to Grade ≤ 1. 
Assess platelet counts weekly or as medically indicated 
until recovery.  Resume treatment without dose 
reduction.  If a patient requires two delays due to 
thrombocytopenia, consider reducing dose by one level. 
Grade 4 at any 
time 
Hold all study treatment until recovered to  >75,000/μl. 
Assess platelet counts weekly or as medically indicated 
until recovery. Reduce T-DM1 by one dose level. If 
event occurs with 3.0 mg/kg dose, discontinue all 
protocol treatment. 
 
 
 
 


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Figure 1: Management of T-DM1 based on LVEF assessments 
 
 
LVEF = left ventricular ejection fraction; EF = ejection fraction % points 
Note:  Baseline refers to the screening LVEF.  
a Three intermittent holds of study treatment will lead to discontinuation. 
 
Dose reduction levels for T-DM1 
 
Dose level reductions for on-protocol toxicity of T-DM1 are listed in Table 7.  If participants 
require a dose reduction during protocol therapy, they will not be allowed to re-escalate the dose 
of T-DM1. 
 
Table 7: Dose reduction for T-DM1 
 
Dose Level 
Dose 
   1 
3.6 mg/kg 
− 1 
3.0 mg/kg 
Indication for further dose reduction 
Off study treatment  
 


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6.3 
Management of toxicities attributable to both pembrolizumab and T-DM1 
 
There are two types of uncommon toxicity that have been previously described in patients on 
both single agent pembrolizumab and single agent T-DM1: (1) hepatotoxicity, specifically 
manifesting as elevated AST, ALT, or total bilirubin; and (2) pneumonitis.  Dose modifications 
for these toxicities are addressed in this Section.  
 
Event 
Grade 
Action To Be Taken 
AST/ALT elevation without 
total bilirubin elevation, in a 
patient without liver 
metastases 
2 – first occurrence 
Hold both drugs until return to 
baseline or ≤Grade 1 and then 
restart both drugs (at the previous 
doses).  Recheck lab value weekly 
or as medically indicated.  
Recommendations for supportive 
care (steroid dosing) are above, in 
Section 6.1.  If toxicity takes >12 
weeks to resolve, permanently 
discontinue pembrolizumab. 
2- second occurrence and 
beyond 
Hold both drugs until return to 
baseline or ≤Grade 1. Restart T-
DM1 only (at the previous dose).  
Permanently discontinue 
pembrolizumab.  Recheck lab 
value weekly or as medically 
indicated.  Recommendations for 
supportive care (steroid dosing) 
are above, in Section 6.1.   
3 
Hold both drugs until return to 
baseline or ≤Grade 1. Restart T-
DM1 with dose reduction.  
Permanently discontinue 
pembrolizumab.  Recheck lab 
value weekly or as medically 
indicated.  Recommendations for 
supportive care (steroid dosing) 
are above, in Section 6.1. 
4 
Discontinue all study treatment 
permanently.  Recommendations 
for supportive care (steroid 
dosing) are above, in Section 6.1.   
AST/ALT elevation without 
total bilirubin elevation, in a 
patient with liver 
Same grade as baseline 
Maintain dose levels with LFTs2 
monitored per protocol. 
Increase of one grade 
Hold both drugs until return to 


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metastases 
from baseline – first 
occurrence 
baseline grade. Restart both drugs 
(at the same doses).  Recheck lab 
value weekly or as medically 
indicated.  Recommendations for 
supportive care (steroid dosing) 
are above, in Section 6.1.   
 
If toxicity takes >12 weeks to 
resolve, permanently discontinue 
pembrolizumab. 
Increase of one grade 
from baseline – second 
occurrence 
Hold both drugs until return to 
baseline grade and then restart T-
DM1 only at the same dose.  
Permanently discontinue 
pembrolizumab.  Recheck lab 
value weekly or as medically 
indicated.  Recommendations for 
supportive care (steroid dosing) 
are above, in Section 6.1.   
Increase of two grades 
from baseline 
Hold both drugs until return to 
baseline grade. Restart T-DM1 
only with a dose reduction.  
Permanently discontinue 
pembrolizumab.  Recheck lab 
value weekly or as medically 
indicated.   
Recommendations for supportive 
care (steroid dosing) are above, in 
Section 6.1. 
4 
Discontinue all study treatment 
permanently.   
Recommendations for supportive 
care (steroid dosing) are above, in 
Section 6.1.   
Total bilirubin elevation 
without transaminase 
elevation (see legend for 
special considerations for 
Gilbert’s Syndrome)1 
2 – first occurrence 
Hold both drugs until return to 
baseline or ≤Grade 1.  Restart 
both drugs (at the previous doses).  
Recheck lab value weekly or as 
medically indicated.  
Recommendations for supportive 
care (steroid dosing) are above, in 
Section 6.1.   
 
If toxicity takes >12 weeks to 
resolve, permanently discontinue 
pembrolizumab. 


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2- second occurrence and 
beyond 
Hold both drugs until return to 
baseline or ≤Grade 1. Restart T-
DM1 only (at the same dose).  
Permanently discontinue 
pembrolizumab.  Recheck lab 
value weekly or as medically 
indicated.  Recommendations for 
supportive care (steroid dosing) 
are above, in Section 6.1.   
 
 
 
 
3 and 4 
Discontinue all study treatment 
permanently.  Recommendations 
for supportive care (steroid 
dosing) are above, in Section 6.1.   
AST or ALT >3.0x upper 
limit of normal (ULN), AND 
total bilirubin >2.0x ULN 
(regardless of presence of 
liver metastases) 
N/A 
Discontinue all study treatment 
permanently.  Recommendations 
for supportive care (steroid 
dosing) are above, in Section 6.1.   
Pneumonitis 
2 – first occurrence 
Hold both drugs until pneumonitis 
improves to baseline or ≤Grade 1. 
Restart T-DM1with a dose 
reduction.  Restart 
pembrolizumab at same dose 
unless toxicity does not resolve 
within 12 weeks of last dose or 
the corticosteroid dose is unable 
to be reduced to ≤10 mg of 
prednisone (or equivalent) per day 
within 12 weeks. 
2 – second occurrence 
Hold both drugs until pneumonitis 
improves to baseline or ≤Grade 1.  
Restart T-DM1 with a dose 
reduction.  Permanently 
discontinue pembrolizumab. 
3 and 4 
Discontinue all study treatment 
permanently.   
Recommendations for supportive 
care (steroid dosing) are above, in 
Section 6.1.   
1In a patient with known Gilbert’s Syndrome, an additional elevation of 0.5 mg/dL in total 
bilirubin is allowed in each case. 
2LFTs include ALT, AST, alkaline phosphatase, total bilirubin. 
 
7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 


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following list of reported and/or potential AEs (Section 7.1) and the characteristics of an 
observed AE (Section 7.2) will determine whether the event requires expedited reporting in 
addition to routine reporting. 
 
 
7.1 
Expected Toxicities 
 
 
7.1.1 
Adverse Events Lists 
 
7.1.1.1 
Adverse Event List for Pembrolizumab 
 
In the pembrolizumab monotherapy trials (P001/P002, P012, P013, and P028, plus the P011 
monotherapy arm), the overall incidence of AEs ranged from 83.0% (73 of 88 subjects in P012) 
to 100% (10 of 10 subjects in P011). The most commonly reported AEs included fatigue, 
diarrhea, decreased appetite, nausea, and anemia. The incidence of drug –related AEs (DRAEs) 
ranged from 39.8% (35 of 88 subjects in P013) to 80.0% (8 of 10 subjects in P011). The most 
commonly reported DRAEs across all studies were nausea, fatigue, and diarrhea. The incidence 
of Grade 3-5 DRAEs across studies ranged from 6.8% (6 of 88 in P013) to 12.0% (187 of 1562 
subjects) in P001/P002. The most commonly reported Grade 3-5 DRAEs were anemia, alanine 
aminotransferase elevation, and aspartate aminotransferase elevation. Most subjects who 
experienced an AE continued in the study, with the incidence of AEs leading to discontinuation 
ranging from 1.9% (8 of 430 subjects in P028) to 12.3% (192 of 1562 subjects in P001/P002). 
The majority of AEs leading to discontinuation were not considered drug related. 
Discontinuations due to a DRAE were infrequent and ranged from 0% (no subjects in P011) to 
4.5% (4 of 88 subjects in P013). The most commonly reported DRAEs leading to discontinuation 
were pneumonitis, alanine aminotransferase elevation, and aspartate aminotransferase elevation. 
 
List of AEs considered expected:  
• Endorcine disorders: Adrenal insufficiency, Hyperthyroidism, Hypophysitis, 
Hypopituitarism, Hypothyroidism, Secondary adrenal insufficiency, Thyroid disorder 
• Eye disorders: Uveitis 
• Gastrointestinal disorders: Abdominal pain, Colitis, Diarrhea, Pancreatitis 
• General disorders and administration site conditions: Asthenia, Pyrexia 
• Hepatobiliary disorders: Autoimmune hepatitis, Hepatitis 
• Infusion related reaction 
• Metabolism and nutrition disorders: Diabetic ketoacidosis, Hyponatremia, Type 1 
diabetes mellitus 
• Musculoskeletal and connective tissue disorders: Arthralgia, Back pain,  Myositis 
• Nervous system disorders: Guillain-Barré syndrome 
• Renal and urinary disorders: Nephritis 
• Respiratory, thoracic and mediastinal disorders: Cough,  Pneumonitis 
• Skin and subcutaneous tissue disorders: Pruritis, Rash, Severe skin reaction, Vitiligo 
 
 


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7.1.1.2 
Adverse Event List(s) for T-DM1 
 
Identified and potential risks of treatment with T-DM1 are based on all available nonclinical 
and clinical data relating to T-DM1 as well as clinical toxicities related to its components 
(trastuzumab and maytansine), in addition to other DM1-containing ADCs.   
 
Pulmonary toxicity, hepatotoxicity, cardiac toxicity (left ventricular dysfunction), infusion-
related reaction/hypersensitivity, thrombocytopenia (including thrombocytopenia associated 
with severe hemorrhage), and peripheral neuropathy are important identified risks with T-DM1 
and are detailed in the subsections below.  Fetal harm and impaired fertility are important 
potential risks with T-DM1. Guidance on dose modifications are provided in Section 6. 
 
Please refer to the Investigator’s Brochure for a full description of the T-DM1 safety profile, 
warnings, precautions, and guidance. 
 
Pulmonary Toxicity 
Cases of interstitial lung disease (ILD), including pneumonitis, some leading to acute 
respiratory distress syndrome or fatal outcome, have been reported in clinical trials with T-
DM1.  Signs and symptoms include dyspnea, cough, fatigue, and pulmonary infiltrates.  These 
events may or may not occur as sequelae of infusion reactions.  Patients with dyspnea at rest as 
a result of complications of advanced malignancy and/or comorbidities may be at increased risk 
of pulmonary events.  Treatment has included administration of steroids and oxygen, as well as 
study drug discontinuation.  
 
Hepatotoxicity 
Hepatotoxicity, predominantly in the form of asymptomatic increases in the concentrations of 
serum transaminases (Grade 1−4 transaminitis), has been observed in patients treated with T-
DM1.  Transaminase elevations were generally transient with peak elevation at Day 8 after 
therapy administration and subsequent recovery to Grade 1 or less prior to the next cycle.  The 
incidence of increased AST was substantially higher than that for ALT.  A cumulative effect of 
T-DM1 on transaminases has been observed:  the proportion of patients with Grade 1 or 2 
elevated transaminases increases with successive cycles; however, no increase in the proportion 
of Grade 3 abnormalities over time was observed.  The majority of patients with elevated 
transaminases improved to Grade 1 or normal within 30 days of the last dose of T-DM1. 
 
Rare cases of severe hepatotoxicity, including death due to drug-induced liver injury (DILI) and 
associated hepatic encephalopathy, have been observed in patients treated with T-DM1.  While 
there is evidence of drug induced liver toxicity in patients treated with T-DM1, its potential to 
cause acute severe liver injury with clinically meaningful changes in liver function is unclear, as 
the observed cases may have been confounded by concomitant medications with known 
hepatotoxic potential and/or underlying conditions.  A contributory role of T-DM1 in these 
cases cannot be excluded so acute severe liver injury (Hy’s law) remains an important potential 
risk with T-DM1.  A Hy’s law case has the following components: 
 


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1. Aminotransferase enzymes are greater than 3 × ULN with concurrent 
elevation of serum TBILI to > 2 × ULN, without initial findings of 
cholestasis (elevated serum alkaline phosphatase). 
2. No other reason can be found to explain the combination of increased 
aminotransferases and serum TBILI, such as viral hepatitis A, B, or C; 
preexisting or acute liver disease; or another drug capable of causing the 
observed injury. 
3. Gross jaundice, clinical disability, or the need for hospital care and should be 
at least probably drug-induced (by T-DM1). 
 
Cases of nodular regenerative hyperplasia (NRH) of the liver have been identified from liver 
biopsies in patients treated with T-DM1 and presenting with signs and symptoms of portal 
hypertension.  NRH is a rare liver condition characterized by widespread benign transformation 
of hepatic parenchyma into small regenerative nodules; NRH may lead to non-cirrhotic portal 
hypertension and also may be fatal.36  NRH should be considered in patients who develop 
clinical symptoms of portal hypertension and/or a cirrhosis-like pattern seen on CT scan of the 
liver but with normal transaminases and no other manifestations of cirrhosis or liver failure 
following long-term treatment with T-DM1.  Diagnosis of NRH can only be confirmed by 
histopathology. 
 
Cardiac Toxicity 
Patients treated with T-DM1 are at increased risk of developing left ventricular dysfunction.  
LVEF < 40% has been observed in patients treated with T-DM1.   
 
Infusion-Related Reactions (IRRs)/Hypersensitivity 
Infusion-related reactions (anaphylactoid/cytokine release reactions) and hypersensitivity 
(anaphylactic/allergic reactions) may occur with the administration of monoclonal antibodies 
and have been reported with T-DM1.  Treatment with T-DM1 has not been studied in patients 
who had trastuzumab permanently discontinued due to an IRR/hypersensitivity; treatment with 
T-DM1 is not recommended for these patients.   
 
Infusion-related reactions (IRRs), characterized by one or more of the following symptoms-
flushing, chills, pyrexia, dyspnea, hypotension, wheezing, bronchospasm, and tachycardia-have 
been reported in clinical trials of T-DM1.  In general, these symptoms were not severe.  In most 
patients, these reactions resolved over the course of several hours to a day after the infusion was 
terminated.  Serious hypersensitivity (anaphylactic-like reactions) has been observed in clinical 
trials of T-DM1.   
 
Patients will be observed closely for infusion related/hypersensitivity reactions during and after 
each T-DM1 infusion as detailed in Section 5.3.2.  Pre-medication is allowed according to 
standard practice guidelines.  In the event of a true hypersensitivity reaction (in which severity 
of reaction increases with subsequent infusions), T-DM1 treatment must be permanently 
discontinued. 
 
Thrombocytopenia 
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DM1.  The majority of these patients had Grade 1 or 2 events (≥ 50,000/mm3), with the nadir 
occurring by Day 8 and generally improving to Grade 0 or 1 (≥ 75,000/mm3) by the next 
scheduled dose.  In clinical trials, the incidence and severity of thrombocytopenia were higher 
in Asian patients.  In Study TDM4370g, the incidence of thrombocytopenia in Asian patients 
was higher (52.5%) compared with the overall population (30.4%).  However, the incidence rate 
of Grade ≥ 2 hemorrhage did not increase in Asian patients compared to the overall population. 
Rare cases of bleeding events with a fatal outcome have been observed.  Cases of severe 
hemorrhagic events, including central nervous system hemorrhage, have been reported in 
clinical trials with T-DM1.  In some of the observed cases the patients were also receiving anti-
coagulation therapy.  Patients on anti-coagulant treatment have to be monitored closely during 
treatment with T-DM1.  Platelet counts will need to be monitored prior to each T-DM1 dose.   
 
Peripheral neuropathy  
Peripheral neuropathy, mainly Grade 1 and predominantly sensory, has been reported in clinical 
trials of T-DM1.  These events were most apparent in patients with preexisting neuropathy. 
There have been no serious events of neuropathy, but there has been 1 patient to date who 
experienced a Grade 3 peripheral neuropathy. Once the AE resolved, the patient continued on 
study drug. One additional patient required a dose reduction for a Grade 2 peripheral neuropathy. 
Patients should be clinically monitored on an ongoing basis for signs/symptoms of 
neurotoxicity.   
 
Dose delay and modification guidelines can be found in Section 6. 
 
Please refer to the Full Prescribing Information for T-DM1 for complete safety information: 
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/.   
 
 
7.2 
 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 
4.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be 
downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic applications/ctc.htm. 
 
 
• 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. 
 






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*Note:  These criteria are based upon available regulatory guidance documents. The purpose 
of the criteria is to specify a threshold of abnormal hepatic tests that may require an 
additional evaluation for an underlying etiology.  
 
7.6.2 
Definition of an Overdose of Pembrolizumab for This Protocol and Reporting of Overdose to 
 
 
For purposes of this trial, an overdose of pembrolizumab will be defined as any dose of 1,000 mg 
or greater.  No specific information is available on the treatment of overdose of pembrolizumab. 
Appropriate supportive treatment should be provided if clinically indicated. In the event of 
overdose, the subject should be observed closely for signs of toxicity.  Appropriate supportive 
treatment should be provided if clinically indicated. 
 
If an adverse event(s) is associated with (“results from”) the overdose of a 
product, the 
adverse event(s) is reported as a serious adverse event, even if no other seriousness criteria are 
met. 
 
If a dose of 
’s product meeting the protocol definition of overdose is taken without any 
associated clinical symptoms or abnormal laboratory results, the overdose is reported as a non-
serious Event of Clinical Interest (ECI), using the terminology “accidental or intentional 
overdose without adverse effect.” 
 
All reports of overdose with and without an adverse event must be reported within 24 hours to 
the Sponsor and within 2 working days hours to 
. 
 
 
 
 
7.6.3 
Reporting of Pregnancy and Lactation to 
 
 
Although pregnancy and lactation are not considered adverse events, it is the responsibility of 
investigators or their designees to report any pregnancy or lactation in a subject (spontaneously 
reported to them) that occurs during the trial. 
Pregnancies and lactations that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be 
excluded from the trial, or are the result of a protocol-specified intervention, including but not 
limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure.   
Pregnancies and lactations that occur from the time of treatment allocation/randomization 
through 120 days following cessation of Sponsor’s product, or 30 days following cessation of 
treatment if the subject initiates new anticancer therapy, whichever is earlier, must be reported 
by the investigator.  All reported pregnancies must be followed to the completion/termination of 
the pregnancy. Pregnancy outcomes of spontaneous abortion, missed abortion, benign 
hydatidiform mole, blighted ovum, fetal death, intrauterine death, miscarriage and stillbirth must 
be reported as serious events (Important Medical Events). If the pregnancy continues to term, 
the outcome (health of infant) must also be reported. 
Such events must be reported within 24 hours to the Sponsor and within 2 working days to 


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Global Safety. (
 
 
7.7 
Routine Adverse Event Reporting 
 
All Grade 2 or higher Adverse Events must be reported in routine study data submissions to the 
Overall PI on the toxicity case report forms.  AEs reported through expedited processes (e.g., 
reported to the IRB, FDA, etc.) must also be reported in routine study data submissions. 
 
 
8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational agents 
administered in this study can be found in Section 7.1. 
 
8.1 
Pembrolizumab 
 
8.1.1 
Description 
 
Pembrolizumab is a humanized monoclonal antibody of the IgG4/kappa isotype.  Other 
names: MK-3475, Keytruda™.  Pembrolizumab blocks negative immune regulatory 
signaling by binding to the PD-1 receptor, inhibiting the interaction between PD-1 and its 
ligands. 
 
The molecular weight of pembrolizumab is 148.9-149.5 KDa. 
 
8.1.2 
Form 
 
Clinical supplies will be manufactured and provided by 
as summarized in Table 7. 
 
Table 7:  Product Description 
Product Name & Potency 
Dosage Form 
Pembrolizumab 100 mg/ 4mL 
Solution for Injection 
 
8.1.3 
Storage and Stability 
 
Store intact vials between 2°C-8°C (36°F-46°F).  Do not freeze.  Protect from light by 
storing in the original box. 
 
Stability testing of the intact vials is ongoing. 
 
Administer prepared solutions immediately after preparation.  If not administered 
immediately, prepared solutions may be stored refrigerated for a total cumulative storage 
time at room temperature and refrigeration of 24 hours.  Pembrolizumab solutions may be 
stored at room temperature for a cumulative time of up to 6 hours.  This includes room 
temperature storage of liquid drug product solution in vials, room temperature storage of 


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infusion solution in the IV bag, and the duration of infusion. 
 
 
8.1.4 
Compatibility 
 
Compatible IV bag materials: PVC plasticized with DEHP, non-PVC (polyolefin), EVA, 
or PE lined polyolefin. 
 
8.1.5 
Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.1.6 
Availability 
 
Pembrolizumab is an investigational agent and will be supplied free of charge from 
 
 
8.1.7 
Preparation 
 
Pembrolizumab solution for infusion must be diluted prior to administration.  Allow the 
required number of vials to equilibrate to room temperature.  Do not shake the vials.  Do 
not use if opaque or extraneous particulate matter other than translucent to white 
proteinaceous particles is observed.  Do not use if discolored.  To prepare the infusion 
solution add the dose volume of pembrolizumab to an infusion bag containing 0.9% 
Sodium Chloride Injection, USP of 5% Dextrose Injection, USP.  Gently invert the bag 
10-15 times to mix the solution.  The final concentration must be between 1 mg/mL to 
10 mg/mL. 
 
8.1.8 
Administration 
 
Route of administration: IV infusion only.  Do not administer as an IV push or bolus 
injection. 
 
Method of administration: Infuse over approximately 30 minutes (range: 25-40 minutes) 
using an infusion set containing a low-protein binding 0.2 to 5 m in-line filter make of 
polyethersulfone or polysulfone.  Infusion rate should not exceed 6.7 mL/min.  A central 
line is not required however if a subject has a central venous catheter in place, it is 
recommended that it be used for the infusion.  Do not co-administer drugs through the 
same infusion line.  Following the infusion, flush the IV line with normal saline. 
 
8.1.9 
Ordering 
 
Pembrolizumab will be obtained directly from 
the study sponsor. 
 


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8.1.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, should maintain a 
careful record of the inventory and disposition of the agent using the NCI Drug 
Accountability Record Form (DARF) or another comparable drug accountability form.  
(See the NCI Investigator’s Handbook for Procedures for Drug Accountability and 
Storage.) 
 
8.1.11 Destruction and Return 
 
At the end of the study, unused supplies of pembrolizumab should be destroyed 
according to institutional policies. Destruction will be documented in the Drug 
Accountability Record Form. 
 
8.2 
T-DM1 
Please refer to the Investigator’s Brochure for detailed agent information, and to the FDA label 
for additional information. 
 
8.2.1 
Formulation, Preparation, and Storage 
 
Trastuzumab-MCC-DM1 (trastuzumab emtansine, T-DM1) is provided as a single-use 
lyophilized formulation in a colorless 20-mL Type I glass vial closed by means of a 
FluroTec-coated stopper and an overseal with flip-off cap.  Upon receipt of T-DM1 vials 
should be refrigerated at 2°C–8°C. All vials of T-DM1 should be handled by appropriately 
trained site staff wearing gloves and visually inspected upon receipt to ensure they are 
intact without exterior contamination. Drug from any vials that appear abnormal upon 
inspection should not be administered to patients. 
 
The lyophilized product should be reconstituted using Sterile Water for Injection (SWFI).  
Using a new syringe, 8mL SWFI should be added to the vial and the vial swirled gently 
until the product is completely dissolved. The vial should not be shaken.  The resulting 
product contains 20 mg/mL T-DM1, 10 mM sodium succinate, pH 5.0, 60 mg/mL sucrose, 
and 0.02% (w/v) polysorbate 20. Each 20 mL vial contains enough T-DM1 to allow 
delivery of 160 mg T-DM1.  The reconstituted product contains no preservative and is 
intended for single use only. The vial should be inspected to ensure the reconstituted 
product is a clear colorless solution, and is free of particulates before proceeding.  Drug 
from any vial that appears abnormal upon inspection should not be administered to patients.  
Using a new syringe, the indicated volume of T-DM1 solution should be removed from the 
vial(s) and added to the IV bag containing at least 250 mL of 0.45% sodium chloride 
(preferred) or 0.9% sodium chloride injection and gently inverted to mix the solution.  A 
0.22 micron non-protein adsorptive polyethersulfone (PES) in-line filter is recommended 
when using 0.45% sodium chloride and required when using 0.9% sodium chloride 
injection.  The solution of T-DM1 should not be shaken.  
 
The solution of T-DM1 for infusion should be used immediately.  If not used immediately, 
storage times should not be longer than 24 hours at 2°C−8°C (36°F−46°F) for solutions of 


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T-DM1 diluted in polyvinyl chloride (PVC) or latex-free PVC-free polyolefin, 
polypropylene, or polyethylene bags containing 0.45% or 0.9% Sodium Chloride Injection, 
USP.   
 
For additional details, please refer to the current version of the T-DM1 Investigator 
Brochure. 
 
8.2.2 
Compatibility 
 
T-DM1 has no known compatibility problems. For additional details, see the T-DM1 
Investigator Brochure. 
 
8.2.3 
Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to themselves 
and the environment, should undertake the preparation, handling, and safe disposal of the 
chemotherapeutic agent in a self-contained and protective environment.  
 
8.2.4 
Availability 
 
T-DM1 will be obtained from commercial supply, as it is being used per the FDA label. 
 
8.2.5 
Administration 
 
The first infusion of T-DM1 will be administered over 90 minutes (± 10 minutes).  
Infusions may be slowed or interrupted for patients experiencing infusion-associated 
symptoms.  Vital signs must be assessed before and after dose administration.  Following 
the initial dose, patients will be observed for at least 60 minutes for fever, chills, or other 
infusion-associated symptoms.  If prior infusions were well tolerated (without any signs or 
symptoms of infusion reactions), subsequent doses of T-DM1 may be administered over 
30 minutes (± 10 minutes), with a minimum 30-minute observation period after infusion. 
 
8.2.6 
Ordering 
 
T-DM1 will be ordered and supply maintained as per standard practices of the Dana-
Farber pharmacy. 
 
8.2.7 
Drug Accountability 
 
The investigator, or a responsible party designated by the investigator, will maintain a 
careful record of the inventory and disposition of the agent using the NCI Drug 
Accountability Record Form (DARF) or another comparable drug accountability form. 
 
8.2.8 
Destruction and Return 
 
T-DM1 should be destroyed according to institutional policies. Destruction will be 


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documented according to institutional policies. 
 
 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
All patients will be asked to provide archival tumor tissue (either paraffin blocks or 15 unstained 
slides, ideally 4 micron thickness).  However, if archival tissue is not available or not evaluable, 
that will not be a basis to exclude the patient from any portion of the trial or the planned analysis.  
Archival tissue will be used for immune profiling assays to ascertain baseline values in patients 
who choose not to undergo baseline research fresh tissue biopsy (in the dose de-escalation 
cohort) or in whom there is insufficient tissue or failed testing of any of the planned assays from 
baseline fresh tissue biopsy. 
 
A baseline research biopsy prior to study therapy is required in the expansion cohort of this trial, 
and optional in the dose de-escalation cohort.  We plan to use baseline biopsy tissue to perform a 
number of immune profiling assays. On baseline tumor biopsies, we will perform 
characterization based on histology (TILs), protein expression, and mRNA expression.   
 
An optional research biopsy after 6 weeks on protocol therapy will be collected for patients who 
consent and have biopsy accessible tumor.  These biopsies will undergo the same 
characterization testing as described for baseline biopsies.  
 
Serial blood draws for correlative science are required on this trial; blood draws will be obtained 
every 3 weeks on treatment days, prior to the infusion of study drugs, at the end-of-treatment 
visit in patients who go off study for progressive disease, and all efforts will be made to obtain a 
sample at the time of progressive disease from participants who went off study for anything other 
than progressive disease.  We will perform flow cytometry on these samples to characterize 
protein expression of immune mediators.  Circulating free DNA will be assessed as well.   
 
If participants agree, a portion of these specimens will be banked for possible future genomic 
analysis, and other further testing. 
 
All patients will additionally be asked to provide a stool sample at three separate timepoints: 
prior to treatment, during treatment, and at the time of disease progression. A fourth collection 
may be requested from patients who experience grade ≥ 2 diarrhea after discussion with the PI. 
This collection is not required, but is strongly encouraged. These samples will be analyzed for 
microbiota content. Please refer to the separate laboratory manual for stool details including 
specific collection, processing, and shipping instructions. 
 
 
9.1 
Summary table: research tissue and blood specimen collection 
 
Research 
Sampling 
Time point 
Contents 
Blood  
Cycle 1 Day 1 
1-10 mL Streck Tube 










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Deliver to:  
Dana-Farber Cancer Institute 
Attn: Lynda Chichester 
Smith 9th Floor, Rm 930 
450 Brookline Avenue 
Boston, MA 02215 
dfcibreastbank@partners.org  
 
Email the blood bank (dfcibreastbank@partners.org) and the current Dana-Farber CRC with the 
sample information and tracking information the day before transporting specimens. 
 
 
9.3.2 
Sites Performing Correlative Studies 
 
 
DFCI Center for Immuno-Oncology  
 
DFCI Clinical Trials Core Laboratory 
 
9.3.3 
Blood and tissue banking 
 
Any leftover blood or tissue will be banked in the lab of 
 and/or the DF/HCC 
Clinical Trials Core Laboratory such that it can be used for additional or future analyses as 
needed. 
 
9.4 
Stool Collection 
 
9.4.1 
Handling and Shipping 
 
All stool samples will be collected by each patient at home using a home-based kit with a pre-
paid mailer that provides nearly equivalent metagenomic and metatranscriptomic data to state-of-
the-art fresh-frozen sample-collection protocol.  Patients will be asked to provide samples at the 
following timepoints: 
 
• Baseline 
• After two cycles of therapy 
• At the time of disease progression 
• Optional collection at the time of grade ≥ 2 diarrhea 
 
Most kits will be provided to the patients at their clinic visits. If the study team is unable to 
provide the kits to the patients in clinic, they may be mailed to patients by members of the study 
team. All kits will contain a questionnaire for patients to complete and return with their samples 
regarding timing and conditions surrounding their stool sample.  
 
Please refer to the separate lab manual for collection and processing instructions. 
 
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by the biorepository to an external lab vendor, Microbiome Dx, who will perform the analysis of 
the samples. 
 
9.4.2 
Sites performing correlative studies 
 
• BWH/Harvard Cohorts Biorepository 
• Microbiome Dx 
 
 
9.5 
Hypotheses for correlative objectives 
 
• We hypothesize that all breast tumors can be placed in a baseline category of general 
“immune activity” level based on histologic, protein-based, and genomic analyses. 
• We hypothesize that breast tumors with a higher level of “immune activity” at baseline, 
as assessed by the mentioned analyses, will have a higher likelihood of responding to 
treatment with T-DM1 plus pembrolizumab. 
• We hypothesize that tumors with a more significant change in “immune activity” over the 
course of 6 weeks of therapy with T-DM1 plus pembrolizumab will have a higher 
likelihood of benefitting from the treatment. 
• We hypothesize that the immune marker profile in the peripheral blood will change over 
the course of T-DM1 plus pembrolizumab therapy. 
• We hypothesize that a larger increase in markers of immune activity in the peripheral 
blood will correlate with a better disease response as assessed on concurrent restaging 
scans and in terms of best radiographic response at any time on trial. 
• We hypothesize that an immune marker or composite of markers in the peripheral blood 
at baseline will correspond to TIL percentage in baseline tumor biopsies. 
• We hypothesize that the structure and function of the gut microbiome differs among 
patients with breast cancer. 
• We hypothesize that the structure and function of the gut microbiome before starting 
pembrolizumab and T-DM1 can be predictive of efficacy of this therapy, with a greater 
microbial diversity, estimated by Shannon index, being predictive of efficacy. 
• We hypothesize that the structure and function of gut microbiome changes in response 
pembrolizumab-based therapy and can predict the likelihood of response to 
pembrolizumab plus T-DM1. 
• We hypothesize that the abundance and functional profile of specific gut bacteria is 
associated with response to pembrolizumab plus T-DM1. 
•  
 
9.6 
Planned assays for correlative objectives 
 
All of the below-mentioned analyses may be altered based on novel developments in the field of 
cancer immune profiling at the time of correlative science.  Additional markers or alternative 
technologies (based on scientific developments and/or novel technologies) may also be used, to 
explore potential prognostic or predictive candidate markers/panels or markers related to 
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biology. Planned collaborators include: Dana-Farber Cancer Institute, The Broad Institute of 
MIT, Brigham and Women’s Hospital, Harvard Medical School, Beth Israel Deaconness 
Medical Center, Adaptive Technologies, and Microbiome Dx. Any samples or data shared with 
collaborators external to the study team will not contain any PHI or identifying information. See 
section 12.4 for more information.  
 
9.6.1 
Tumor infiltrating lymphocyte (TIL) percentage and determination of lymphocyte predominant breast 
cancer (LPBC) 
 
Paraffinized, hematoxylin and eosin-stained slides taken from two tissue planes will be derived 
from each biopsy and will be reviewed by certified pathologists.  The extent of lymphocytic 
infiltrate in tumor tissue will be assessed and stromal TIL percentage will be determined.  More 
detailed guidelines for the quantification of stromal TILs in breast cancer can be found in the 
recommendations from the International TILs Working Group 2014.31 
 
After assessment of the TIL percentage, the specimen may be categorized as lymphocyte 
predominant breast cancer (LPBC), defined as a tumor that contains >60% stromal lymphocytes, 
or non-LPBC. 
 
9.6.2 
Immunohistochemistry 
 
Tissue will be collected and fixed by 10% neutral buffered formalin overnight, dehydrated, and 
paraffin embedded.  Four micrometer-thick sections will be cut.  The paraffin blocks and 
unstained slides will be stored at room temperature.  All immunohistochemical staining will be 
performed in the Center for Immuno-Oncology Pathology Core at Dana-Farber/Harvard Cancer 
Center (DF/HCC) Specialized Histopathology Core.  
 
Formalin fixed-paraffin embedded (FFPE) tumor slides will be prepared and H&E stained for 
assessment of TIL in pre- and post-treatment tumor samples.  To identify subsets of different 
immune populations (effector/memory CD8 cells, T regulatory cells, dendritic cells, tumor 
associated macrophages, and Tie-2 expressing monocytes (TEM)), immunohistochemical (IHC) 
staining will be performed on FFPE tumor slices using some or all of the following antibodies: 
Core set: CD8, PD-1, PD-L1, PD-L2 
Others: CD3, CD4, CD25, FoxP3, Indoleamine 2,3 deoxygenase-1 (IDO1), CD11c, CD83, 
CD86, CD56, CD14, CD16, Tie2 (See also Appendix E) 
 
Chen et al37 describe a semi-quantitative scoring method, which is in accordance with typical 
biomarker scoring in anatomic and surgical pathology.  Briefly, staining is scored according to 
intensity (0=no staining, 1=weak staining, 2=moderate staining, 3=strong staining), staining 
patter (M=predominantly cell membrane; C=predominantly cell cytoplasm), and the percentage 
of cells showing positive staining (0-100%).  The semi-quantitative scoring is performed for: 1) 
the neoplastic tumor cells and 2) the non-neoplastic infiltrating immune cells.  Significant 
discordant results have been rare during case evaluations.37 
 
It should be noted that the above staining protocols are based on standard methods used at the 
time of protocol writing.  It is possible that at the time protein expression assays are conducted, 


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novel and improved methods for staining will exist.  In this case, we plan to use the best 
available, best validated experimental method available at the time. 
 
9.6.3 
Flow cytometry, genomic analysis of biopsy stissue 
 
TILs will be isolated from the biopsy specimen and assessed by surface staining.  
 
Messenger RNA (mRNA) expression within tumor biopsy specimens will be assessed using the 
most current and informative methodologies at the time that correlative science is performed on 
all specimens.  NanoString signatures and comprehensive RNA sequencing may be used.  
Potential genes of interest, based on prior immune profiling of breast tumors,27 include CXCL9, 
CCL5, CD8ACD80, CXCL13, IGKC, CD21, IDO1, PD-1, PD-L1, PD-L2, CTLA4, and FOXP3.  
Additional DNA analysis, for example to assess mutational load and neoantigen burden, may 
also be performed. 
 
9.6.4 
Analysis of PBMCs 
 
PBMCs will be and used to assess immune cell populations by flow cytometry.  
 
9.6.5 
Analysis of cell-free DNA 
 
Blood will be collected at baseline, restaging visits and at time of progression for evaluation of 
cell-free DNA (cfDNA).  The cfDNA will be banked in the DF/HCC Clinical Trials Core 
laboratory for future research purposes.  The banked samples will be used to analyze DNA, RNA 
and protein in future studies.  
 
9.6.6 
Analysis of DNA extraction from stool samples 
 
Microbial DNA is extracted using the Mag-Bind Universal Pathogen DNA Kit (Omega Bio-
Tek). Briefly, 250 mg of the specimen is transferred to a deep-well plate for bead beating 
followed by DNA precipitation and purification following the manufacturer’s instructions. 
Finally, DNA is eluted in 100 uls of Elution Buffer and stored at -80°C until further use. 16S 
sequencing libraries are generated by amplifying the v3-v4 hypervariable regions of the 16S 
gene in a polymerase chain reaction using primers F341and R785. Resulting amplicons are 
tagged with unique molecular barcodes that are later used to demultiplex sequencing reads into 
individual sample buckets. Libraries are loaded on a MiSeq flowcell and sequenced following 
Illumina’s loading instructions. Sequence data are retrieved from the instrument by converting 
base call format files into fastq files for data processing purposes.  
 
MicrobiomeDX uses BacPro™, a proprietary algorithm, to inspect and validate sequencing files 
by employing demultiplexing, trimming, merging, and quality filtering steps. Paired sequencing 
reads are merged using an overlap of 25 bp allowing for 10 base mismatches. Merged sequences 
are dereplicated and clustered in a de-novo fashion using VSEARCH, while filtering out 
sequence chimeras and singletons. Representative sequences from each cluster are mapped 
against the SILVA database at 99% sequence identity to obtain accurate taxonomic 
classifications and relative abundances. In parallel, feature tables are constructed to derive alpha 


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diversity indices, and distance matrices are built to derive beta diversity indices. The BacProTM 
pipeline generates a comprehensive report that includes alpha diversity scores describing 
community richness and evenness, taxonomic composition with relative abundances, and beta 
diversity metrics to determine the in-between sample differences based on the bacterial 
communities identified.  
 
 
9.6.7 
Shotgun sequencing and metabolic pathway reconstruction of stool samples 
 
Stool samples from patients included in the trial will be subjected to whole genome shotgun 
sequencing. Libraries will be constructed with Illumina barcodes from the TruSeq DNA Sample 
Prep kit (Illumina) and reagents from KAPA Library Preparation kit (Kapa Biosystems), and 
then sequenced on an Illumina MiSeq platform using 2_250 nucleotide paired-end sequencing, 
according to the manufacturer’s instructions. Sequencing reads will be converted into relative 
abundances of microbial metabolic modules using HUMAnN35, the Human Microbiome Project 
metabolic reconstruction pipeline and mapped to the KEGG36. Relative species abundances will 
be calculated by the MetaPhlAn pipeline37. 
 
 


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10. STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 14 days prior to start of protocol therapy (unless 
otherwise specified).  If these screening assessments occur within 3 days before start of study 
treatment, then they may serve as the baseline Cycle 1 Day 1 values.  Scans must be done within 
28 days prior to the start of therapy. 
 
As detailed in the Study Calendar, a negative pregnancy test in women of child-bearing potential 
must be documented within 7 days before the first dose of study medication. 
 
A baseline tumor biopsy, obtained within 7 days before starting protocol therapy, is also required 
in patients in the expansion cohort, and optional in patients in the dose de-escalation cohort. 
 
In the event that the participant’s condition is deteriorating, laboratory evaluations should be 
repeated within 48 hours prior to initiation of the next cycle of therapy. 
 
Assessments must be performed prior to administration of any study agent. Study assessments 
and agents should be administered within + 3 days of the protocol-specified date, unless 
otherwise noted. 
 
 
Screenin
g 
Cycle 1 
Day 1 
Cycle 1 
Day 8a 
Cycle 1 
Day 15 a 
Cycle 2 
Day 1 
Cycle 3 
Day 1 
Cycle 4+ 
Day 1 
Off-
Treatment p 
Follow-
Up p 
Informed consent 
X 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
Concurrent medications 
X 
X-----------------------------------------------------------------------------------------X 
 
Adverse event evaluation r 
 
X------------------------------------------------------------------------------------------X 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
 
Vital signs b 
X 
X 
X 
X 
X 
X 
X 
X 
 
Weight 
X 
X 
 
 
X 
X 
X 
X 
 
Performance status 
X 
X 
X 
X 
X 
X 
X 
X 
 
NYHA classification 
X 
 
 
 
 
 
 
 
 
CBC with differential 
X 
X 
X 
X 
X 
X 
X 
X 
 
COMP c 
X 
X 
X 
X 
X 
X 
X 
X 
 
TSH, free T4 
X 
 
 
 
X 
X 
X 
 
 
Cortisols 
X 
 
 
 
X 
X 
X 
 
 
Coagulation panel d  
X 
 
 
 
 
 
 
 
 
Hepatitis Screen e 
X 
 
 
 
 
 
 
 
 
Pregnancy test f 
X 
 
 
 
 
 
 
 
 
Single, 12-lead EKG 
X 
 
 
 
 
 
 
 
 
Echocardiogram or MUGA g 
X 
 
 
 
 
 
X g 
 
 
Tumor Assessments h 
X 
 
 
 
 
X 
X 
X 
Xi 
Survival Assessments q 
 
 
 
 
 
 
 
 
X 
Tumor biopsy 
X j 
 
 
 
 
Xk 
 
 
 
Research Blood Collection l  
 
X 
 
 
X 
X 
X 
X m 
X n 
Research Stool Collection t 
X 
 
 
 
 
X 
 
X 
 
Stool Questionnaire u 
X 
 
 
 
 
X 
 
X 
 
Archival tumor tissue 
X o 
 
 
 
 
 
 
 
 
Pembrolizumab: 200mg given IV over 30 minutes (-5, +10 minute window) q3weeks on Day 1 of each cycle 
T-DM1: dose level dependent, given IV over 90 minutes (+/- 10 minute window) on Cycle 1Day 1. T-DM1 will be administered q 3 
weeks on Day 1 over 30 minutes (+/- 10 minute window) for subsequent cycles if no infusion reaction occurs.  


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a. 
Visits are required on Cycle 1 Days 8 and 15 only for participants in the dose de-escalation cohort.   
b. 
Vitals should include: diastolic and systolic blood pressure, heart rate, and temperature.  Height only required on Cycle 1 
Day 1. 
c. 
COMP should include: sodium, potassium, chloride, bicarbonate, BUN, serum creatinine, glucose, calcium, albumin, total 
protein, alkaline phosphatase, ALT, AST, total bilirubin (NOTE: the frequency of checking magnesium and phosphorus 
levels is left up to the treating provider) 
d. 
Coagulation Panel: PT/INR and PTT 
e. 
Hepatitis B surface Antibody, Hepatitis B surface Antigen, and Hepatitis C Antibody 
f. 
Female subjects of child-bearing potential, within 7 days before the first dose of study medication.  If the urine test is 
positive or cannot be confirmed as negative, then a serum test is required. 
g. 
Echocardiogram or MUGA should be performed within 28 days of registration and then at the end of every 4 cycles (every 
12 weeks).  After 24 weeks on study, echocardiogram or MUGA may be spaced to every 18 weeks. 
h. 
Baseline assessments must be done within 28 days prior to the start of therapy. Tumor assessments will be performed every 
2 cycles (6 weeks days 15-21  for the first 24 weeks.  If at 24 weeks, a participant has SD or better by RECIST the 
frequency of assessments may be reduced to every 3 cycles (9 weeks) days 15-21.  Effort should be made to use the same 
type of imaging to assess measurable lesions at baseline and in follow-up. 
i. 
During follow-up of patients who went off study for reasons other than PD, tumor assessments should continue every 6 to 9 
weeks from the date of the last assessment until progressive disease is documented 
j. 
Baseline biopsy should be obtained within 7 days of initiating protocol therapy.  This biopsy is optional for participants in 
the dose-descalation cohort but mandatory in the dose expansion cohort. See Section 9.1 for biopsy handling and processing 
instructions. 
k. 
Optional tumor biopsy after 6 weeks on treatment therapy (i.e. at cycle 3 day 1, or within 5 days prior).   
l. 
Research blood collection for immune cells and cfDNA.  See Section 9 for additional blood handling and processing 
instructions  
m. 
Research blood should only be collected on patients who come off treatment for progressive disease. 
n. 
Optional blood collection for immune cells/cfDNA may be offered to patients who develop progressive disease during 
follow-up.   
o. 
All patients will also be asked to provide archival tumor tissue (either paraffin blocks or 15 unstained slides).  However, if 
archival tissue is not available or not evaluable, that will not be a basis to exclude the patient from any portion of the trial or 
the planned analysis 
p. 
Off-treatment visit is to occur within 21 days of last dose.  End of treatment assessments do not have to be repeated if the 
same assessments were performed within 7 days prior to the visit (28 days for tumor assessments)).  If study treatment is 
discontinued for PD, then tumor assessments are not required for that study participant. 
q. 
Survival status should be collected annually, either by review of the medical record or by phone call (see Section 5.7). 
r. 
SAEs and ECIs need to be collected and reported up to 30 days post treatment to meet the DF/HCC reporting requirements 
and for 
 they need to be reported from the time consent is signed through 90 days following cessation of treatment 
(120 days for pregnancy and lactations), or the initiation of new anti-cancer therapy, whichever is earlier. 
s. 
Cortisol may be drawn at any time of day, at baseline and on every Day 1. 
t. 
Baseline stool collection should be obtained within 28 days before starting protocol therapy. The C3D1 stool collection 
should be performed as close to C3D1 as possible, but may be collected up to 14 days prior. A sample will additionally be 
collected at the time of disease progression. An optional stool sample may be collected at the time of grade ≥ 2 diarrhea 
after discussions with the PI. As these collections are for exploratory correlative purposes, failure to provide a sample at 
these timepoints will not constitute a protocol violation. See section 9 and/or lab manual for stool collection and processing 
instructions. 
u. 
Each stool collection kit will contain a questionnaire for the patients to complete regarding the conditions surrounding their 
collection. These will be a part of the kit and are not to be administered in clinic. Failure to complete these questionnaires at 
the required or optional timepoints will not constitute a protocol violation.  
  
 
11. MEASUREMENT OF EFFECT 
 
Although response is not the primary endpoint of this trial, participants with measurable disease 
will be assessed by standard criteria.  For the purposes of this study, participants should be re-
evaluated every 6 weeks for the first 24 weeks and then every 9 weeks until progression. 
 
11.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, participants should be re-evaluated for response every 6 weeks for 
the first 24 weeks and then every 9 weeks until progression.  In addition to a baseline scan, 
confirmatory scans should also be obtained 9 weeks (+/- 7 days) following initial documentation 
of objective response. In all participants, the date of progression will be documented as the first 


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date progression was observed. 
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the 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. 
 
 
 
 
11.1.1 Definitions 
 
Evaluable for Target Disease response.  Only those participants 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 target disease response.  These 
participants will have their response classified according to the definitions stated below.  
(Note:  Participants who exhibit objective disease progression prior to the end of cycle 1 
will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Participants 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.  
 
11.1.2 Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as ≥ 20 mm by 
chest x-ray or ≥10 mm 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 node must be ≥15 mm in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm).  At baseline and in follow-up, only 
the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions 
(longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), 
are considered non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
abdominal masses (not followed by CT or MRI), and cystic lesions are all considered 


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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 participant, 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.  
 
11.1.3 Methods for Evaluation of Disease 
 
All measurements should be taken and recorded in metric notation using a ruler, calipers, 
or a digital measurement tool.  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.  
 
Clinical lesions. Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and ≥10 mm in diameter as 
assessed using calipers (e.g., skin nodules).  In the case of skin lesions, documentation by 


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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 thickness is 5mm or less. If CT scans have slice 
thickness greater than 5 mm, the minimum size of 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. 
 
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 


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greater than twice that of the surrounding tissue on the attenuation corrected image. 
 
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.   
MIBG (meta-iodobenzylguanidine).The following is recommended, to assure high 
quality images are obtained.  
Patient preparation: Iodides, usually SSKI (saturated solution of potassium iodide), 
are administered to reduce thyroidal accumulation of free radioiodine, preferably 
beginning the day prior to injection and continuing for 3 additional days (4 days 
total). For infants and children, one drop t.i.d. is sufficient, for adolescents 2 drops 
t.i.d., and for adults 3 drops t.i.d. Participants and/or parents are asked about exposure 
to potential interfering agents. If none is noted, an indwelling intravenous line is 
established. The dose of MIBG is administered by slow intravenous injection over 90 
seconds.  
Images from the head to the distal lower extremities should be obtained.  
I-123MIBG scintigraphy is performed to obtain both planar and tomographic images.  
Planar: Anterior and posterior views from the top of the head to the proximal lower 
extremities are obtained for 10 minutes at 24 hours and occasionally at 48 hours 
following injection of 10 mCi/1.7 square meters of body surface area (~150 μCi/kg, 
maximum 10 mCi). Anterior views of the distal lower extremities are adequate. A 
large field of view dual head gamma camera with low energy collimators is preferred.  
 
SPECT: Most participants receiving I-123 MIBG also undergo SPECT at 24 hours, 
using a single or multi-headed camera with a low energy collimator. The camera is 
rotated through 360 degrees, 120 projections at 25 seconds per stop. Data are 
reconstructed using filtered back projections with a Butterworth filter and a cut off 
frequency of 0.2-0.5. SPECT/CT may be performed at institutions with this capacity. 
 
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 data 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 


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study, confirmation by CT or MRI is advised. If there is concern about radiation exposure 
from 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 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 participant 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. 
 
11.1.4 Response Criteria 
 
 
11.1.4.1 
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. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of 
target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study).  In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm.  (Note:  
the appearance of one or more new lesions is also considered 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 


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study. 
 
11.1.4.2 
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 
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). 
 
11.1.4.3 
Evaluation of New Lesions 
 
The finding of a new lesion should be unequivocal (i.e. not due to difference in 
scanning technique, imaging modality, or findings thought to represent something 
other than tumor (for example, some ‘new’ bone lesions may be simply healing or 
flare of pre-existing lesions). However, a lesion identified on a follow-up scan in an 
anatomical location that was not scanned at baseline is considered new and will 
indicate PD. If a new lesion is equivocal (because of small size etc.), follow-up 
evaluation will clarify if it truly represents new disease and if PD is confirmed, 
progression should be declared using the date of the initial scan on which the lesion 
was discovered. 
 
11.1.4.4 
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. 
 
For Participants with Measurable Disease (i.e., Target Disease) 
 


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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. 
***      In exceptional circumstances, unequivocal progression in non-target lesions may be 
            accepted as disease progression. 
 
Note:  Participants 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 Participants 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 
 
11.1.5 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, or 
death due to any cause. Participants without events reported are censored at the last 
disease evaluation). 


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Duration of overall complete response: 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, or death due to any cause. Participants without events 
reported are censored at the last disease evaluation. 
 
 
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.  
 
11.1.6 Progression-Free Survival 
 
Overall Survival: Overall Survival (OS) is defined as the time from randomization (or 
registration) to death due to any cause, or censored at date last known alive. 
 
Progression-Free Survival: Progression-Free Survival (PFS) is defined as the time from 
randomization (or registration) to the earlier of progression or death due to any cause. 
Participants alive without disease progression are censored at date of last disease 
evaluation. 
 
Time to Progression: Time to Progression (TTP) is defined as the time from 
randomization (or registration) to progression, or censored at date of last disease 
evaluation for those without progression reported. 
 
11.1.7 Response Review 
 
N/A 
 
11.2 
Antitumor Effect – Hematologic Tumors 
 
N/A 
 
11.3 
Other Response Parameters: Immune-Related Response Criteria (irRECIST) 
 
 
11.3.1 Definition of Tumor Response Using Immune-Related Response Criteria (irRECIST) 
 
irRECIST is RECIST 1.1 adapted as described below to account for the unique tumor response 
seen with immuno-therapeutics. 
 
irRECIST will be used by site investigators and local radiology review to assess tumor response 
and progression, and may be used to make treatment decisions.  This data will be collected in the 
clinical database.  
 
irRECIST will be used by the central imaging vendor, however, this evaluation will be done 
retrospectively.  


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irRECIST takes into account the clinical condition/stability of subjects, as described in the table 
below, in addition to response or progression via tumor imaging. 
 
Clinically stable is defined by the following criteria: 
• Absence of symptoms and signs indicating clinically significant progression of disease, 
including worsening of laboratory values. 
• No decline in ECOG performance status 
• Absence of rapid progression of disease 
• Absence of progressive tumor at critical anatomical sites (e.g., cord compression) 
requiring urgent alternative medical intervention.  
 
 
 


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Table: irRECIST: Tumor Imaging and Treatment after 1st Radiologic Evidence of PD or SD, 
CR, or PR 
 
 
In determining whether or not the tumor burden has increased, decreased or stayed stable, site 
investigators should consider all target lesions a well as non-target lesions. 
 
Any subject deemed clinically unstable should be discontinued from trial treatment at first 
evidence of progressive disease by tumor imaging and is not required to have repeat tumor 
imaging for confirmation. 
 
For a clinically stable subject with first radiologic evidence of progressive disease (i.e. 
unconfirmed progression of disease), it is at the discretion of the site investigator to continue 
treating the subject with the assigned treatment per protocol until progression of disease is 
confirmed at least 28 days from the date of the tumor imaging first suggestiong PD. If 
progression is not confirmed on the subsequent tumor imaging, the subject should continue to 
receive study therapy and have tumor imaging preformed per protocol, or sooner if clincially 


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indicated, to monitor disease status. If radiologic progression is confirmed by subsequent tumor 
imaging, then the subject will be discontinued from trial treatment. 
 
NOTE: If a subject with confirmed progression by tumor imaging (i.e. 2 scans at least 28 days 
apart demonstrating progressive disease) is clinically stable or clinically improved, and there is 
no further increase in the tumor burden at the confirmatory scan, an exception may be considered 
to continue treatment upon consultation with the principal investigator.  
 
The same imaging modality (i.e., CT or MRI), acquisition and technical parameters should be 
used throughout the study for a given subject. 
 
11.3.1.1 
Immune-Related Best Overall Response Using irRECIST (irBOR) 
 
irBOR is the best confirmed overall response over the study as a whole, recorded 
between the date of first dose until the last tumor assessment before subsequent therapy 
(except for local palliative radiotherapy for painful bone lesions) for the individual 
subject in the study.  For the assessment of irBOR, all available assessments per subject 
are considered. 
 
irCR or irPR determinations included in the irBOR assessment must be confirmed by a 
second (confirmatory) evaluation meeting the criteria for response and performed no less 
than 4 weeks after the criteria for response are first met. 
 
12. DATA REPORTING / REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Data Reporting 
 
12.1.1 Method 
 
The ODQ will collect, manage, and perform quality checks on the data for this study. 
 
 
12.1.2 Responsibility for Data Submission 
 
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or 
data forms to the ODQ according to the schedule set by the ODQ. 
 
12.2 
Data Safety Monitoring 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity 
and accrual data from this study. The committee is composed of clinical specialists with 
experience in oncology and who have no direct relationship with the study. Information that 
raises any questions about participant safety will be addressed with the Overall PI and study 


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team. 
 
The DSMC will review each protocol up to four times a year or more often if required to review 
toxicity and accrual data. Information to be provided to the committee may include: up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or higher 
unexpected adverse events that have been reported; summary of all deaths occurring with 30 
days of intervention for Phase I or II protocols; for gene therapy protocols, summary of all deaths 
while being treated and during active follow-up; any response information; audit results, and a 
summary provided by the study team. Other information (e.g. scans, laboratory values) will be 
provided upon request.  
 
12.3 
Multicenter Guidelines 
 
N/A 
 
12.4 
Collaborative Research Future Use of Data and Biospecimens 
 
Tissue, blood, stool, bodily fluids, and other materials derived from these will be collected in this 
study to analyze genes, DNA, RNA, proteins and cells for the study’s correlative endpoints and 
potential future research, utilizing new types of biomarker testing as it becomes available.  
 
These samples and any data generated as a part of these clinical trials may be used for future 
research studies and may be provided to collaborating investigators both within and outside of the 
DF/HCC for either correlative endpoints or secondary use. Samples and data may be shared with 
outside non-profit academic investigators, as well as with for-profit pharmaceutical investigators 
or commercial entitites, with whom we collaborate. When samples or data are sent to collaborators 
and when any research is performed on them, all information will be identified with a code, and 
will not contain any PHI, such as name, birthday, or MRNs.  
 
In order to allow the greatest amount of research to be performed on the specimens and 
information generated as a part of this trial, researchers in this study may share results of genetic 
sequencing with other scientists. De-identified specimen or genetic data may be placed into one 
of more publicly-accessible scientific databases, such as the National Institutes of Health’s 
Database for Genotypes and Phenotypes (dbGaP). The results from the correlative research on 
this study will be shared with these public databases. Through such databases, researchers from 
around the world will have access to de-identified samples or data for future research. More 
detailed information, beyond the public database, may only be accessed by scientists at other 
research centers who have received special permission to review de-identified data. 
 
13. STATISTICAL CONSIDERATIONS 
 
All statistics for both primary and secondary endpoints will be descriptive in nature. 
 
13.1 
Study Design/Endpoints 
 
 This is a phase Ib dose de-escalation study with a primary objective of evaluating the safety and 


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tolerability of pembrolizumab in combination with T-DM1 in patients with metastatic HER2+ 
breast cancer.  A cohort of 6 patients will initially be enrolled at dose level 1.  If 2 or more 
patients experience a DLT, 6 additional patients will be treated at dose level -1.  If 2 or more 
patients experience a DLT at dose level -1, the study will be terminated.  If 0 or 1 of 6 patients 
experience a DLT at dose level 1 or dose level -1, that dose level will be considered as RP2D.  
Once the RP2D is determined, 15 additional patients will be enrolled in an expansion cohort. 
 
Primary Endpoint 
• Safety and tolerability profile.  
o Assessment of DLTs during the first 21 days of treatment, as defined in Section 
5.4 
o Determination of the RP2D 
o Maximum grade of all treatment-related adverse events using CTCAE v4.0 
 
Secondary Endpoints include: 
• Objective response rate (ORR) using RECIST 1.1 and irRECIST 
• Progression-free survival (PFS) using RECIST 1.1 and irRECIST 
• Duration of response, in patients who achieve an objective response 
• Disease control rate (CR+PR+SD) at 18 weeks using RECIST 1.1 and irRECIST 
• Overall survival 
 
Blood and tissue correlative science objectives include: 
• To characterize a broad array of immune markers in metastatic HER2-positive breast 
tumors (characterization will be based on histology, protein expression, mRNA 
expression, and genomic analysis) 
• To explore how different immunosuppressive and/or immune-stimulating immune 
marker profiles at baseline correlate with disease response to therapy (response assessed 
by RECIST 1.1 and irRECIST) 
• To characterize changes in immune marker profile in peripheral blood mononuclear cells 
(PBMCs) from baseline (pre-trial therapy) to on-treatment assessments 
• To explore whether induction of changes in the immunosuppressive and/or immune-
stimulating immune marker profile in PBMCs between baseline and on-treatment 
assessments correlates with disease response to therapy (response assessed by RECIST 
1.1 and irRECIST) 
o In terms of response as assessed on serial scans 
o In terms of best response achieved at any time on trial 
• To investigate whether there is an immune marker in circulating PBMCs that corresponds 
to tumor infiltrating lymphocyte (TIL) percentage in baseline tumor 
• In the cohort of patients who have re-biopsy at week 6 of treatment: To characterize 
changes in a broad array of immune markers from baseline (as characterized above) to 6 
weeks on trial therapy, and explore changes in the tumor microenvironment that correlate 
with disease response to therapy 
 
 
 


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13.2 
Sample Size, Accrual Rate and Study Duration 
 
Sample size for this trial will depend on the outcome of the dose de-escalation phase. Six to 12 
patients will be enrolled in the dose de-escalation phase, and once RP2D is determined, 15 more 
patients will be enrolled in an expansion cohort. The operating characteristics of the dose de-
escalation portion of this study are shown below, which provides the probability of declaring the 
RP2D for a range of underlying true DLT rates. For example, for a toxicity that occurs in 60% of 
patients, there is less than 5% probability (0.04) of declaring the RP2D.   
 
True underlying DLT rate 
10% 20% 30% 40% 50% 60% 70% 
80% 
90% 
Probability of declaring RP2D 
89% 66% 42% 23% 11% 
4% 
1% 
0.2% <0.01% 
 
With 6 patients treated at the RP2D during dose de-escalation, and 15 patients in the dose 
expansion cohort (n = 21), the probability of observing at least one serious toxicity event is 89% 
if the true toxicity rate is 10%, and 66% if the true toxicity rate is 5%.  
 
Objective response rate will be estimated among 15 patients in the expansion cohort and patients 
with measurable disease at screening who were treated at RP2D in the dose de-escalation phase.  
A total of 15 to 21 patients will be evaluable for ORR.  The table below gives the 95% CI 
(calculated using the exact binomial method) for the ORR estimate in a cohort size of 15 
patients, given various true underlying ORR.  For example, if the true underlying response rate is 
40% among 15 patients, the 95% CI would be 19-64%. 
 
 
True underlying ORR 
20% 
27% 
33% 
40% 
47% 
53% 
95% CI (n=15) 
4-48% 
8-55% 
12-62% 
16-68% 
21-73% 
27-79% 
 
We estimate accrual to be 2 per month, and estimate accrual will take 12-18 months to complete. 
 
13.3 
Stratification Factors 
 
N/A 
 
13.4 
Interim Monitoring Plan 
 
During the dose de-escalation phase, the first 6 patients within a dosing cohort need to complete 
21 days of treatment and the safety data will be reviewed before enrolling additional patients.   
 
13.5 
Analysis of Primary Endpoints 
 
The determination of the RP2D under the dose de-escalation scheme is defined in Section 13.1.  
Treatment-related toxicities will be summarized by maximum grade and by term using CTCAE 
v4.0 and reported with 90% binomial exact confidence intervals.  
 
13.6 
Analysis of Secondary Endpoints 
 


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Best overall response will be assessed among patients who received at least one dose of both 
study drugs at the RP2D and have measurable disease at screening. Radiographic response will 
be assessed using RECIST 1.1 criteria as defined in section 11.1.4, and irRECIST will be 
assessed as defined in section 11.3.  The objective response rate by RECIST 1.1 (CR + PR) and 
immune-related response (irCR + irPR) will be reported with 95% exact confidence intervals.   
 
PFS will be described using the method of Kaplan-Meier, and it will be presented with a 95% 
confidence interval. PFS is defined as the time from study registration to radiographic evidence 
of disease progression (as defined in Section 5.6) or death due to any cause, whichever occurred 
first. Patients alive without disease progression are censored at the date of last disease evaluation. 
 
Correlative objectives will be descriptive-only, using summary statistics (such as mean, sd, 
median, IQR and range) to give the empirical distribution of immune markers detected in the 
study population. With 15 patients evaluable for immune markers and under a Gaussian 
assumption to a continuous measure, a 95% confidence interval around a mean will have a width 
of approximately one standardized unit.   Correlation to responses will be reported as odds-ratios 
with 95% confidence intervals.  Specifically, as an example, we plan to measure PD-L1 
expression by immunohistochemistry in baseline biopsies as a continuous variable, and correlate 
baseline PD-L1 expression and change in PD-L1 expression with response (by RECIST and 
irRECIST) as an exploratory analysis. All analysis of Oncopanel in correlation with patient 
outcomes are exploratory and hypothesis-generating. Any promising findings will be explored in 
future studies.  
 
 
 
13.7 
Reporting and Exclusions 
 
13.7.1 Evaluation of Toxicity 
 
All patients who receive any amount of either study drug will be evaluable for safety and 
tolerability, even if there are major protocol treatment deviations or if they are later found 
to be ineligible. 
 
13.7.2 Evaluation of the Primary Efficacy Endpoint 
 
All participants who have received at least one dose of study medication at the RP2D will 
be assessed for PFS, and the subset of patients with measurable disease will be assessed 
for objective response.  
 
14. PUBLICATION PLAN 
 
The Primary Investigator will be the final arbiter of the manuscript content.   
 


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Hudock S, Kloth DD, Kuter DJ, Lyman GH, McMahon B, Rugo HS, Saad AA, 
Schwartzberg LS, Shayani S, Steensma DP, Talbott M, Vadhan-Raj S, Westervelt P, 
Westmoreland M, Dwyer M, Ho M. Myeloid growth factors. J Natl Compr Canc Netw 
2013;11:1266-90. 
 36. Hartleb M, Gutkowski K, Milkiewicz P. Nodular regenerative hyperplasia: evolving 
concepts on underdiagnosed cause of portal hypertension. World J Gastroenterol 
2011;17:1400-9. 
 37. Chen BJ, Chapuy B, Ouyang J, Sun HH, Roemer MG, Xu ML, Yu H, Fletcher CD, 
Freeman GJ, Shipp MA, Rodig SJ. PD-L1 expression is characteristic of a subset of 
aggressive B-cell lymphomas and virus-associated malignancies. Clin Cancer Res 
2013;19:3462-73. 
38. 
DeSantis CE, Fedewa SA, Goding Sauer A, Kramer JL, Smith RA, Jemal A. Breast 
cancer statistics, 2015: Convergence of incidence rates between black and white women. 
CA: a cancer journal for clinicians. Jan-Feb 2016;66(1):31-42. 
39. 
Kroemer G, Senovilla L, Galluzzi L, Andre F, Zitvogel L. Natural and therapy-induced 
immunosurveillance in breast cancer. Nature medicine. Oct 2015;21(10):1128-1138. 
40. 
Stanton SE, Disis ML. Clinical significance of tumor-infiltrating lymphocytes in breast 
cancer. J Immunother Cancer. 2016;4:59. 
41. 
Dirix L, Takacs I, Nikolinakos P, et al. Abstract S1-04: Avelumab (MSB0010718C), an 
anti-PD-L1 antibody, in patients with locally advanced or metastatic breast cancer: A 
phase Ib JAVELIN solid tumor trial. Cancer Research. 2016;76(4 Supplement):S1-04-
S01-04. 
42.. 
Nanda R, Chow LQ, Dees EC, et al. Pembrolizumab in Patients With Advanced Triple-
Negative Breast Cancer: Phase Ib KEYNOTE-012 Study. J Clin Oncol. Jul 20 
2016;34(21):2460-2467. 
43.. 
Rugo H, Delord J-P, Im S-A, et al. Abstract S5-07: Preliminary efficacy and safety of 
pembrolizumab (MK-3475) in patients with PD-L1–positive, estrogen receptor-positive 
(ER+)/HER2-negative advanced breast cancer enrolled in KEYNOTE-028. Cancer 
Research. 2016;76(4 Supplement):S5-07-S05-07. 
44. 
Trinchieri G. Cancer Immunity: Lessons From Infectious Diseases. J Infect Dis. Jul 15 
2015;212 Suppl 1:S67-73. 
45. 
Human Microbiome Project C. Structure, function and diversity of the healthy human 
microbiome. Nature. Jun 13 2012;486(7402):207-214. 
46. 
Qin J, Li R, Raes J, et al. A human gut microbial gene catalogue established by 
metagenomic sequencing. Nature. Mar 04 2010;464(7285):59-65. 
47. 
Roy S, Trinchieri G. Microbiota: a key orchestrator of cancer therapy. Nat Rev Cancer. 


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Mar 17 2017. 
48. 
Sivan A, Corrales L, Hubert N, et al. Commensal Bifidobacterium promotes antitumor 
immunity and facilitates anti-PD-L1 efficacy. Science. Nov 27 2015;350(6264):1084-
1089. 
49. 
Vetizou M, Pitt JM, Daillere R, et al. Anticancer immunotherapy by CTLA-4 blockade 
relies on the gut microbiota. Science. Nov 27 2015;350(6264):1079-1084. 
50. 
Goedert JJ, Jones G, Hua X, et al. Investigation of the association between the fecal 
microbiota and breast cancer in postmenopausal women: a population-based case-control 
pilot study. J Natl Cancer Inst. Aug 2015;107(8). 
 
 
Gao, J., Shi, L.Z., Zhao, H., Chen, J., Xiong, L., He, Q. et al. (2016) Loss of Ifn-Gamma 
Pathway Genes in Tumor Cells as a Mechanism of Resistance to Anti-Ctla-4 Therapy. Cell 167: 
397-404.e399. 
 
Zaretsky, J.M., Garcia-Diaz, A., Shin, D.S., Escuin-Ordinas, H., Hugo, W., Hu-Lieskovan, S. et 
al. (2016) Mutations Associated with Acquired Resistance to Pd-1 Blockade in Melanoma. N 
Engl J Med 
 
Casey, S.C., Tong, L., Li, Y., Do, R., Walz, S., Fitzgerald, K.N. et al. (2016) Myc Regulates the 
Antitumor Immune Response through Cd47 and Pd-L1. Science 352: 227-231. 
 
Spranger, S., Bao, R., and Gajewski, T.F. (2015) Melanoma-Intrinsic Beta-Catenin Signalling 
Prevents Anti-Tumour Immunity. Nature 523: 231-235. 
 
George, S., Miao, D., Demetri, G.D., Adeegbe, D., Rodig, S.J., Shukla, S. et al. (2017) Loss of 
Pten Is Associated with Resistance to Anti-Pd-1 Checkpoint Blockade Therapy in Metastatic 
Uterine Leiomyosarcoma. Immunity 46: 197-204. 
 
Li, S., Zhu, M., Pan, R., Fang, T., Cao, Y.Y., Chen, S. et al. (2016) The Tumor Suppressor Pten 
Has a Critical Role in Antiviral Innate Immunity. Nat Immunol 17: 241-249. 
 
Peng, W., Chen, J.Q., Liu, C., Malu, S., Creasy, C., Tetzlaff, M.T. et al. (2016) Loss of Pten 
Promotes Resistance to T Cell-Mediated Immunotherapy. Cancer Discov 6: 202-216. 
 
Snyder, A., Makarov, V., Merghoub, T., Yuan, J., Zaretsky, J.M., Desrichard, A. et al. (2014) 
Genetic Basis for Clinical Response to Ctla-4 Blockade in Melanoma. The New England journal 
of medicine: 2189-2199. 
 
Rizvi, N.A., Hellmann, M.D., Snyder, A., Kvistborg, P., Makarov, V., Havel, J.J. et al. (2015) 
Cancer Immunology. Mutational Landscape Determines Sensitivity to Pd-1 Blockade in Non-
Small Cell Lung Cancer. Science 348: 124-128. 
 
Davoli, T., Uno, H., Wooten, E.C., and Elledge, S.J. (2017) Tumor Aneuploidy Correlates with 
Markers of Immune Evasion and with Reduced Response to Immunotherapy. Science 355:  
 


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Wagle, N., Berger, M.F., Davis, M.J., Blumenstiel, B., Defelice, M., Pochanard, P. et al. (2012) 
High-Throughput Detection of Actionable Genomic Alterations in Clinical Tumor Samples by 
Targeted, Massively Parallel Sequencing. Cancer Discov 2: 82-93. 
 


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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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APPENDIX B 
NEW YORK HEART ASSOCIATION (NYHA) CLASSIFICATIONS 
 
The New York Heart Association (NYHA) Cardiac Disease Classification provides a functional 
and therapeutic classification for the prescription of physical activity for cardiac subjects.  Based 
on NYHA definitions, subjects are to be classified as follows: 
                     
 
 


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APPENDIX C 
STRONG CYP3A INDUCERS/INHIBITORS 
 
The list provided below is not exhaustive.  For a more comprehensive, frequently updated list, 
please visit: http://medicine.iupui.edu/clinpharm/ddis/table.aspx. 
 
Medications that strongly inhibit CYP3A: 
Amprenavir 
Atazanavir 
Boceprevir 
Clarithromycin 
Conivaptan 
Delavirdine 
Diltiazem 
Erythromycin 
Fosamprenavir 
Indinavir 
Itraconazole 
Ketoconazole 
Lopinavir 
Mibefradil 
Miconazole 
Nefazodone 
Nelfinavir 
Posaconazole 
Ritonavir 
Saquinavir 
Telaprevir 
Telithromycin 
Verapamil 
Voriconazole 
Grapefruit, grapefruit juice, or any product containing grapefruit 
 
Medications that strongly induce CYP3A: 
Carbamazepine 
Felbamate 
Nevirapine 
Phenobarbital 
Phenytoin 
Primidone 
Rifabutin 
Rifampin 
Rifapentin 
St. John’s wort 
 
 


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APPENDIX D 
GUIDELINES FOR LIVER BIOPSY 
 
As nodular regenerative hyperplasia (NRH) can be a very subtle diagnosis to make on liver biopsy, 
every attempt should be made to maximize the amount of tissue obtained. A minimum size of an 
18 gauge needle and percutaneous biopsies of at least 1.5 cm in length are recommended, if 
clinically appropriate. In order to diagnose NRH, reticulin and trichrome stains are necessary. 
Smaller biopsies obtained via a transjugular approach, as well as smaller biopsy gun needle 
biopsies, are discouraged. Small wedge biopsies are also discouraged. 


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91 
 APPENDIX E 
GUIDELINES FOR COLLECTING RESEARCH BIOPSY TISSUE 
 
Tissue specimens will be collected from metastatic lesions using standard institutional 
procedures. The amount of tissue collected may follow the guidelines listed below. 
 
Skin/chest wall: A goal of 2 5-mm punch biopsies will be obtained. 
 
Lymph node: A goal of 5-7 core biopsy specimens will be obtained using an 18-gauge needle. 
 
Liver: A goal of 5-7 core biopsy specimens will be obtained using an 18-gauge needle. 
 
Lung: Because of the risk of pneumothorax associated with core needle biopsies of lung nodules, 
no core biopsies of lung nodules are mandated on this protocol, unless they are clinically 
indicated.  
Bone: Because the yield of malignant tissue from bone biopsies tends to be relatively low, if a 
patient has another accessible site of disease (i.e. skin, lymph node, liver), that site should be 
biopsied preferentially. If bone is the only biopsy-accessible site, then a goal of 3-6 core biopsy 
specimens will be obtained using an 11-13 gauge needle.  
 
Please note that the above are guidelines for the amount of tissue to be obtained, and are 
not meant to replace clinical judgment at the time the procedure is performed.  Less than 
the goal quantity of tissue is accepted for each type of biopsy, and will be left to the clinical 
judgment of the physician performing the procedure.  Alternative amounts of tissue collected, 
based on best judgment of the physician performing the procedure, are allowed per protocol. 
 
If a patient is undergoing resection of a lesion for clinical reasons (i.e. wedge resection of a 
new lung lesion for confirmation of diagnosis or re-testing of hormone receptor or HER2 status; 
or, a resection of a chest wall lesion; or, resection of  a lymph node), then the patient may opt to 
have a portion of that tissue (roughly equivalent to the goal amount of tissue listed in the 
guidelines above, i.e. the equivalent of two 5-mm punch biopsies of the skin, or 4-6 18-gauge 
core biopsies) stored for research at the time of the procedure (provided that the tissue is 
processed as specified), in which case, the patient would not be required to undergo a separate 
research biopsy at baseline on this protocol.   
 


Protocol #16-492: Drafted (10/4/16) (LJK)/Approved 2/2/2017 MML/Revised 1/22/18 JL 
 
2DANA-FARBER CANCER INSTITUTE 
Nursing Protocol Education Sheet 
Protocol Number: 
16-492 
Protocol Name: 
A Phase 1b Study of Pembrolizumab in combination with Trastuzumab-DM1 in Metastatic 
HER2-Positive Breast Cancer 
DFCI Site PI: 
Sara Tolaney, MD 
DFCI Research Nurse: 
Margaret Campbell, Elizabeth Kasparian, Kathleen Roche, Jaclyn Lehnus, Kelly O’Neil, Kelly 
Marchetti, Morgan Marx 
Page the DFCI research nurse or DFCI site PI if there are any questions/concerns about the protocol.   
Please also refer to ONC 15: Oncology Nursing Protocol Education Policy 
*** Remember to check the ALERT PAGE*** 
              SPECIAL NURSING CONSIDERATIONS UNIQUE TO THIS PROTOCOL 
Study 
Design 
 
• 
Pembrolizumab is a monoclonal antibody of the IgG4/kappa isotype designed to directly block the interaction 
between PD-1 and its ligands, PD-L1 and PD-L2. (Section 2.2) 
• 
T-DM1 is an anti-HER2 agent (Section 2.3) 
• 
A cycle is defined as 21 days.  (Section 5.1)  
Dose 
Calc. 
• 
Pembrolizumab is dosed as a fixed dose. (Section 5.1) 
• 
T-DM1 is dosed in mg/kg. (Section 5.1)  
• 
The total dose of T-DM1 will be calculated according to institutional standards. (Section 5.3.2) 
Study Drug  
Administration 
Agent Administration Guidelines are found in Section 5.3. 
• 
Pembrolizumab will be administered as a 30 minute (-5/+10 minutes) IV infusion on day 1(+/- 3 days) of each 
cycle. (Section 5.3.1) 
• 
T-DM1 will be administered on day 1 (+/- 3 days) of each cycle.  The first infusion of T-DM1 will be 
administered over 90 minutes (+/- 10 minutes) with a 60 minute observation period.  If well tolerated, 
subsequent doses of T-DM1 may be administered over 30 minutes (+/- 10 minutes), with a minimum 30-minute 
observation period after infusion. (Section 5.3.2) 
• 
Pembrolizumab should be administered prior to T-DM1 administration.  There should be no overlap in timing of 
the two administrations. (Section 5.3.1) 
• 
Premedication for nausea and infusion reactions are not commonly required but may be given at the 
investigator’s discretion. (Section 5.3.2) 
• 
Pre-treatment Criteria is found in section 5.2. 
• 
Following Pembrolizumab infusion, flush the IV line with normal saline. (Section 8.1.8) 
• 
The solution of T-DM1 should not be shaken. (Section 8.2.1) 
Dose  
Mods & 
Toxicity 
Criteria to Treat, Dose Modifications/Dosing Delays for Toxicities are outlined in Section 6.0. 
• 
This protocol uses NCI CTCAE criteria, version 4.0. (Section 6.0) 
• 
The definition of a DLT is found in Section 5.4. 
• 
T-DM1 can be held for a maximum of 42 days from the time of the last scheduled dose for resolution of 
toxicities. (Section 6.2) 
Con 
Meds 
Concomitant Therapy Guidelines are in Section 5.5 
• 
Please review the cited sections for permitted, prohibited, and “use with caution” medications/therapies/foods 
Required  
Data  
Study Calendar and Assessment Required data are outlined in Section 10.0. 
• 
The study calendar is in Section 10.0. 
• 
Vital signs: The time points are in Section 10.0/Footnote b.   
• 
ECGs:  Single 12-lead EKG at screening visit only. (Section 10.0) 
• 
Biomarkers: The time points are in Section 10.0. 
Tips 
All study drugs require documentation of exact administration time. 
 
 
 


1 
 
Breast Cancer Stool Collection Questionnaire   
Subject ID: 
 
 
Date collected  ______/________/_____ 
                          Month      Day         Year   
 
Hour collected _______ 
1. 
Based on the small chart included in the postcard, what did the stool you put into the tube 
look like? (Choose one or two answers).  
  
2. 
Prior to this collection, when was your last bowel movement?  
 
  
 
 
3. 
In the past 2 months, how often have you had a bowel movement and what was the 
frequency of stool with the following textures? 
 
More than 
twice per day 
Twice 
per day 
Once 
per day 
Every 
other day 
Every 3-6 
days 
Once a 
week or 
less 
Never 
Any bowel movement 
 
 
 
 
 
 
 
Stool texture (The answers can be different from the above) 
Hard / lumpy 
 
 
 
 
 
 
 
Soft / smooth 
 
 
 
 
 
 
 
Watery liquid 
 
 
 
 
 
 
 
 
 
 
 
Earlier today, in 
the last 6 hours 
Earlier today, more 
than 6 hours ago 
Yesterday 
Two days 
ago 
More than two 
days ago 
 
 
 
 
 
o am 
o pm 


2 
 
4. 
In the past 2 months, have you used any of the following medications? 
 
No 
Yes, 
occasionally 
Yes, regularly 
Oral antibiotics 
 
 
 
If yes, what is the name (list of used)?  
 
 
Injected antibiotics 
 
 
 
If yes, what is the name (list of used)?  
 
 
Prilosec, Nexium, Prevacid (Iansoprazole), Protonix, 
Aciphex 
 
 
 
H2 blocker: Pepcid, Tagamet, Zantac, Axid 
 
 
 
 
5. 
In the past 2 months, have you used any medications modifying bile production,                
including (but not limited to): Cholesytramine (e.g. Questran, Prevalite, Locholest), colestipol 
(e.g, colestid), colesevelam (e.g. Welchol), chenodeoxycholic acids (e.g. CDCA), or           
ursodeoxycholic acid (e.g. UDCA, Ursodiol, Actigall)? 
 
No      
 
Yes, occasionally  
Yes, regularly 
 
6. 
In the past 2 months, have you undergone a colonoscopy or other procedure requiring bowel 
preparation?  
No  
Yes 
 
7. 
In the past week, have you taken (or eaten) any of the following? If so, please specify the 
frequency. 
 
Not 
used 
Once 
or 
twice 
Three 
to six 
times 
Daily 
More than 
once per 
day 
Fiber substitute, such as Metamucil, Konsyl or Citracel 
 
 
 
 
 
Laxatives, such as Ex-lax, Dulcolax, MiraLax, Senna, or 
enema 
 
 
 
 
 
Stool softener, such as Colace 
 
 
 
 
 
Probiotic supplements 
 
 
 
 
 
Yogurt or kefir 
 
 
 
 
 
Other fermented foods, such as sauerkraut or kombucha 
 
 
 
 
 
 
8. 
In the past 6 months, did you gain or lose weight? 
No 
Gained ≤5 lbs. 
Gained >5 lbs. 
Lost ≤5 lbs. 
Lost >5 lbs. 
 
 
 
 
 
 
9. 
Did you have any problems or concerns with the stool sample collection, for example the 
solution spilled out of the tube or you had problems with catching stool in the toilet 
accessory? (Please describe) 
 
__________________________________________________________________________________________ 
__________________________________________________________________________________________ 




Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
Template Version 5.0 
21-Mar- 2018
Protocol Version  
13-Mar-2018
1 
SUMMARY OF REVISIONS 
The following are a list of revisions to the Pharmacy Manual for pembrolizumab 
(MK-3475): 
Revision Date 
Revisions to Document 
New Version #: 
10-Dec-14
Global change: updated  MK-3475 to 
pembrolizumab 
2.0 
10-Dec-14
Global change: Inserted header Pembrolizumab 
(MK-3475) Pharmacy Manual for Investigational 
Studies 
2.0 
10-Dec-14
Expanded table of contents 
2.0 
10-Dec-14
Removed  trailing zeros after decimal points 
2.0 
10-Dec-14
Section 2:  
Revised footnote 1 in trial treatment table 
2.0 
10-Dec-14
Section 3.1: Removed text, “The pH is maintained 
using a 10 mM histidine buffer” 
2.0 
10-Dec-14
2.0 
10-Dec-14
Section 3.3: 
Clarified weight based dosing calculation for 
changes in weight (10% rule)  
Removed calculation for 200 mg fixed dosing 
2.0 
10-Dec-14
Section 3.4:  
Clarified preferred method of dose preparation  as 
volumetric reconstitution 
Clarified reconstitution technique. 
2.0 
10-Dec-14
Section 3.6: 
Inserted text stating infusion rates may differ for 
2.0 
Section 3.2:  
Added text to emphasize normal saline as 
preferred diluent  
Insert cautionary statement regarding drug 
transport and delivery  
Inserted text that any deviation from the guidance 
listed in this manual, must be discussed with 
sponsor 


Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
Template Version 5.0 
21-Mar- 2018
Protocol Version  
13-Mar-2018
2 
infusion reactions 
Inserted text that entire bag  needs to be dosed 
during infusion 
Removed  text regarding excess volume 
preparation  
Added text to document volume administered per 
DEG instructions 
10-Dec-14
2.0 
10-Dec-14
2.0 
10-Dec-14
Section 4.4: 
Clarified preferred method of dose preparation  as 
volumetric method 
2.0 
10-Dec-14
Section 4.5: 
Inserted text stating infusion rates may differ for 
infusion reactions 
Inserted text that entire bag  needs to be dosed 
during infusion 
Removed  text regarding excess volume 
preparation 
Added text to document volume administered per 
DEG instructions 
2.0 
21-Oct-15
Section 2: 
3.0 
Section 4.2  
Added text to emphasize normal saline as 
preferred diluent 
Insert cautionary statement regarding drug 
transport and delivery  
Inserted text that any deviation from the guidance 
listed in this manual, must be discussed with 
sponsor 
Section 4.3: 
Clarified weight based dosing calculation for 
changes in weight (10% rule)  
Removed calculation for 200 mg fixed dosing 


Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
Template Version 5.0 
21-Mar- 2018
Protocol Version  
13-Mar-2018
3 
Text added to footnote 2 for sourcing and 
recording of lot number, manufacturer, and expiry 
date.  
21-Oct-15
3.0 
21-Oct-15
Section 3.3: 
Clarified re-calculation of weight based dosing 
guidance.  
3.0 
21-Oct-15
Section 3.5 
Additional text added for concentration range 
requirements.  
3.0 
21-Oct-15
Section 3.7: 
Removed chemotherapeutic waste designation for 
solution remaining in vials that must be discarded. 
3.0 
Section 3.2: 
Added guidance for collection of the following 
diluent information (manufacturer, lot, and 
expiry). 
Removed the following text, “ unless instructed by 
the sponsor in writing” in the following sentence : 
Pembrolizumab (MK-3475) SHOULD NOT BE 
MIXED WITH OTHER DILUENTS unless 
instructed by the SPONSOR in writing. 
Added diluted drug product in the following 
sentence:  
Sites should follow their SOPs for drug transport 
and delivery, with all possible effort to minimize 
agitation of the reconstituted and diluted drug 
product between the pharmacy and the clinic 


Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
Template Version 5.0 
21-Mar- 2018
Protocol Version  
13-Mar-2018
4 
21-Oct-15
Section 4.1:  
Text added about cap color. 
3.0 
21-Oct-15
Section 4.2: 
Added guidance for collection of the following 
diluent information (manufacturer, lot, and 
expiry). 
3.0 
21-Oct-15
Section 4.3: 
Clarified re-calculation of weight based dosing 
guidance. 
3.0 
21-Oct-15
Section 4.4: 
Additional text added for concentration range 
requirements.  
3.0 
21-Oct-15
Section 4.5: 
Added the following text regarding infusion set 
materials: 
*Contact Sponsor for materials not listed above
3.0 
21-Oct-15
Section 4.6: 
Added text for discarding used vials. 
3.0 
28-Feb-17
Section 2.0: 
Updated footnote in trial treatment table to include 
SmPC and guidance regarding locally sourced 
drug. 
4.0 
28-Feb-17
Section 3.1 
4.0 


Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
Template Version 5.0 
21-Mar- 2018
Protocol Version  
13-Mar-2018
5 
Added text stating formulation is latex free 
28-Feb-17
Section 3.2 
Added rounding guidance.  
Added guidance on temperature excursions. 
Clarified 4 hour room temperature time limitation. 
Updated language around particulates. 
4.0 
28-Feb-17
Section 3.3 
Updated units from lb to kg to align with weight 
based dosing examples.  
4.0 
28-Feb-17
Section 3.4  
Clarified use of biosafety cabinets. 
Updated gravimetric dosing guidance.  
Added statement for use of spikes.  
Updated text for potential for foaming. 
4.0 
28-Feb-17
Section 3.5 
Deleted duplicate text regarding use of biosafety 
cabinets.  
Updated text regarding formation of particulates. 
4.0 
28-Feb-17
Section 3.6 
Added guidance for preparation of placebo. 
4.0 
28-Feb-17
Section 3.7 
Added instructional text that states 250mL volume 
is only applicable to weight based studies. 
4.0 
28-Feb-17
Section 3.8 
4.0 


Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
Template Version 5.0 
21-Mar- 2018
Protocol Version  
13-Mar-2018
6 
Clarified instructions for return of un-used vials. 
28-Feb-17
Section 4.1  
Added text stating formulation is latex free. 
Updated cap color for liquid formulation. 
Added text regarding overfill volume.  
4.0 
28-Feb-17
Section 4.2 
Added rounding guidance.  
Added guidance on temperature excursions. 
Clarified 4 hour room temperature time limitation. 
Updated language around particulates. 
4.0 
28-Feb-17
Section 4.3 
Updated units from lb to kg to align with weight 
based dosing examples. 
4.0 
28-Feb-17
4.0 
28-Feb-17
Section 4.5  
Added guidance for preparation of placebo. 
4.0 
28-Feb-17
Section 4.6 
Added instructional text that states 250mL volume 
is only applicable to weight based studies. 
Additional text added regarding formation of 
4.0 
Section 4.4  
Clarified use of biosafety cabinets. 
Updated gravimetric dosing guidance.  
Added statement for use of spikes.  
Updated text for potential for foaming. 


Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
Template Version 5.0 
21-Mar- 2018
Protocol Version  
13-Mar-2018
7 
foam. 
28-Feb-17
Section 4.7 
Clarified instructions for return of un-used vials. 
4.0 
21-Mar-2018
Section 1.0: 
Added unblinded clinical scientist to contact list 
Updated CDS title to CS 
Updated IVRS to IRT throughout document 
5.0 
21-Mar-2018
5.0 
21-Mar-2018
Section 3.6 
Revised flushing statement. 
Section 3.7 
Updated drug destruction instructions. 
5.0 
21-Mar-2018
Section 4.2 
Added text for temperature excursions that 
temperature data needs to be included in clinical 
complaint.  
Clarified for blinded studies that uCRA should be 
5.0 
Section 3.2 
Added text for temperature excursions that 
temperature data needs to be included in clinical 
complaint.  
Clarified for blinded studies that uCRA should be 
contacted for temperature excursions.  
Updated the room temperature allowance from 4 
hours to 6 hours and clarified fridge time 
allowance.  
Clarified the start of room temperature time. 


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contacted for temperature excursions. 
Updated the room temperature allowance from 4 
hours to 6 hours and clarified fridge time 
allowance. 
Clarified the start of room temperature time. 
21-Mar-2018
Section 4.4 
Updated room temperature time allowance to 6 
hours and clarified cumulative storage time.  
5.0 
21-Mar 2018
Section 4.5: 
Revised flushing statement. 
Section 4.6: 
Updated drug destruction instructions. 
5.0 


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TABLE OF CONTENTS 
Contents 
1. Contact List ................................................................................................................... 10
2. Trial Treatment ............................................................................................................. 11
3. Drug Preparation – Pembrolizumab (MK-3475) Powder for Solution for Infusion, 50
mg/vial .............................................................................................................................. 12
3.1
DRUG PRODUCT ............................................................................................. 12
3.2
STABILITY AND HANDLING OF DRUG PRODUCT ................................. 12
3.3
DOSE CALCULATION .................................................................................... 14
3.4
FOR INFUSION, 50 MG/VIAL) .................................................................................. 17
3.5
PREPARATION OF INFUSION SOLUTION.................................................. 19
3.6
ADMINISTRATION ......................................................................................... 21
3.7
RETURN AND DISCARDING OF PEMBROLIZUMAB (MK-3475) VIALS
22
4.
Drug Preparation – Pembrolizumab (MK-3475) Solution for Infusion ................. 24
4.1
DRUG PRODUCT ............................................................................................. 24
4.2
STABILITY AND HANDLING OF DRUG PRODUCT ................................. 24
4.3
DOSE CALCULATION .................................................................................... 26
4.4
PREPARATION OF INFUSION SOLUTION.................................................. 29
4.5
ADMINISTRATION ......................................................................................... 31
4.6
RETURN AND DISCARDING OF PEMBROLIZUMAB (MK-3475) VIALS
33
RECONSTITUTION OF DRUG PRODUCT (POWDER FOR SOLUTION 




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Pembrolizumab (MK-3475) Pharmacy Manual for Investigational Studies 
2. Trial Treatment
1 Refer to protocol for specific study drug administration sequence for combination studies of pembrolizumab (MK-3475) and chemo/immunotherapy
2 Refer to local product label/SmPC for drug preparation and administration instructions; For any commercially available product that is provided by the trial site, subsidiary or 
designee, every attempt will be made to source these supplies from a single lot/batch number  Local guidelines should be followed for collection of locally sourced product 
information such as manufacturer, lot and expiry, unless otherwise instructed by sponsor  When the product is provided by
 drug accountability log should be used 
for collection of this information 


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3. Drug Preparation – Pembrolizumab (MK-3475) Powder for
Solution for Infusion, 50 mg/vial 
3.1 DRUG PRODUCT 
3.2 STABILITY AND HANDLING OF DRUG PRODUCT 
•
Pembrolizumab (MK-3475) Powder for Solution for Infusion vials should be stored at
refrigerated conditions 2 – 8 °C (36 - 46 ºF).  Prior to reconstitution, the vial of
lyophilized powder can be out of refrigeration (temperatures at or below 25°C (77°F))
for up to 24 hours.
•
To determine whether to report a temperature excursion, the temperature values should
be rounded to whole numbers.
•
Rounding:
1. Decimal values from 0.1 to 0.4 round down to the nearest whole number (e.g., 8.3
= 8)
2. Decimal values from 0.5 to 0.9 round up to the nearest whole number (e.g., 8.7 = 9)
•
Then compare the rounded values to the required temperature range to determine if
there's an excursion.
•
Pembrolizumab (MK-3475) Powder for Solution for Infusion, 50 mg/vial
•
Pembrolizumab (MK-3475) Powder for Solution for Infusion is a sterile, non-pyrogenic
lyophilized powder for intravenous infusion supplied in single-use Type I glass vial
containing 50 mg of pembrolizumab (MK-3475). The product is preservative-free, latex
free, white to off-white powder and free from visible foreign matter.
•
Pembrolizumab (MK-3475) Powder for Solution for Infusion is reconstituted with 2.3
mL sterile water for injection (WFI) to yield a 2.4 mL solution containing 25 mg/mL of
pembrolizumab (MK-3475) at pH 5.2 – 5.8.
•
Pembrolizumab (MK-3475) Powder for Solution for Infusion vial contains an excess fill
of 10 mg (equivalent to 0.4 mL of reconstituted solution) to ensure the recovery of label
claim of 50 mg pembrolizumab (MK-3475) per vial (equivalent to 2 mL of
reconstituted solution).




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•
If refrigerated, allow the vials and/or IV bags to come to room temperature prior to use.
3.3 DOSE CALCULATION 
Follow directions applicable to the dose level (mg/kg) of the study 
2 mg/kg Dose 
•
The preparation of infusion solutions should be based on the dose level and the
subject’s actual body weight in kilograms (kg) on the day of dosing. However if
preparation of the infusion is required to be completed prior to the subject’s visit
•
Parenteral drug products should be inspected visually for particulate matter and
discoloration prior to administration. Discard the drug product vial if visible particles
are observed.
•
Sites should follow their SOPs for drug transport and delivery, with all possible effort to
minimize agitation of the reconstituted and diluted drug product between the pharmacy
and the clinic
•
DO NOT USE PEMBROLIZUMAB (MK-3475) IF DISCOLORATION IS
OBSERVED.
•
DO NOT SHAKE OR FREEZE THE VIAL(S).
•
DO NOT ADMINISTER THE PRODUCT AS AN INTRAVENOUS (IV) PUSH
OR BOLUS.
•
DO NOT COMBINE, DILUTE OR ADMINISTER IT AS AN INFUSION WITH
OTHER MEDICINAL PRODUCTS.
•
DO NOT CO-ADMINISTER OTHER DRUGS THROUGH THE SAME
INFUSION LINE.
•
Any departure  from the guidance listed in this manual, must be discussed with
sponsor


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(e.g., per local SOP, logistical issues, etc.), then the solution may be prepared in 
advance in accordance with the instructions in this manual. 
•
If infusion solution is prepared in advance, weight from the most recent scheduled or
unscheduled visit should be used.
•
If the weight from the most recent scheduled or unscheduled visit is used, the dose
amount should be recalculated and a new preparation of the infusion solution created
if the subject's weight on the day of dosing changes by more than 10% from the last
weight measurement.
o
Ex:  100 kg. at previous visit but current visit is less than 90 kg. or greater
than 110 kg. then recalculation of the dose and a new preparation of
infusion solution is  required
10 mg/kg Dose 
•
The preparation of infusion solutions should be based on the dose level and the
subject’s actual body weight in kilograms (kg) on the day of dosing. However if
preparation of the infusion is required to be completed prior to the subject’s visit
(e.g., per local SOP, logistical issues, etc.), then the solution may be prepared in
advance in accordance with the instructions in this manual.
•
If infusion solution is prepared in advance, weight from the most recent scheduled or
unscheduled visit should be used.
•
If the weight from the most recent scheduled or unscheduled visit is used, the dose
amount should be recalculated and a new preparation of the infusion solution created if
•
Required dose amount (mg) = dose level (mg/kg) * subject weight (kg)
•
Calculate the required number of pembrolizumab (MK-3475) vials by dividing the
required dose amount (mg) by 50 (mg) and rounding to the next whole number.
Example 1 (2 mg/kg dose)
Dose level = 2 mg/kg, subject weight = 69 kg
Required dose amount (mg) = 2 mg/kg * 69 kg = 138 mg
Required number of pembrolizumab (MK-3475) vials = 138/50 = 2.76
Rounded to next whole number = 3 vials


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the subject's weight on the day of dosing changes by more than 10% from the last 
weight measurement. 
o
Ex:  100 kg. at previous visit but current visit is less 90 kg. or greater
110 kg. then recalculation of the dose and a new preparation of
infusion solution is  required
200 mg Fixed Dose 
•
Required Number of vials = 4 vials (50 mg/vial)
•
8 mLs Total
•
Required dose amount (mg) = dose level (mg/kg) * subject weight (kg)
•
Calculate the required number of pembrolizumab (MK-3475) vials by dividing the
required dose amount (mg) by 50 (mg) and rounding to the next whole number.
Example 2 (10 mg/kg dose)
Dose level = 10 mg/kg, subject weight = 69 kg
Required dose amount (mg) = 10 mg/kg * 69 kg = 690 mg
Required number of pembrolizumab (MK-3475) vials = 690/50 = 13.8
Rounded to next whole number = 14 vials
•
Preference is for sites to prepare study medication on day of infusion. For sites that
must prepare dose in advance, weight from most recent scheduled or unscheduled
visit can be used for advanced preparation. Then on day of dosing, reweigh subject
for actual weight.
▪
If the weight on day of dosing is within 10% of weight used for
advanced dose calculation, you can  proceed with dosing what was
prepared during advanced preparations
▪
If a patient’s weight on day of dosing has fluctuated by more than 10%
compared to weight used for advanced study prep, then the dose should
be recalculated using the new weight measurement.


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3.4 RECONSTITUTION OF DRUG PRODUCT (POWDER FOR SOLUTION FOR 
INFUSION, 50 MG/VIAL) 
•
Aseptic technique must be strictly observed throughout the preparation procedure.
•
Use of a biosafety cabinet is preferred since no anti-microbial preservative is present in
the product; however, it is not mandatory unless specified by site standard operating
procedure.
•
Equilibrate required number of pembrolizumab (MK-3475) vials to room temperature.
•
The preferred method of dose preparation is the volumetric method.
•
Sponsor recommends reconstitution and administration of pembrolizumab (MK-3475)
that follows the parameters in this manual, however if use of gravimetric preparation is
mandatory due to local site procedures, the following requirements must be satisfied and
documented:
•
Draw the required volume up to 2.0 mL (50 mg) of pembrolizumab from each
vial
•
Limit the number of punctures of each vial to two (one for reconstitution, one
for withdrawal)
•
For gravimetric preparation method using density of reconstituted pembrolizumab
solution, a value of 1.03 g/mL should be used
•
For gravimetric preparation method using the total solid content information, the
following information on the total solid and active contents per vial of pembrolizumab
lyophilized product should be used:
•
Total calculated weight of pembrolizumab per vial = 60.0 mg
•
Total calculated weight of solids per vial (including pembrolizumab) = 232.2
mg
•
does not support methods of preparation of 
 agents beyond what is
stated in the product literature. Sites should reference the SmPCs or packaging inserts
for preparation instructions.


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Caution: To avoid foaming, ensure that water is delivered along the walls 
of the vial and not directly squirted on the lyophilized powder.  
•
Remove the needle(s) from the stopper of pembrolizumab (MK-3475) vial.
•
Slowly swirl the vial to allow reconstitution of the lyophilized powder. Allow up   to 5
minutes for the bubbles to clear.
•
Remove the cap from the seal. Do not decrimp the vial.
•
Insert a needle through the stopper of the pembrolizumab (MK-3475) Powder for
Solution for Infusion vial(s) to release vacuum (if any). Leave the needle inserted in the
stopper. If local standard operating procedures (SOPs) prohibit leaving a needle
inserted in the stopper, this step can be skipped.
•
If the site procedures require use of spikes or other closed system transfer devices
(CSTDs), please contact sponsor for approval.
•
If one WFI bottle is used to reconstitute one pembrolizumab (MK-3475) vial: Attach a
3 mL syringe to a needle. Insert the needle through the stopper of the sterile water for
injection (WFI) bottle. Draw excess of 2.3 mL of WFI in the syringe and remove the
syringe-needle assembly from the vial.
•
If one WFI bottle is used to reconstitute more than one pembrolizumab (MK-3475)
vials: Insert a needle through the stopper of the sterile WFI bottle. Attach a 3 mL
syringe to the needle inserted in the sterile WFI bottle and draw excess of 2.3 mL of
WFI in the syringe. Carefully detach the syringe without removing the needle from the
WFI bottle. Repeat the process to fill additional syringes while keeping the needle
inserted in sterile WFI bottle to minimize particle shedding from stopper. Use a new
sterile WFI bottle after filling approximately 10 syringes.
•
Attach a new needle to the filled syringe (if applicable). Remove excess air and WFI
from the syringe-needle assembly while ensuring that there is 2.3 mL WFI still
remaining in it.
•
Aseptically add 2.3 mL of sterile water for injection to yield a 25 mg/mL (pH 5.2-5.8)
solution of pembrolizumab (MK-3475).


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Caution: Do not shake the vials otherwise this may result in formation of foam. If 
foam is noticed in either vial or bag, the drug product will need to be discarded. A new 
preparation should be made, taking care not to shake or agitate the product.  
3.5 PREPARATION OF INFUSION SOLUTION 
•
Calculate the volume of pembrolizumb (MK-3475) and normal saline required to
prepare the infusion (admixture) bag
Volume of reconstituted pembrolizumab (MK-3475) (mL) = required dose amount (mg)
/ 25 (mg/mL)
Volume of normal saline = total infusion volume – volume of pembrolizumab (MK-
3475) from above
•
If a bag pre-filled with normal saline is being used, remove the excess volume of normal
saline using a sterile syringe (Polypropylene, latex-free) attached to a suitable needle.
Keep in consideration the excess bag fill volume as well as the volume of reconstituted
• Aseptic technique must be strictly observed throughout the preparation procedure.
• Reconstitute the required number of vials to prepare the infusion solution.
• Choose a suitable infusion bag size so that the following conditions are met:
•
Concentration of pembrolizumab (MK-3475) is between 1 mg/mL and 10
mg/mL
•
The infusion volume to bag capacity ratio should not be less than 0.3.  In
other words, the bag must be filled to at least 30% of its capacity.
•
Choose a suitable infusion bag material. The bag may be empty or it may contain
normal saline.  The following infusion bag materials are compatible with
pembrolizumab (MK-3475):
•
PVC plasticized with DEHP
•
Non-PVC (polyolefin)
•
EVA
•
PE lined polyolefin
*Contact Sponsor for materials not listed above


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pembrolizumab (MK-3475) to be added to the bag to prepare the infusion solution. This 
helps ensure that the concentration in the bag can be accurately calculated and falls 
within the acceptable range of 1 mg/mL to 10 mg/mL. If the site would like to proceed 
without removing excess saline they must ensure that the concentration of MK-3475 
would still fall within acceptable range. 
•
If an empty bag is being used, withdraw the necessary volume of normal saline from
another appropriate bag and inject into the empty bag. Keep in consideration the volume
of reconstituted pembrolizumab (MK-3475) to be added to the bag to prepare the
infusion solution.
•
Withdraw the required volume of pembrolizumab (MK-3475) from the vial(s) (up to 2
mL from each vial) using a sterile syringe attached to a suitable needle. The vial(s) may
need to be inverted to remove solution.
Volume of pembrolizumab (MK-3475) (mL) = required dose amount (mg) / 25
(mg/mL)
Note: If it is necessary to use several vials, it is advisable to withdraw from several
vials into a suitable size single use syringe using a new needle for each vial.
•
Add the required pembrolizumab (MK-3475) (reconstituted solution) into the infusion
IV bag containing normal saline and gently invert the bag 10-15 times to mix the
solution.
•
If the infusion bag is excessively handled or shaken, particulates may form. If this
occurs, discard the bag and create a new bag. Please contact your HQ clinical study
team if particulates are noticed for further instructions. Be prepared to provide the
following information:
•
IV bag manufacture, lot and expiry
•
Target volume of admixture solution in the IV bag (e.g. 100 mL, 200 mL
etc.)
•
Amount of drug product (mL or mg) added to the bag
•
Drug product lot
•
Brief description of the nature of visible particles (color, shape, size, numbers
etc.)
•
DO 
NOT 
FREEZE 
THE 
PEMBROLIZUMAB 
(MK-3475) 
INFUSION
SOLUTION.
•
Discard any unused portion left in the vial as the product contains no preservative


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3.6 ADMINISTRATION 
*Contact Sponsor for materials not listed above
In case of infusion reactions, infusion rate may differ; refer to protocol for specific 
instructions.  
•
Whenever possible, the lowest infusion rate should be used that will allow
completion of the infusion within the 30 minutes
•
A sterile, non-pyrogenic, low-protein binding 0.2 to 5 µm in-line filter made of
polyethersulfone (PES) must be used during administration to remove any adventitious
particles. If the infusion set does not contain 0.2 to 5 µm in-line filter, it is
recommended to use 0.2 to 5 µm add-on filter which may contain an extension line
(Note: the materials of the extension line and filter should be as mentioned above).
•
Attach the infusion line to the pump and prime the line, either with normal saline (at
least 25 mL) or with infusion solution as per local SOP, before starting the infusion.
•
Infuse pembrolizumab (MK-3475) over approximately 30 minutes, with a window of -5
and +10 minutes, through a peripheral line or indwelling catheter.
•
Ensure the entire contents of the bag are dosed and all remaining drug solution in the
line is administered through saline flushing.
•
Document volume administered according to data entry guidelines.
•
Pembrolizumab (MK-3475) infusions should be administered in 30 minutes, with a
window of -5 and +10 minutes, using an infusion pump. A central catheter is not
required for infusion; however if a subject has a central venous catheter in place, it is
recommended that it be used for the infusion.
•
The following infusion set materials are compatible with pembrolizumab (MK-3475):
o
PVC Infusion set that is plasticized using DEHP
o
PVC and tri-(2-ethylhexyl) trimellitate (TOTM) infusion set
o
Polyethylene lined PVC infusion set
o
PVC Infusion set that is plasticized using Di-2-ethylhexyl Terephthalate
(DEHT)
o
Polyurethane set




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•
For Interactive response technology (IRT) studies, the IRT Clinical Drug Supply
Return Forms generated  in the system must be used
•
Solution remaining in a used vial should be discarded according to your local
procedures.
•
Any information on the label identifying the subject should be redacted prior to
returning the study medication.


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4. Drug Preparation – Pembrolizumab (MK-3475) Solution for
Infusion 
4.1 DRUG PRODUCT  
Pembrolizumab (MK-3475) Solution for Infusion, 100 mg/ 4 mL vial 
•
Pembrolizumab (MK-3475) Solution for Infusion is a sterile, non-pyrogenic aqueous
solution supplied in single-use Type I glass vial containing 100 mg/4 mL of
pembrolizumab (MK-3475). The product is preservative-free, latex free solution which
is essentially free of extraneous particulates.
•
Cap color of MK-3475 (Pembrolizumab) 100 mg vials:
•
Both red, salmon, and blue color caps may be used. Though the cap color
may be different, the product inside the vial is the same MK-3475 drug
product.
•
Pembrolizumab (MK-3475) Solution for Infusion vials are filled to a target of
4.25mL (106.25mg) to ensure recovery of 4.0mL (100mg).
4.2 STABILITY AND HANDLING OF DRUG PRODUCT 
•
Pembrolizumab (MK-3475) Solution for Infusion, 100 mg/ 4 mL vial:
pembrolizumab (MK-3475) Solution for Infusion vials should be stored at refrigerated
conditions 2 – 8 °C (36 - 46 °F) and protected from light.
•
To determine whether to report a temperature excursion, the temperature values should
be rounded to whole numbers.


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•
Rounding:
o Decimal values from 0.1 to 0.4 round down to the nearest whole number
(e.g., 8.3 = 8)
o Decimal values from 0.5 to 0.9 round up to the nearest whole number
(e.g., 8.7 = 9)
•
Then compare the rounded values to the required temperature range to determine if 
there's an excursion.
•
All temperature excursions, however small, must be reported by the site to the Clinical 
Complaint Intake mailbox 
for investigation 
within 1 business day using the Clinical Supply Complaint & GCP Inquiry Form (excel 
version) and attached temperature data.  Please also notify your CRA.  All Clinical 
Supply stock that is subject to an investigation must be placed in quarantine and remain 
unavailable to dispense to patients until disposition has been determined.
•
Please note temperature excursions after drug product is prepared are out of scope of the 
clinical complaint process. Please contact HQ clinical study team for further guidance.
Note: vials should be stored in the original box to ensure the drug product is protected 
from light.
•
Pembrolizumab (MK-3475) infusion solutions should be prepared in 0.9% Sodium 
Chloride Injection, USP (normal saline) or regional equivalent or 5% Dextrose 
Injection, USP (5% dextrose) or regional equivalent and the final concentration of 
pembrolizumab (MK-3475) in the infusion solutions should be between 1 mg/mL and 
10 mg/mL.
•
Please note, the preferred diluent is 0.9% Sodium Chloride and 5% dextrose is only 
permissible if normal saline is not available.
•
Local guidelines should be followed for collection of diluent information such as 
manufacturer, lot and expiry. When the diluent is provided by 
 the drug 
accountability log should be used for collection of diluent information.
•
Pembrolizumab (MK-3475) SHOULD NOT BE MIXED WITH OTHER DILUENTS.
•
Pembrolizumab (MK-3475) solutions may be stored at room temperature for a 
cumulative time of up to 6 hours. The 6 hour countdown begins when the vial is 
pierced, and includes room temperature storage of admixture solutions in the IV bags 


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and the duration of infusion. (Please note this 6 hour timeframe is to provide a 
microbial control strategy. The microbial clock only starts when the product stopper is 
pierced and not when the vial is removed from the refrigerator.) 
4.3 DOSE CALCULATION 
Follow directions applicable to the dose level (mg/kg) of the study. 
2 mg/kg Dose 
•
In addition, IV bags may be stored under refrigeration at 2 °C to 8 °C (36 °F to 46 °F),
total cumulative storage time at room temperature and refrigeration should not exceed
24 hours.
•
If refrigerated, allow the IV bags to come to room temperature prior to use.
•
Parenteral drug products should be inspected visually for particulate matter and
discoloration prior to administration. Discard the drug product vial if visible particles
are observed.
•
Sites should follow their SOPs for drug transport and delivery, with all possible effort
to minimize agitation of the drug product between the pharmacy and the clinic
•
DO NOT USE PEMBROLIZUMAB (MK-3475) IF DISCOLORATION IS
OBSERVED.
•
DO NOT SHAKE OR FREEZE THE VIAL(S).
•
DO NOT ADMINISTER THE PRODUCT AS AN INTRAVENOUS (IV) PUSH
OR BOLUS.
•
DO NOT COMBINE, DILUTE OR ADMINISTER IT AS AN INFUSION WITH
OTHER MEDICINAL PRODUCTS.
•
Any departure from the guidance listed in this manual, must be discussed with
sponsor


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10 mg/kg Dose 
•
The preparation of infusion solutions should be based on the dose level and the
subject’s actual body weight in kilograms (kg) on the day of dosing. However if
preparation of the infusion is required to be completed prior to the subject’s visit
(e.g., per local SOP, logistical issues, etc.), then the solution may be prepared in
advance in accordance with the instructions in this manual.
•
If infusion solution is prepared in advance, weight from the most recent scheduled or
unscheduled visit should be used.
•
The preparation of infusion solutions should be based on the dose level and the
subject’s actual body weight in kilograms (kg) on the day of dosing. However if
preparation of the infusion is required to be completed prior to the subject’s visit (e.g.,
per local SOP, logistical issues, etc.), then the solution may be prepared in advance in
accordance with the instructions in this manual.
•
If infusion solution is prepared in advance, weight from the most recent scheduled or
unscheduled visit should be used.
•
If the weight from the most recent scheduled or unscheduled visit is used, the dose
amount should be recalculated and a new preparation of the infusion solution created
if the subject's weight on the day of dosing changes by more than 10% from the last
weight measurement.
o
Ex: 100 kg at previous visit but current visit is less than 90 kg or greater
than 110 kg, then re-calculation of the dose and a new preparation of
infusion solution is required.
•
Required dose amount (mg) = dose level (mg/kg) * subject weight (kg)
•
Calculate the required number of pembrolizumab (MK-3475) vials by dividing the
required dose amount (mg) by 100 (mg).
Example 1 (2 mg/kg dose):
Dose level = 2 mg/kg, subject weight = 69 kg
Required dose amount (mg) = 2 mg/kg * 69 kg = 138 mg
Required number of pembrolizumab (MK-3475) vials = 138/100 = 1.38
Rounded to next whole number = 2 vials


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•
If the weight from the most recent scheduled or unscheduled visit is used, the dose
amount should be recalculated and a new preparation of the infusion solution created
if the subject's weight on the day of dosing changes by more than 10% from the last
weight measurement.
o
Ex:  100 kg at previous visit but current visit is less than 90 kg or greater than
110 kg, then recalculation of the dose and a new preparation of infusion
solution is required.
•
Required dose amount (mg) = dose level (mg/kg) * subject weight (kg)
•
Calculate the required number of pembrolizumab MK-3475 vials by dividing the
required dose amount (mg) by 100 (mg).
Example 2 (10 mg/kg dose):  
Dose level = 10 mg/kg, subject weight = 69 kg 
Required dose amount (mg) = 10 mg/kg * 69 kg = 690 mg 
Required number of pembrolizumab (MK-3475) vials = 690/100 = 6.9 
Rounded to next whole number = 7 vials 
200 mg Fixed Dose 
•
2 vials (100 mg/4 mL)
•
8 mL total
•
Preference is for sites to prepare study medication on day of infusion. For sites
that must prepare dose in advance, weight from most recent scheduled or
unscheduled visit can be used for advanced preparation.  Then on day of dosing,
reweigh subject for actual weight.
▪
If the weight on day of dosing is within 10% of weight used for advanced
dose calculation, you can proceed with dosing what was prepared during
advanced preparations
▪
If a patient’s weight on day of dosing has fluctuated by more than 10%
compared to weight used for advanced study prep, then the dose should
be recalculated using the new weight measurement.


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4.4 PREPARATION OF INFUSION SOLUTION 
•
Aseptic technique must be strictly observed throughout the preparation procedure
•
Use of a biosafety cabinet is preferred since no anti-microbial preservative is present
in the product; however, it is not mandatory unless specified by site standard operating
procedure.
•
Equilibrate required number of pembrolizumab MK-3475 vials to room temperature
•
The preferred method of dose preparation is the volumetric method
•
Sponsor recommends reconstitution and administration of pembrolizumab (MK-3475)
that follows the parameters in this manual, however if use of gravimetric preparation is
mandatory due to local site procedures, the following requirements must be satisfied
and documented:
•
Draw the required volume up to 4.0 mL (100 mg) of pembrolizumab from
each vial
•
Limit the number of punctures of each vial to one
•
For gravimetric preparation method using density of pembrolizumab solution, a value
of 1.03 g/mL should be used
 does not support methods of preparation of 
 agents beyond what is
stated in the product literature.  Sites should reference the SmPCs or packaging inserts
for preparation instructions
•
If the site procedures require use of spikes or other closed system transfer devices
(CSTDs), please contact sponsor for approval
•
Choose a suitable infusion bag size so that the following conditions are met:
•
Concentration of pembrolizumab MK-3475 is between 1 mg/mL and 10
mg/mL
•
The infusion volume to bag capacity ratio should not be less than 0.3.  In
other words, the bag must be filled to at least 30% of its capacity.
•
Choose a suitable infusion bag material. The bag may be empty  or it may contain
normal saline The following infusion bag materials are compatible with pembrolizumab
(MK-3475):


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▪
PVC plasticized with DEHP
▪
Non-PVC (polyolefin)
▪
EVA
▪
PE lined polyolefin
*Contact Sponsor for materials not listed above
•
Calculate the volume of pembrolizumab (MK-3475) and normal saline required to
prepare the infusion (admixture) bag
Volume of pembrolizumab (MK-3475) (mL) = required dose amount (mg) / 25
(mg/mL)
Volume of normal saline = total infusion volume – volume of pembrolizumab (MK-
3475) from above
•
If a bag pre-filled with normal saline is being used, remove the excess volume of
normal saline using a sterile syringe (Polypropylene, latex-free) attached to a suitable
needle. Keep in consideration the excess bag fill volume as well as the volume of
pembrolizumab (MK-3475) to be added to the bag to prepare the infusion solution. This
helps ensure that the concentration in the bag can be accurately calculated and falls
within the acceptable range of 1 mg/mL to 10 mg/mL. If the site would like to proceed
without removing excess saline they must ensure that the concentration of MK-3475
would still fall within acceptable range.
•
If an empty bag is being used, withdraw the necessary volume of normal saline from
another appropriate bag and inject into the empty bag. Keep in consideration the
volume of pembrolizumab (MK-3475) to be added to the bag to prepare the infusion
solution.
•
Withdraw the required volume of pembrolizumab (MK-3475) from the vial(s) (up to 4
mL from each vial) using a sterile syringe attached to a suitable needle. The vial(s) may
need to be inverted to remove solution.
Volume of pembrolizumab (MK-3475) (mL) = required dose amount (mg) / 25
(mg/mL)
Note: If it is necessary to use several vials, it is advisable to withdraw from several
vials into a suitable size single use syringe using a new needle for each vial.


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4.5 ADMINISTRATION 
•
Pembrolizumab (MK-3475) infusions should be administered in 30 minutes, with a
window of -5 and +10 minutes, using an infusion pump. A central catheter is not
required for infusion; however if a subject has a central venous catheter in place, it is
recommended that it be used for the infusion.
•
The following infusion set materials are compatible with (pembrolizumab) MK-3475:
o
PVC Infusion set that is plasticized using DEHP
•
Add the required pembrolizumab (MK-3475) into the infusion IV bag containing
normal saline and gently invert the bag 10-15 times to mix the solution.
•
Pembrolizumab (MK-3475) solutions may be stored at room temperature for a
cumulative time of up to 6 hours. This includes room temperature storage of admixture
solutions in the IV bags and the duration of infusion.
•
In addition, IV bags may be stored under refrigeration at 2 °C to 8 °C (36 °F to 46 °F),
total cumulative storage time at room temperature and refrigeration should not exceed
24 hours.
•
If refrigerated, allow the IV bags to come to room temperature prior to use.
•
If the infusion bag is excessively handled or shaken, particulates may form. If this
occurs discard the bag and create a new bag taking care not to shake. Please contact
your HQ clinical study team if particulates are noticed for further instructions.  Be
prepared to provide the following information:
•
IV bag manufacture, lot and expiry
•
Target volume of admixture solution in the IV bag (e.g. 100 mL, 200 mL
etc.)
•
Amount of drug product (mL or mg) added to the bag
•
Drug product lot
•
Brief description of the nature of visible particles (color, shape, size, numbers
etc.).
•
DO 
NOT 
FREEZE 
THE 
PEMBROLIZUMAB 
(MK-3475) 
INFUSION
SOLUTION.
•
Discard any unused portion left in the vial as the product contains no preservative


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o
PVC and tri-(2-ethylhexyl) trimellitate (TOTM) infusion set
o
Polyethylene lined PVC infusion set
o
PVC Infusion set that is plasticized using Di-2-ethylhexyl Terephthalate
(DEHT)
o
Polyurethane set
*Contact Sponsor for materials not listed above
•
A sterile, non-pyrogenic, low-protein binding 0.2 to 5 µm in-linefilter made of 
polyethersulfone (PES) must be used during administration to remove any adventitious 
particles.  If the infusion set does not contain 0.2 to 5 µm in-line filter, it is 
recommended to use 0.2 to 5 µm add-on filter which may contain an extension line 
(Note: the materials of the extension line and filter should be as mentioned above).
•
Attach the infusion line to the pump and prime the line, either with normal saline (at 
least 25 mL) or with infusion solution as per local SOP, before starting the infusion.
•
Infuse pembrolizumab (MK-3475) over approximately 30 minutes, with a window of
-5 and +10 minutes, through a peripheral line or indwelling catheter.
•
Ensure the entire contents of the bag are dosed and all remaining drug solution in the 
line is administered through saline flushing.
•
Document volume administered according to data entry guidelines.
•
In case of infusion reactions, infusion rate may differ; refer to protocol for specific 
instructions.
•
Whenever possible, the lowest infusion rate should be used that will allow completion 
of the infusion within the 30 minutes.
•
Maximum rate of infusion should not exceed 6.7 mL/min. through a peripheral line or 
indwelling catheter.
 




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21-Mar- 2018
Protocol Version  
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34 
•
Any information on the label identifying the subject should be redacted prior to
returning the study medication.


1 
 
 
 
[Date] 
Dear Research Participant: 
 
You are receiving this letter because you participated in the research study called, “A phase Icancer 
Study of Pembrolizumab in Combination with Trastuzumab-DM1 in Metastatic HER2-Positive Breast 
Cancer,” and we would like to share some recent changes with you.   
 
 
WHAT HAS HAPPENED? 
 
The overall study plan has not changed, however the consent form for this study has recently been 
updated to reflect changes in the regulations regarding the way that biological specimens (blood, tissue, 
and stool (which were collected for research purposes)) and data may be handled. These changes are as 
follows:    
 
1. Biobanking—biological specimens previously collected from you may be shared with an 
outside lab or collaborator and will be banked for future research.  
 
Biological specimens (such as blood, tissue, bodily fluids, other specimens collected as a part of 
the study, and any materials that may be derived from these) will be collected and shared with 
an outside lab or collaborator for analysis. The specimens will not be identifiable. The specimens 
will be banked for future use. 
 
As a part of this study, you previously agreed to provide researchers with a sample of your 
tumor tissue from a prior biopsy, surgery, or procedure. There is a risk associated with 
submitting this type of tissue for research studies and biobanking. Generally, hospitals will keep 
some of your tissue from a prior biopsy, surgery, or procedure. This tissue may be used to help 
treat your cancer in the future. There is a small risk that when the tissue sample is submitted to 
the study or the biobank that your tissue could be used up.  
 
 
2. Data Collection—Your data may be shared with an outside collaborator or stored for future 
use. 
 
Data will be collected and shared with an outside collaborator for analysis. The data will not be 
identifiable. The data will be banked for future use. 
 
 
3. Future use of data and specimens—Your de-identifiable data and/or biospecimens which 
were previously collected during this study may be stored and used for future research.    


2 
 
 
Your personal information and/or biospecimens collected during this study may be stored and 
used for future research.  If so, any personal identifiers will be removed so that the information 
or samples cannot be linked back to you. As a result, we will no longer be able to identify and 
destroy them. 
 
Investigators, including investigators from collaborating institutions, can request this data and 
samples for new research.  Samples and data may also be shared with outside non-profit 
academic investigators as well as with for-profit pharmaceutical investigators or commercial 
entities, with whom we collaborate. 
 
You will not be asked to provide additional informed consent for the use of your de-identified 
information or samples in future research.  
 
Future research studies may include genetic research.  Your genes are unique to you.  At this 
time, you cannot be identified through this research.  There is a risk that you might be 
reidentified in the future as genetic research progresses. 
 
NEXT STEPS? 
 
After reviewing this information, we ask that you sign below acknowledging receipt of this information 
and your continued consent to participation in this study.  
 
Documentation of Re-Consent – 16-492 “A Phase 1b Study of Pembrolizumab in Combination with 
Trastuzumab-DM1 in Metastatic HER2-Positive Breast Cancer” 
 
My signature below indicates: 
 
• 
I have had enough time to read this letter and think about its contents 
• 
I have had all of my questions answered to my satisfaction 
• 
I am willing to participate in this study 
• 
I have been informed that my participation is voluntary, and I can withdraw at any time 
 
 
_________________________________________                                        _________________________ 
Signature of Participant  
 
 
 
 
 
Date 
Or Legally Authorized Representative 
 
 
____________________________________________________ 
Relationship of Legally Authorized Representative to Participant 
 
 
Please return this letter to us at your earliest convenience using one of the following methods and 
contact information below: scan and email, fax, or mail (using the enclosed mailer). 
 


3 
 
[If DFCI participant, add DFCI CRC contact information. If BIDMC participant, add BIDMC CRC contact 
information] 
 
If we do not receive your signed acknowledgement within approximately 30 days, a member of the 
study team will contact you by phone or email or will meet with you at your next clinic visit. 
 
In closing, it is important that you understand that your participation in this research study is purely 
voluntary. It is up to you to decide whether your biospecimens or data may be shared or banked for 
future research. You have the right to choose not to continue your participation in this study, and to not  
sign this letter.  
 
We hope that by sharing your biospecimens and data with internal and external collaborators, we will 
increase the number of research opportunities available to us to learn more about breast cancer. We 
hope to use the lessons learned from this trial to develop other research studies and novel approaches 
to better the lives of people living with this disease. We greatly appreciate your participation in this 
important study and thank you for your continued support.   
 
For any questions about the content of this letter you may contact a member of the study team using 
the contact information provided above. 
 
 
Sincerely, 
 
<Insert Consenting/Treating Physician Signature>