Conditions: Pancreas Cancer
Keywords: Pancreas pembrolizumab azacitidine metastatic pancreatic cancer first-line
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 36
Healthy volunteers: no

Brief summary:
The purpose of this study is to determine the effectiveness of combining immune therapy, pembrolizumab, with a hypomethylating agent, azacitidine, for pancreatic cancer. People who have advanced pancreatic cancer with disease progression on first-line therapy are usually treated with a second chemotherapy regimen. However, there is no single accepted chemotherapy regimen and national guidelines recommend chemotherapy or clinical trial participation. In this study, all study subjects will receive a combination of immune therapy (every 3 weeks) and a hypomethylating agent (every 4 weeks). To date, studies have shown that combining a hypomethylating agent with chemotherapy or immune therapy may benefit patients across different solid tumor types including pancreatic cancer. Preclinical data in a mouse model of pancreatic cancer demonstrates improvement in survival with the combination of a hypomethylating agent and immune therapy. However, the use of single agent hypomethylating agent or immune therapy has not been shown to be effective in patients with pancreatic cancer. The one exception, to date, is the use of immune therapy in those individuals with a particular genetic feature known as mismatch repair deficiency and microsatellite instability. The combination of immune therapy and a hypomethylating agent has not been studied in human subjects and is not approved by the FDA for use in pancreatic cancer.

This is a non-randomized, single-center, open-label trial of pembrolizumab and azacitidine in subjects with locally advanced or metastatic pancreatic adenocarcinoma. Approximately 31 individuals will be asked to participate in this study.

Detailed description:
Pancreatic ductal adenocarcinoma (PDA) has the worst prognosis of any major malignancy in the United States and, unlike other common cancers, annual deaths from PDA are rising. Despite recent advances, cytotoxic chemotherapy for PDA has been disappointing. Even among the small subset of patients who are suitable for surgical resection at the time of diagnosis, complete resection is followed by recurrence in majority of patients without further systemic therapy. Thus all PDA patients require systemic chemotherapy and more effective regimens are urgently needed.

Combination chemotherapy is effective in controlling disease and prolonging survival in patients with advanced pancreatic cancer. Despite recent successful phase 3 studies in the first-line setting, there is no defined second-line treatment for patients who experience disease progression following first-line therapy. Consensus guidelines (such as the National Comprehensive Cancer Network (NCCN) guidelines) recommend clinical trial participation in this setting.

The investigators' pre-clinical data suggests that decitabine treatment in the KPC model of pancreatic cancer leads to a significant up-regulation of interferon-related genes and a polarization of the infiltrating immune cells. Based on these results, the investigators have evaluated the effect of single agent decitabine or anti-PD1H (a homologue of PD1 with very similar function and expression pattern) compared to combination therapy (treatment with decitabine followed by PD1H blockade). The investigators' preliminary results showed minimal effect of either agent alone on tumor growth but marked decrease in tumor progression in the combination arm. These results form the foundation of this phase II study.

This study will treat patients with the combination of azacitidine and pembrolizumab. A direct comparison between azacitidine and decitabine in terms of efficacy within a controlled clinical trial has not been performed thus far. In randomized myelodysplastic syndrome (MDS) trials, the remission rates were similar for azacitidine and decitabine but the overall survival in the experimental arm was significantly shorter in the decitabine trial compared to the azacitidine trial. A primary reason to utilize azacitidine in this setting is our desire to amply reduced dose therapy with the goal of maintaining subjects on therapy Low-dose azacitidine is being tested in phase I/II clinical trials for advanced solid tumors-mainly colorectal cancer, small-cell lung carcinomas, ovarian cancer, and breast cancer.

Arms:
arm 1: Patients with advanced pancreatic cancer will receive pembrolizumab with the hypomethylating agent azacitidine.

Interventions: intervention 1: Pembrolizumab intervention 2: Azacitidine
Intervention descriptions: intervention 1: Pembrolizumab 200 mg IV every 3 weeks until progression intervention 2: 50 mg/m2 subcutaneous daily for 5 days every 28 days

Protocol document:
Prot_SAP_001.pdf: 
1 
Herbert Irving Comprehensive Cancer Center 
Protocol 
Phase II Open-Label, Single-Center Study Evaluating Safety and Efficacy of Pembrolizumab Following 
Induction with the Hypomethylating Agent Azacitidine in Patients with Advanced Pancreatic Cancer After 
Failure of First-Line Therapy
NCT03264404
March 17, 2022


2 
CUMC IRB#: AAAR3554 
Version Date: 10/19/2020 
TITLE: Phase II Open-Label, Single-Center Study Evaluating Safety and Efficacy of 
Pembrolizumab Following Induction with the Hypomethylating Agent Azacitidine in Patients 
with Advanced Pancreatic Cancer After Failure of First-Line Therapy. 
Coordinating Center: 
Columbia University Medical Center 
Principal Investigator: 
Ruth White, M.D.. PhD 
Columbia University Medical Center 
Herbert Irving Comprehensive Cancer Center 
161 Fort Washington Avenue, 8th floor 
New York, NY,10032
 Phone: 212-305-9422
 Fax: 212-305-3035 
Email address: raw2168@cumc.columbia.edu 
Co-Investigators: 
Richard D. Carvajal, M.D.  
Susan Bates, M.D. 
Gulam Manji, M.D., Ph.D. 
 Antonio Fojo, M.D. 
Statistician: 
Shing Lee, Ph.D. 
722 W 168th St, 6th Floor, Room 645
New York, NY 10032 
Phone: 212-342-1266 
Email address: sml2114@columbia.edu 


3 
Initial version: July 22, 2016 
Regulatory Sponsor: 
Ruth White, M.D., PhD. 
Columbia University Medical Center 
Herbert Irving Comprehensive Cancer Center 
Email 
address: 
raw2168@cumc.columbia.edu 
161 Fort Washington Avenue, 8th floor 
New York, NY 10032 Phone: 212-305-9422 
Funding Source: 
Merck & Co., Inc. One Merck Drive 
P.O. Box 100 
Whitehouse Station, New Jersey 08889 
Study Agent: 
Pembrolizumab, Keytruda 
Other Agent: 
Azacitidine, Vidaza 
IND Status: 
IND #: ###### 
IND Sponsor: Columbia University Medical Center 


4 
PROTOCOL SIGNATURE PAGE 
VERSION DATE 17MAR2022 
I confirm that I have read this protocol, I understand it, and I will work according to this 
protocol and to the ethical principles stated in the latest version of the Declaration of Helsinki, 
the applicable ICH guidelines for good clinical practices, and the applicable federal, state, and 
local laws, rules, and regulations relating to the conduct of the protocol. I have read and 
understand the information in the Investigators’ Brochure (or Manufacturer’s Brochure) 
regarding the risks and potential benefits. I will promptly submit the protocol to the applicable 
IRB for review and approval. Once the protocol has been approved by the IRB, I understand 
that any modification made during the course of the study must first be approved by the IRB, 
prior to implementation except when such modification is made to remove an immediate hazard 
to the subject. I certify that I, and the study staff, have received the requisite training to conduct 
this research protocol. I agree to maintain adequate and accurate records in accordance with 
Columbia University and Herbert Irving Comprehensive Cancer Center policies, Federal, state 
and local laws and regulations. I agree to maintain the confidentiality of all information 
received or developed in connection with this protocol. 
Signature of Principal Investigator 
Date 
Principal Investigator Name (Print) 
Name of Institution 
Instructions to Principal Investigator: Sign and Date this signature page and print your name. 
Return the original, completed and signed to the Clinical Protocol & Data Management Office. 
Retain a copy in the regulatory binder. 


5 
 
Table of Contents 
1. 
PROTOCOL SYNOPSIS ................................................................................................ 11 
1.1. 
Trial Design Overview ........................................................................................ 12 
1.2. 
Trial Schema ....................................................................................................... 13 
2. 
STUDY OBJECTIVES ................................................................................................... 14 
2.1. 
Primary Objective & Hypothesis ........................................................................ 14 
2.2. 
Secondary Objectives & Hypothesis ................................................................... 14 
2.3. 
Exploratory Objectives & Hypothesis Objectives: ............................................. 15 
3. 
BACKGROUND & RATIONALE ................................................................................. 15 
3.1. 
Pancreatic Cancer Background ........................................................................... 15 
3.2. 
Immunotherapy Background ............................................................................... 15 
3.3. 
Epigenetic Background ....................................................................................... 17 
3.4. 
Rationale.............................................................................................................. 18 
3.5. 
Rationale for Combining Hypomethylating Agents with Immunotherapy ......... 18 
3.6. 
Rationale for the Combination in Pancreatic Cancer .......................................... 18 
3.7. 
Selected Subject Population ................................................................................ 19 
3.8. 
Rationale for Dose Selection/Regimen/Modification ......................................... 19 
3.9. 
Rationale for Endpoints ....................................................................................... 19 
3.10. 
Efficacy Endpoints .............................................................................................. 19 
3.11. 
Safety Endpoints ................................................................................................. 19 
3.12. 
Biomarker Research and Exploratory Endpoints ................................................ 20 
3.13. 
Immunohistochemistry ........................................................................................ 20 
3.14. 
Transcriptional Analyses ..................................................................................... 20 
3.15. 
Proteomic analysis............................................................................................... 20 
3.16. 
Gene Analyses ..................................................................................................... 21 
4. 
INVESTIGATIONAL AGENTS .................................................................................... 21 
4.1. 
Pembrolizumab.................................................................................................... 21 
4.1.1 
Preclinical Data ............................................................................................................... 22 
4.1.2 
Clinical Data to Date ....................................................................................................... 23 
4.1.3 
Rationale for Dose Selection ........................................................................................... 23 
4.2. 
Azacitidine (Vidaza) ........................................................................................... 24 
5. 
STUDY DESIGN ............................................................................................................ 25 
5.1. 
General Design .................................................................................................... 25 
5.2. 
Dose Limiting Toxicities ..................................................................................... 27 
5.3. 
Number of Patients .............................................................................................. 28 
6. 
SUBJECT SELECTION AND WITHDRAWAL .......................................................... 28 
6.1. 
Inclusion Criteria ................................................................................................. 28 
6.2. 
Exclusion Criteria ................................................................................................ 29 


6 
 
6.3. 
Inclusion of Women and Minorities.................................................................... 31 
6.4. 
Subject Recruitment ............................................................................................ 31 
6.5. 
Early Withdrawal of Subjects ............................................................................. 32 
6.5.1 
When and How to Withdraw Subjects ............................................................................ 32 
6.5.2 
Data Collection and Follow-up for Withdrawn Subjects ................................................ 33 
6.6. 
Post-Treatment Visits .......................................................................................... 33 
6.6.2 
Follow-Up Visits ............................................................................................................. 33 
6.6.3 
Survival Follow-Up ......................................................................................................... 33 
7. 
REGISTRATION PROCEDURES ................................................................................. 34 
7.1. 
CUMC Research Participant Registration........................................................... 34 
CPDM Central Registration Procedures: .................................................................................... 34 
8. 
TREATMENT PLAN ..................................................................................................... 35 
8.1. 
Agent Administration .......................................................................................... 35 
8.2. 
Dose Selection/Modification ............................................................................... 36 
8.2.2 
Dose Modification (Escalation/Titration/Other) ............................................................. 36 
8.3. 
Pembrolizumab.................................................................................................... 37 
8.2.5 
Acceptable Concomitant Medications ............................................................................. 37 
8.2.6 
Prohibited Concomitant Medications .............................................................................. 37 
8.2.7 
Rescue Medications ......................................................................................................... 38 
8.2.8 
Supportive Care Guidelines ............................................................................................. 38 
8.4. 
Azacitidine .......................................................................................................... 53 
8.5. 
Diet/Activity/Other Considerations..................................................................... 54 
8.2.10 Contraception .................................................................................................................. 54 
8.2.11 Use in Pregnancy ............................................................................................................. 55 
8.2.12 Use in Nursing ................................................................................................................. 56 
8.6. 
Duration of Therapy ............................................................................................ 56 
8.7. 
Duration of Follow Up ........................................................................................ 56 
8.8. 
Criteria for Removal from Study ........................................................................ 56 
9. 
DOSING DELAYS/DOSE MODIFICATIONS ............................................................. 56 
9.1. 
Dose Modification for Pembrolizumab ............................................................... 56 
9.2 
Dose Modification for Azacitidine .................................................................................. 58 


7 
 
10. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS .......................... 58 
10.1. 
Definition of an Overdose for this Protocol and Reporting of Overdose to 
Sponsor- Investigator and to Merck .................................................................... 58 
10.2. 
Anticipated Adverse Events ................................................................................ 59 
10.3. 
Adverse Events Definitions:................................................................................ 59 
10.2.2 Serious Adverse Event: ................................................................................................... 59 
10.2.3 Unanticipated Problem: ................................................................................................... 60 
10.4. 
Events of Clinical Interest ................................................................................... 60 
10.5. 
Adverse Event Reporting Period ......................................................................... 61 
10.2.4 Baseline/Preexisting Condition ....................................................................................... 61 
10.2.5 General Physical Examination Findings ......................................................................... 61 
10.2.6 Post-study Adverse Event ............................................................................................... 61 
10.2.7 Abnormal Laboratory Values .......................................................................................... 62 
10.2.8 Hospitalization, Prolonged Hospitalization or Surgery ................................................... 62 
10.6. 
Assessing and Recording of Adverse Events ...................................................... 62 
10.7. 
Evaluating Adverse Events ................................................................................. 63 
10.8. 
Reporting of Serious Adverse Events ................................................................. 64 
10.2.10 FDA Notification by Sponsor-Investigator ..................................................................... 64 
10.2.11 DSMC Reporting by the Sponsor Investigator................................................................ 65 
10.2.12 Reporting to Drug Manufacturer by Sponsor-Investigator ............................................. 65 
11. 
PHARMACEUTICAL INFORMATION ....................................................................... 66 
11.1. 
Pembrolizumab.................................................................................................... 66 
11.2. 
Packing and Labeling Information ...................................................................... 66 
11.3. 
Clinical Supplies Disclosure ............................................................................... 66 
11.4. 
Storage and Handling Requirements ................................................................... 67 
11.5. 
Discard/Destruction/Returns and Reconciliation ................................................ 67 
11.6. 
Standard Policies ................................................................................................. 67 
11.7. 
Other Agent: Azacitidine .................................................................................... 67 
12. 
STUDY CALENDAR ..................................................................................................... 68 
12.1. 
Trial Flow Chart .................................................................................................. 68 
12.2. 
Trial Procedures .................................................................................................. 72 
12.3. 
Administrative Procedures .................................................................................. 72 
12.1.2 Inclusion/Exclusion Criteria ............................................................................................ 72 
12.1.3 Medical History ............................................................................................................... 72 


8 
 
12.1.4 Prior and Concomitant Medications ................................................................................ 72 
12.1.4.2 
Concomitant Medications.................................................................................... 73 
12.1.5 Disease Details and Treatments ...................................................................................... 73 
12.1.5.2 
Prior Treatment Details ....................................................................................... 73 
12.1.5.3 
Subsequent Anti-Cancer Therapy Status ............................................................. 73 
12.1.6 Clinical Procedures/Assessments .................................................................................... 73 
12.1.6.2 
Physical Exam ..................................................................................................... 73 
12.1.6.3 
Vital Signs ........................................................................................................... 73 
12.1.6.5 
Tumor Imaging and Assessment of Disease ....................................................... 74 
12.1.6.6 
Tumor Tissue Collection and Correlative Studies Blood Sampling ................... 74 
12.1.6.7 
Laboratory Procedures/Assessments ................................................................... 74 
13. 
MEASUREMENT OF EFFECT ..................................................................................... 74 
13.1. 
Antitumor Effect – Solid Tumors ........................................................................ 74 
13.1.1 Definitions of evaluable subjects..................................................................................... 75 
13.2. 
Disease Parameters .............................................................................................. 75 
13.3. 
Methods for Evaluation of Measurable Disease ................................................. 76 
13.4. 
Response Criteria- RECIST Criteria ................................................................... 77 
13.4.2 Evaluation of Non-Target Lesions .................................................................................. 77 
13.4.3 Evaluation of Best Overall Response .............................................................................. 77 
13.5. 
Assessment of Disease According to Immune Related RECIST for Solid Tumors
 ............................................................................................................................. 78 
13.5.1 Evaluation of Target Lesions by irRECIST .................................................................... 79 
13.5.2 Evaluation of Best Overall Response with irRECIST ..................................................... 80 
13.6. 
Analysis of Endpoints ......................................................................................... 80 
13.6.1 Efficacy Endpoints .......................................................................................................... 80 
13.6.2 Safety Endpoints ............................................................................................................. 80 
13.6.3 Correlative Endpoints ...................................................................................................... 81 
13.6.3.2 Epigenetic effect in tumor tissue ..................................................................................... 81 


9 
 
13.6.3.3 Immune phenotyping ....................................................................................................... 82 
13.7. 
Unblinding Procedures ........................................................................................ 82 
13.8. 
Stopping Rules .................................................................................................... 82 
14. 
DATA REPORTING / REGULATORY REQUIREMENTS ........................................ 83 
14.1. 
Data Collection .................................................................................................... 83 
14.2. 
Data Reporting .................................................................................................... 83 
14.3. 
Data and Safety Monitoring Committee ............................................................. 83 
14.4. 
Quality Control and Quality Assurance .............................................................. 84 
14.5. 
Confidentiality ..................................................................................................... 85 
14.6. 
Source Documents............................................................................................... 85 
14.7. 
Case Report Forms .............................................................................................. 85 
14.8. 
Records Retention ............................................................................................... 85 
15. 
STATISTICAL CONSIDERATIONS ............................................................................ 86 
15.1. 
Statistical Analysis Plan Summary ...................................................................... 86 
15.2. 
Populations for Statistical Analysis and Reporting ............................................. 86 
15.2.2 Safety Population ............................................................................................................ 86 
15.2.3 Efficacy Population ......................................................................................................... 86 
15.2.4 Reporting of Outcomes ................................................................................................... 87 
15.3. 
Study Design/Endpoints ...................................................................................... 87 
15.2.6 Secondary Endpoints ....................................................................................................... 87 
15.2.6.1 
Definition of secondary endpoints: ..................................................................... 87 
▪ 
Duration of Response ...................................................................................................... 88 
▪ 
Disease Control Rate ....................................................................................................... 88 
▪ 
Overall Survival (OS) ...................................................................................................... 88 
15.2.7 Exploratory and Ancillary Studies .................................................................................. 88 
15.4. 
Size/Accrual Rate ................................................................................................ 88 
15.5. 
Stratification Factors ........................................................................................... 89 
15.6. 
Statistical Methods for Safety Analysis .............................................................. 89 
15.7. 
Analysis Populations ........................................................................................... 89 
16. 
PROTECTION OF HUMAN SUBJECTS ...................................................................... 89 
17. 
STUDY FINANCES ....................................................................................................... 89 
17.1. 
Conflict of Interest............................................................................................... 89 
18. 
PUBLICATION PLAN ................................................................................................... 90 


10 
 
19. 
REFERENCES ................................................................................................................ 90 
20. 
APPENDICES ................................................................................................................. 95 
20.1. 
Appendix 1- ECOG Performance Status ............................................................. 95 
20.2. 
Appendix 2- Common Terminology Criteria for Adverse Events V4.0 (CTCAE)
 ............................................................................................................................. 95 
20.3. 
Appendix 3- Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 ...... 95 
 
 
LIST OF TABLES 
 
Table 1. 
Adequate Organ Function Laboratory Values .................................................... 29 
Table 2. 
Inclusion of Women and Minorities.................................................................... 31 
Table 3 
Trial Treatment Schedule .................................................................................... 36 
Table 4 
Infusion Reaction Treatment Guidelines............................................................. 53 
Table 5 
Dose Modification Guidelines for Pembrolizumab-Related Adverse Events ..... 57 
Table 6 
Dose Levels for Trial Medications ...................................................................... 58 
Table 7 
Evaluating Adverse Events ................................................................................. 63 
Table 8 
Product Description- Pembrolizumab ................................................................. 66 
Table 9 
Disease Assessment For Patients with Measurable Disease ............................... 78 


11 
 
1. 
PROTOCOL SYNOPSIS 
This document is a protocol for a human research study. This study is to be conducted 
according to US and international standards of Good Clinical Practice (FDA Title 21 part 312 
and International Conference on Harmonization guidelines), applicable government 
regulations and Columbia University Medical Center institutional research policies and 
procedures. 
 
Title 
Phase II open-label, single-center study evaluating safety and efficacy of 
pembrolizumab following induction with the hypomethylating agent 
azacitidine in patients with locally advanced or metastatic pancreatic 
cancer after failure of first-line therapy. 
Protocol Number 
AAAR3554 
Trial Phase 
2 
Methodology 
This is a single arm, open-label phase II trial of combination azacitidine 
and pembrolizumab in patients with locally advanced or metastatic 
pancreatic cancer in order to evaluate safety and efficacy. The primary 
endpoint is progression-free survival. 
Study Duration 
We estimate that the trial will require approximately 24 months to 
complete, with up to 18 months accrual and an additional 6 months 
follow-up to evaluate the primary efficacy outcomes for all subjects. 
Study Center(s) 
Columbia University Medical Center 
Objectives 
1. Primary objective: To evaluate the progression-free survival per 
RECIST 1.1. 
2. Secondary Objectives: 
a. Safety Objective: To determine the safety and tolerability 
of induction therapy with azacitidine followed by 
pembrolizumab in advanced pancreatic cancer. 
b. To evaluate the overall response rate (ORR), duration of 
response (DOR), disease control rate (DCR), and time to 
progression (TTP) per RECIST 1.1, and OS. 
Number of Subjects 31 evaluable subjects will be enrolled overall 
Diagnosis and Main 
Inclusion Criteria 
Locally advanced or metastatic pancreatic cancer who progressed on a 
single line of  5-FU- or gemcitabine-based chemotherapy. 
Study Product, 
Dose, Route, 
Regimen 
• Pembrolizumab 200 mg IV every 3 weeks until progression 
• Azacitidine 50 mg/m2 subcutaneous daily for 5 days every 28 
days 
 


12 
 
Duration of 
administration 
Treatment will continue until progressive disease, unacceptable adverse 
events, intercurrent illness that prevents further administration of 
treatment, investigator’s decision to withdraw the subject, subject 
withdrawal of consent, pregnancy of the subject, noncompliance with 
trial treatment or procedure requirements, subject receives 35 treatments 
(approx. 2 years) of pembrolizumab, or administrative reasons requiring 
cessation of treatment. 
Reference therapy 
Not applicable – Single arm study. 
Statistical 
Methodology 
This is a single arm, phase II study. To detect an improvement in 
progression free survival from a historical control of 2 months to 4 
months, with a one-sided p-value of 0.05 and 80% power, 31 evaluable 
patients will be required. We anticipate accrual over 18 months with an 
additional 6 months required for follow-up. 
 
 
1.1. Trial Design Overview 
This is a single-arm, single-center, open-label trial of azacitidine combined with 
pembrolizumab in subjects with locally-advanced or metastatic pancreatic adenocarcinoma. 
Thirty-one evaluable subjects will be enrolled to assess the efficacy and safety of combination 
therapy in the second- line setting. 
 
All subjects will have received systemic first-line chemotherapy, 5-FU or gemcitabine-based 
combination or monotherapy, prior to enrollment on the study. Azacitidine daily for 5 days 
will be given every 4 weeks (28 days). Fixed-dose pembrolizumab will be administered 
every 3 weeks for up to approximately 2 years beginning 2 weeks after initiation of 
azacitidine. The primary efficacy endpoint will be progression-free survival among all 
enrolled subjects. Disease progression will be determined based on RECIST 1.1 criteria; 
however, patients will be permitted to continue therapy following the development of 
progression of disease by RECIST 1.1 criteria if considered clinically appropriate by the 
study principal investigator. 
 
As preliminary data suggests there is minimal toxicity overlap between pembrolizumab and a 
hypomethylating agent, there will be an accelerated Phase 1 dose determination component 
of the study. In the initial cohort, low-dose azacitidine will be administered, as studied in 
patients with advanced or metastatic solid tumors,1 and pembrolizumab will be administered 
at fixed dose 
as detailed in the protocol. An initial cohort of 6 subjects will be enrolled, treated with 
combination therapy, and assessed for safety. Following enrollment of the initial 6 
evaluable subjects all toxicity data will be reviewed. If 2 or more patients experience a 
treatment related dose-limiting toxicity (DLT) within the first 6 weeks of treatment 
administration (Defined in Section 5.2), then accrual at that dose level will stop. We will 
allow for 1 dose reduction in azacitidine and if agreed by the PI, the study will resume at 
the lower dose (Dose -1) and will again accrue 6 subjects who will receive combination 
therapy. If 2 or more subjects experience treatment related DLTs at this level, we will 
discontinue the combination study. 


13 
 
If the combination dose is deemed safe (≤ 1 DLT), the study will complete accrual with 
treatment of an additional 25 subjects at the safe combination dose. Adverse events will be 
 
monitored throughout the trial and graded in severity according to the guidelines in the NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. DLT is defined as a 
grade 3 or above toxicity according to the CTCAE version 4.0. 
 
After the end of treatment, each subject will be followed by 30 days for adverse event 
monitoring. Serious adverse events and Events of Clinical Interest (ECI) will be collected for 
90 days after the end of treatment or 30 days after the end of treatment if the subject initiates 
new anticancer therapy, whichever is earlier. Subjects who discontinue treatment for reasons 
other than disease recurrence will have post-treatment follow-up for disease status until disease 
recurrence, withdrawing consent, or becoming lost to follow-up. All subjects will be contacted 
by telephone every 3 months for overall survival until death, withdrawal of consent or the end 
of the study, whichever comes first. 
 
Every subject enrolled will be required to have pre-treatment, biopsy-confirmed disease. 
Development of a predictive diagnostic assay that enables prospective identification of patients 
who are likely to respond to azacitidine plus pembrolizumab may allow for preselection of 
patients likely to benefit from treatment with these regimens in future clinical studies. To 
facilitate additional PD analysis, on-treatment biopsies will be required for all subjects after 8 
weeks of therapy if felt to be clinically feasible by the treating physician. Tumor samples will 
be collected and analyzed for molecular changes that occur during treatment with azacitidine 
and pembrolizumab. These analyses will help elucidate early mechanisms of action, predictors 
of treatment response, and predictors of survival in pancreatic cancer. Changes in tumor-
infiltrating T-cell activity, measured by expression of granzyme B and other exploratory 
makers, will be explored in freshly obtained tumor tissue prior to and during induction and 
maintenance treatment. 
 
Changes in blood biomarkers may provide evidence for biologic activity of combination 
azacitidine and pembrolizumab in humans and may allow for the development of a blood-
based biomarker to help predict which patients may benefit from priming with 
hypomethylation followed by PD-1 inhibition. An exploratory objective is to evaluate changes 
in pharmacodynamics markers, including methylation status. 
 
This study will be conducted in conformance with Good Clinical Practices. 
 
Specific procedures to be performed during the trial, as well as their prescribed times and 
associated visit windows, are outlined in the Trial Flow Chart – Section 12.1. 
 
1.2. Trial Schema 


14 
 
 
 
2. 
STUDY OBJECTIVES 
 
We will conduct a clinical trial of azacitidine combined with pembrolizumab in patients with 
advanced pancreatic cancer who progressed on first-line systemic therapy. 
 
2.1. Primary Objective & Hypothesis 
 
Objective: To evaluate the progression-free survival (PFS) per RECIST 1.1. 
Hypothesis: We hypothesize that anti-tumor immunity can be achieved in pancreatic 
adenocarcinoma and that combining hypomethylation with PD-1 blockade will alter 
gene signature pathways and shift the immune milieu to enhance immune activation 
leading to delayed time to death or progression in subjects with pancreatic 
adenocarcinoma. 
 
2.2. Secondary Objectives & Hypothesis 
 
Safety and Tolerability Objective: To determine the safety and tolerability of azacitidine 
combined with pembrolizumab in advanced pancreatic cancer. 
Hypothesis: We hypothesize that azacitidine priming in conjunction with pembrolizumab will 
 
be safe and tolerable and will delay progression of pancreatic cancer. 
 
Efficacy Objective: To evaluate the overall response rate (ORR), duration of response (DOR), 
disease control rate (DCR) per RECIST 1.1, and overall survival (OS). 


15 
 
Hypothesis: We hypothesize that combination hypomethylation with PD-1 blockade will 
enhance immune activation and lead to high response rates, longer periods of response, 
improve disease control, and prolonged survival compared to historical controls. 
2.3. Exploratory Objectives & Hypothesis Objectives: 
▪ To explore the relationship between response rate and tumor-infiltrating lymphocytes 
and macrophage tumor infiltration within the tumor and the tumor microenvironment 
from pre- versus on-treatment biopsies. 
▪ To evaluate the methylation status within tumor and peripheral blood. 
▪ To identify molecular (genomic, metabolic, and/or proteomic) determinants of 
response or resistance (e.g. PD-L1, gene expression profiling, or genomic variation), 
using blood and/or tumor tissue to define novel predictive and pharmacodynamics 
biomarkers and better understand the mechanism of action of pembrolizumab. 
Hypothesis: We hypothesize that baseline markers of immune activation will correlate with 
response to pembrolizumab and that responders to pembrolizumab will have distinct tumor 
immune phenotype and gene expression profiling compared to non-responders. 
 
 
3. 
BACKGROUND & RATIONALE 
 
3.1. Pancreatic Cancer Background 
 
Pancreatic ductal adenocarcinoma (PDA) has the worst prognosis of any major malignancy in 
the United States and, unlike other common cancers, annual deaths from PDA are rising. 
During the year 2014, it was estimated that 46,420 people would be diagnosed with PDA and 
approximately 39,590 people would die in the U.S.2 Despite recent advances, cytotoxic 
chemotherapy for PDA has been disappointing with response rates of 20-30% for the most 
active regimens3 and little activity for targeted therapies. Even among the small subset of 
patients who are suitable for surgical resection at the time of diagnosis, complete resection is 
followed by recurrence in >90% of patients without further systemic therapy, with a median 
time to recurrence of 6.9 months.4 Thus all PDA patients require systemic chemotherapy and 
more effective regimens are urgently needed.5 
 
Combination chemotherapy is effective in controlling disease and prolonging survival in 
patients with advanced pancreatic cancer. Despite recent successful phase 3 studies in the first-
line setting, there is no defined second-line treatment for patients who experience disease 
progression following first-line therapy. Consensus guidelines (such as the NCCN guidelines) 
recommend clinical trial participation in this setting. The median progression-free and overall 
survival for second-line therapy has been disappointing with a recent randomized cooperative 
group study (SWOG S11156) resulting in a median PFS of 2 months in the control group. 
 
3.2. Immunotherapy Background 
Immune checkpoint inhibitors have recently emerged as an important treatment modality for a 
variety of malignancies. Immune responses directed against tumors are one of the body’s 
natural defense against the growth and proliferation of cancer cells. T cells play a critical role 
in antitumor immunity and their infiltration and activity have been linked to improved 


16 
 
prognosis 
in a number of cancers.7,8 T-cells are activated when the T-cell receptor (TCR) recognizes 
tumor antigens bound to major histocompatibility complex proteins on antigen-presenting 
cells (APCs). This interaction leads to differentiation of T-cells into antitumor effectors that 
are capable of destroying cancer cells expressing the cognate antigen. An additional 
costimulatory signal is also necessary for T-cell activation, which is provided by the 
interaction between CD28 (on the T- cell) and B7 proteins (CD80 or CD86 on APCs). Once 
activated, T-cells upregulate inhibitory (checkpoint) molecules, which attenuate and 
eventually terminate the T-cell response. Over time 
and under pressure from immune attack, cancers develop strategies to evade immune-
mediated killing allowing them to develop unchecked. Immune evasion can occur via a wide 
range of mechanisms and is now recognized as one of the hallmarks of cancer. One such 
mechanism involves exploitation of immune checkpoint molecules to suppress anti-tumor T-
cell activity. 
 
Programmed cell death ligand 1 (PD-L1) is another checkpoint protein and is upregulated in 
a broad range of cancers with a high frequency – up to 88% expression in some tumor types. 
In a number of these cancers, including lung,9 renal,10-12 pancreatic,13,14 ovarian cancer15, and 
hematologic malignancies,16,17 tumor cell expression of PD-L1 is associated with reduced 
survival and an unfavorable prognosis. 
 
PD-L1 is part of a complex system of receptors and ligands that are involved in controlling 
T- cell activation. PD-L1 acts at multiple sites in the body to help regulate normal immune 
responses and is utilized by tumors to help evade detection and elimination by the host 
immune system tumor response. In the lymph nodes, PD-L1 on antigen-presenting cells binds 
to PD-1 or CD80 on activated T cells and delivers an inhibitory signal to the T cell.18,19 This 
results in reduced T-cell activation and fewer activated T cells in circulation. In the tumor 
microenvironment, PD-L1 expressed on tumor cells binds to PD-1 and CD80 on activated T 
cells reaching the tumor. This delivers an inhibitory signal to those T cells, preventing them 
from killing target cancer cells and protecting the tumor from immune elimination.20 
 
Tumor types characterized as being responsive to immunotherapy-based approaches include 
melanoma,21 renal cell carcinoma,22 urothelial carcinoma,23 malignant mesothelioma,24 
classical Hodgkin lymphoma, and non-small cell lung cancer.25 Both nivolumab and 
pembrolizumab are approved for advanced melanoma and advanced NSCLC refractory to 
first-line chemotherapy.26- 30 Pembrolizumab is also approved in NSCLC for two other 
indications: as first-line treatment for metastatic NSCLC with expression of PD-L1 on at 
least 50% of tumor cells, and to be used with pemetrexed and carboplatin for patients with 
previously untreated advanced nonsquamous NSCLC regardless of whether their tumors 
express PD-L11 (Langer CJ et al. Lancet Oncol. 
2016; 17(11):1497-1508). Additionally, pembrolizumab is approved for recurrent or 
metastatic head and neck squamous cell carcinoma (HNSCC) after platinum-based 
chemotherapy regardless of PD-L1 staining. Recently, pembrolizumab was FDA-approved 
for patients with solid tumors that were mismatch repair deficient and microsatellite unstable  
 
Despite the success of checkpoint inhibitors as single therapy in several cancers, treatment of 
patients with pancreatic cancer with these single agents has been ineffective. One difference 


17 
 
between tumors that have responded to checkpoint inhibitors and pancreatic cancer is the 
immune status of the tumor microenvironment.32 Cancers that respond to checkpoint 
inhibitors tend to be naturally infiltrated with effector lymphocytes while pancreatic cancer is 
characterized by a highly 
immunosuppressive tumor microenvironment composed of multiple immunosuppressive 
regulatory cells. 
 
3.3. Epigenetic Background 
Gastrointestinal (GI) cancers possess high degrees of epigenetic dysregulation. Epigenetic 
changes, such as DNA methylation, in tumor cells control gene expression and are known to 
alter immune cell phenotype and function.  Methylation of cytosine residues, at CpG sites 
that are unmethylated in normal tissue, is catalyzed by the DNA methyltransferases 
(DNMTs).33,34 In many malignancies, CpG islands within promoters of tumor suppressor 
genes become abnormally hypermethylated and thereby silenced.35,36 The global methylation 
pattern of the cancer genome is observed across many different cancer phenotypes and has a 
profound impact on genome-wide transcriptional regulation, ultimately creating an 
immunosuppressive environment that impairs endogenous tumor clearance and promotes 
evasion. 
 
In pancreatic cancer, DNA methylation is a mechanism through which tumor suppressor genes 
such as p16 are inactived.37 In fact, evidence supports the notion that aberrant methylation 
takes place very early during the histopathological development of this neoplasia. The loss of 
p16 expression in pancreatic intraepithelial neoplasia (PanIN) lesions has been reported in 
patients with chronic pancreatitis38, suggesting that this modification may contribute to the 
predisposition of patients affected by this disease who transition to develop pancreatic cancer. 
DNA from 65 PanIN lesions was assessed for methylation status of 8 genes previously 
recognized to be abnormally hypermethylated in invasive pancreatic adenocarcinoma.39 
Methylation at any one of these genes was identified in 68%. Additionally, aberrant CpG 
island hypermethylation was observed at early stages of PanINs and the incidence 
progressively increased during neoplastic development. 
 
Epigenetically modulated re-expression of silenced genes induces chemosensitization, and the 
use of epigenetic therapy to sensitize for immune therapy is also now emerging. A recent 
study showed that after treatment with low-dose 5-azacitidine in breast, ovarian, and 
colorectal cell line lines as well as primary tumors, 20% of all upregulated gene sets 
belonged to immunomodulatory pathways (e.g. interferon signaling, cytokines, antigen 
presentation, inflammation, and cancer testes antigens, and the commonly upregulated gene 
sets between the 3 cancer types.40 In murine mouse model, checkpoint inhibition combined 
with 5-azacitidine and entinostat resulted in a striking improvement in mouse survival and 
tumor growth inhibition with complete eradication of large colon cancers.41 
 
An important feature of pancreatic cancer is its low cellularity and surrounding desmoplastic 
reaction, highlighting the importance of the tumor microenvironment in the initiation and 
progression of pancreatic cancer. In one study, the use of hypomethylating agents 
successfully inhibited tumor progression in a stroma-rich mouse model of pancreatic cancer. 
 


18 
 
In summary, a novel approach to improve response rates with immune checkpoint blockade 
is the use of epigenetic therapy to “prime” the tumor and its microenvironment. Expression 
of critical immune-related genes can be restored with hypomethylating agents (HMAs), 
impairing tumor growth through a variety of mechanisms. 
 
3.4. Rationale 
 
3.5. Rationale for Combining Hypomethylating Agents with Immunotherapy 
Cancer testis antigens (CTAs) are protein fragments that are derived from proteins normally 
only expressed during embryonic development or in immune privileged organs such as the 
testes and brain. Because they are not typically expressed in the thymus nor exposed to antigen 
presenting cells, they are recognized as foreign the human immune system and are able to 
stimulate an immune response.42 For poorly understood reasons, these proteins and the fragment 
CTAs are commonly expressed by tumor cells and are thus a potential target for a tumor-
specific immune response. 
 
In some cancers, it has been shown that expression of CTAs can be epigenetically silenced 
via hypermethylation of gene promoters.43 This phenomenon appears to be reversible, as 
increased CTA expression and enhanced immunogenicity in cancerous but not normal cells 
following HMA therapy has been demonstrated in several pre-clinical models and clinical 
trials.40,44-49 Epigenetic alterations have also been found to silence antigen-presenting 
machinery genes and downregulate MHC class I expression on tumor cells.44 Treatment with 
agents such as azacitidine (a DNMT inhibitor) has reversed this phenotype in various in vitro 
and in vivo models.50 Most importantly, HMA therapy has the potential to enhance antitumor 
immune responses by upregulating checkpoint elements such as PD-L1 and PD-1. Recent 
work has demonstrated that hypermethylation of the PD-L1 gene promoter is associated with 
decreased PD-L1 expression on tumor cells,51 and azacitidine has been shown to increase PD-
L1 expression in NSCLC cell lines at both the transcript and protein level.50 Bone marrow 
samples from patients with a variety of hematologic malignancies have confirmed that 
treatment with HMAs is followed by evidence of increased PD-1/PD-L1 signaling.52 A recent 
study used an animal metastatic cancer model that is known to be resistant to treatment with 
immune checkpoint blockade. HMAs and histone deacetylating agents were successfully 
used to reverse this resistance, presumably by depleting myeloid derived suppressor cells 
(MDSCs) within the tumor microenvironment.41 
 
In summary, given that epigenetic dysregulation is present in pancreatic cancer and that 
epigenetic modifiers induce sensitization to immune therapy, there is strong pre-clinical and 
clinical rationale to investigate the combination of induction with a hypomethylating agent 
followed by checkpoint inhibition. In this trial, subjects will be treated with azacitidine, a 
DNMT inhibitor, and pembrolizumab in a sequential fashion. 
 
3.6. Rationale for the Combination in Pancreatic Cancer 
Our pre-clinical data suggests that decitabine treatment in the KPC model of pancreatic cancer 
leads to a significant upregulation of interferon-related genes and a polarization of the 
infiltrating immune cells.53  We identified a shift towards a favorable macrophage phenotype 


19 
 
(M1 vs M2) and an increase in tumor infiltrating CD8 T cells. Based on these results we have 
evaluated the effect of single agent decitabine or anti-PD1H (a homologue of PD1 with very 
similar function and expression pattern) compared to combination therapy (treatment with 
decitabine followed by PD1 blockade). Our preliminary results showed minimal effect of 
either agent alone on tumor growth but marked decrease in tumor progression in the 
combination arm. These results form the foundation of this phase II study. 
 
This study will treat patients with a combination of azacitidine and pembrolizumab. A direct 
comparison of azacitidine and decitabine, in terms of efficacy within a controlled clinical trial, 
has not been performed thus far. In randomized MDS trials, the remission rates were similar 
for azacitidine and decitabine but the overall survival in the experimental arm was 
significantly shorter in the decitabine trial compared to the azacitidine trial.54,55 A primary 
reason to utilize azacitidine in this setting is our desire to utilize reduced dose therapy with the 
goal of maintaining subjects on therapy for as long as tolerated. Low-dose azacitidine is being 
tested in phase I/II clinical trials for advanced solid tumors—mainly colorectal cancer, small-
cell lung carcinomas, ovarian cancer, and breast cancer. Furthermore, low-dose azacitidine 
with the HDAC inhibitor etinostat in refractory advanced non-small cell lung cancer was well-
tolerated and led to impressive results in a subset of patients.56 
 
3.7. Selected Subject Population 
This study will enroll subjects with advanced pancreatic cancer who have progressed on first 
line chemotherapy. This is a population with few good therapeutic options beyond first line 
chemotherapy. Current guidelines and clinical practice recommend clinical trial as a preferred 
option for this patient population. This study will enroll eligible patients in the second-line 
setting irrespective of PD-L1 status, however, this will be checked in the baseline tumor 
specimens. 
 
3.8. Rationale for Dose Selection/Regimen/Modification 
Low-dose azactidine, as used in conjunction with cytotoxic chemotherapy for solid tumors, 
will be given in combination with fixed dose pembrolizumab as detailed in Section 4.1.3. 
 
3.9. Rationale for Endpoints 
 
3.10. Efficacy Endpoints 
The primary efficacy objective of this study is to evaluate anti-tumor activity of 
pembrolizumab in combination with azacitidine as measured by progression-free survival. 
Additional efficacy endpoints will be assessed, most notably overall response rate and overall 
survival. 
 
3.11. Safety Endpoints 
The primary safety objective of this trial is to characterize the safety and tolerability of 
pembrolizumab in combination with azacitidine in subjects with locally-advanced or 
metastatic pancreatic cancer. The primary safety analysis will be based on subjects who 
experienced toxicities as defined by CTCAE (Appendix 2). Safety will be assessed by 
quantifying the toxicities and grades experienced by subjects who have received any study 


20 
 
drug, including serious adverse events (SAEs) and events of clinical interest (ECIs). 
 
Safety will be assessed by adverse experiences using CTCAE, Version 4.0. The attribution to 
drug, time-of-onset, duration of the event, its resolution, and any concomitant medications 
administered will be recorded. Adverse events will be analyzed including but not limited to all 
adverse events (AE), SAEs, fatal AEs, and laboratory changes. Furthermore, specific events of 
clinical interest will be collected as described in Section 10.4. 
 
3.12. Biomarker Research and Exploratory Endpoints 
Additional biomarker research to identify factors important for azacitidine and pembrolizumab 
 
therapy may also be pursued. For example, tumor and blood samples (including serum and 
plasma) from this study may undergo proteomic, genomic, metabolomics, and transcriptional 
analyses. This research may evaluate factors important for predicting responsiveness or 
resistance to azacitidine and pembrolizumab therapy and other immunologic targets. 
 
Both blood and tissue samples will be collected as available for these assays and patients will 
be asked to consent to use of any medically extra samples. Assays may include but are not be 
limited to the following: 
 
3.13. Immunohistochemistry 
PD-L1 expression in tumor tissue will be characterized by immunohistochemistry to explore 
the relationship between PD-L1 expression and response to treatment with pembrolizumab 
(this is a secondary objective of the trial). Other exploratory biomarkers (e.g. PD-1 expression, 
markers of T-cell phenotype) may also be evaluated. 
 
3.14. Transcriptional Analyses 
As an exploratory analysis, messenger RNA (mRNA) expression profiling in archival material 
(biopsy specimens, peripheral blood) will be completed to assess expression of approximately 
500 genes and attempt to define a gene set critical for clinical response to pembrolizumab. The 
hypothesis to be tested is that pembrolizumab induces responses in tumors that reflect an 
inflamed/ immune phenotype based on gene expression signatures capturing PD -L1 & 
interferon gamma transcriptional programs. Global profiling will also be pursued. Expression 
of individual genes related to the immune system may also be evaluated such as immune 
signatures and critical cytokines (e.g., IL-10). MicroRNA profiling may also be pursued in 
serum samples. 
 
3.15. Proteomic analysis 
In addition to expression on the tumor tissue, PD-L1 can be shed from tumor and released into 
the blood. Enzyme-linked immunoassay can measure PD-L1 in serum and correlate this 
expression with response to pembrolizumab therapy, as well as levels of PD-L1 IHC or protein 
in the tumor. Blood would be a less invasive component from which to measure PDL1 protein 
biomarker. In addition to this specific protein biomarker, both tissue and blood derivatives can 
be subjected to proteomic profiling studies using a variety of platforms that could include but 
are not limited to immunoassay, Liquid Chromatography/Mass Spectrometry. This approach 
could identify novel protein biomarker that could aid in subject selection for pembrolizumab 


21 
 
therapy. 
 
3.16. Gene Analyses 
The application of new technologies, such as next generation sequencing, has provided 
scientists the opportunity to define certain tumor types at the genetic level as being 
‘hypermutated’ or can detect the presence of specific T-cell clones within the tumor 
microenvironment or in the peripheral blood. There is a potential that the hypermutated state 
and/or increased T-cell clonality may correlate with response to pembrolizumab therapy, 
and/or that the converse, ‘hypomutated’ state or lack of dominant T-cell clones may correlate 
with non-response. 
 
In addition, understanding genetic determinants of drug response is an important endeavor 
during medical research. This research will evaluate whether genetic variation within a clinical 
trial population correlates with response to the treatment(s) under evaluation. If genetic 
variations found to predict efficacy or adverse events, the data might inform optimal use of 
therapies in the subject population. 
 
 
4. 
INVESTIGATIONAL AGENTS 
 
4.1. Pembrolizumab 
 
Pembrolizumab (MK-3475) 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, programmed death ligand 1 (PD-L1) and programmed 
death ligand 2 
(PD-L2). KEYTRUDA® (pembrolizumab) has recently been approved in the United States 
for the treatment of patients with unresectable or metastatic melanoma and disease 
progression following treatment with ipilimumab or a BRAF inhibitor, if BRAF V600 
mutation-positive. Pembrolizumab was also recently approved for the treatment of patients 
with metastatic non- small cell lung cancer (NSCLC) whose tumors express PD-L1 as 
determined by a Food and Drug Administration (FDA)-approved test, with disease 
progression on or after platinum- containing chemotherapy. 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades57. Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in 
various malignancies58-61. 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 


22 
 
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)62. 
 
The structure of murine PD-1 has been identified. 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-regulatory cells and natural killer cells63. 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 tumors64-66. 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 (PD-L1 or PD-L2) 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. 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. 
 
4.1.1 
Preclinical Data 
Therapeutic studies in mouse models have shown that the administration of antibodies 
blocking the PD-1/PD-L1 interaction enhances infiltration of tumor-specific CD8+ T-cells 
and leads ultimately to tumor rejection, either as a monotherapy or in combination with other 
treatment modalities. Anti-mouse PD-1 and anti-mouse PD-L1 antibodies have demonstrated 
anti-tumor responses as monotherapy in models of squamous cell carcinoma, pancreatic 
carcinoma, melanoma, and colorectal carcinoma. Blockade of the PD-1 pathway effectively 
promotes CD8+ T-cell infiltration into the tumor and the presence of IFN-ɣ, granzyme B and 
perforin, indicating that the mechanism of action involved local infiltration and activation of 


23 
 
effector T-cell function in vivo67,68. Experiments have confirmed the in vivo efficacy of PD-
1 blockade as a monotherapy as well as in combination with chemotherapy in syngeneic 
mouse tumor models (see the Investigator Brochure for additional details). 
 
4.1.2 
Clinical Data to Date 
Clinical trials have demonstrated efficacy using pembrolizumab in subjects with advanced 
melanoma, non-small cell lung cancer (NSCLC), head and neck cancer, bladder cancer, 
Hodgkin’s lymphoma, triple-negative breast cancer, and gastric adenocarcinoma. In addition, 
recent data demonstrate emerging evidence of single-agent activity in additional tumor types 
such as mesothelioma, urothelial cancer, ovarian cancer, neuroendocrine carcinoma, and small 
cell lung cancer. 
 
4.1.3 
Rationale for Dose Selection 
The dose of pembrolizumab planned to be studied in this trial is 200 mg Q3W. Information on 
the rationale for selecting the 200 mg Q3W dose is summarized below. 
 
Keynote-001, an open-label Phase I study, was conducted to evaluate the safety, tolerability, 
pharmacokinetics (PK) and pharmacodynamics, and anti-tumor activity of single agent 
pembrolizumab. The dose escalation portion of this trial evaluated three dose levels, 1 mg/kg, 
3 mg/kg and 10 mg/kg, administered every 2 weeks (Q2W) and dose expansion cohorts 
evaluated 2 mg/kg Q3W and 10 mg/kg Q3W in subjects with advanced solid tumors. All dose 
levels were well tolerated and no dose-limiting toxicities were observed. This first-in- human 
study of pembrolizumab showed evidence of target engagement and objective evidence of 
tumor size reduction at all dose levels. No maximum tolerated dose (MTD) has been 
identified. In addition, two randomized cohort evaluations of melanoma subjects receiving 
pembrolizumab at a dose of 2 mg/kg versus 10 mg/kg Q3W have been completed, and one 
randomized cohort evaluating 10 mg/kg Q3W versus 10 mg/kg Q2W has also been completed. 
The clinical efficacy and safety data demonstrate a lack of important differences in the 
efficacy and safety profiles across doses. 
 
An integrated body of evidence, based on dose/exposure efficacy and safety relationships, 
demonstrated no clinically significant differences in efficacy and safety between doses of 200 
mg or 2 mg/kg Q3W in patients with melanoma and NSCLC. As such, the recommended fixed 
dose is 200 mg Q3W. 
 
The pharmacokinetics (PK) of pembrolizumab was characterized using a population PK 
analysis with concentration data collected from 2841 patients with various cancers who 
received pembrolizumab doses of 1 to 10 mg/kg Q2W or 2 to 10 mg/kg Q3W. The PK profile 
of pembrolizumab was consistent with that of other humanized monoclonal antibodies, which 
typically have a low clearance and a limited volume of distribution. The distribution of 
exposures from the 200 mg fixed dose overlapped with the 2 mg/kg dose and, importantly, 
maintained individual patient exposures within the exposure range established in melanoma 
and NSCLC associated with maximal clinical response. Pharmacokinetic properties of 
pembrolizumab, and specifically the weight-dependency in clearance and volume of 
distribution, were consistent with no meaningful advantage to weight -based dosing relative to 
fixed dosing. 


24 
 
 
In translating to other tumor indications, flat exposure-response relationships for efficacy and 
safety are observed, as the anti-tumor effect of pembrolizumab is driven through immune 
system activation rather than through a direct interaction with tumor cells, rendering it 
independent of the specific tumor type. In addition, available PK results in subjects with 
melanoma, NSCLC, and other tumor types support a lack of meaningful difference in 
pharmacokinetic exposures obtained at tested doses among tumor types. Thus, the 200 mg 
Q3W fixed-dose regimen is now considered an appropriate fixed dose for other tumor 
indications as well. 
 
4.2. Azacitidine (Vidaza) 
 
Azacitidine is a pyrimidine nucleoside analog of cytdidine. It is a metabolic inhibitor that 
promotes hypomethylation of DNA and restores normal gene differentiation and proliferation. 
Azacitidine is also directly cytotoxic to rapidly dividing cells and hematopoeietic cells in the 
bone marrow. Hypomethylation may promote episensitization to immunotherapy by 
immunogenicity priming, improving the tumor microenvironment, and enhancing gamma 
interferon sensitivity40,50,69,70. 
 
Despite encouraging results with demethylating agents in hematologic malignancy, single 
agent results in solid tumors have been disappointing. One of the historical reasons for this has 
been the use of cytotoxic doses which led to significant toxicity.71 Since these initial studies, 
several recent pre-clinical and human studies have shown that much lower doses are sufficient 
to achieve a similar effect on methylation status without reaching doses that are associated with 
significant side effects. In solid tumors, treatment with demethylating agents such as 
decitabine or azacitidine has encouraging results when administered prior to cytotoxic 
chemotherapy. 
 
In recent clinical trials for non-small cell lung cancer, a small number of patients had 
remarkably robust and durable responses to immune checkpoint blockade after first receiving 
azacitidine50,56. Azacitidine induces interferon signaling and concordant upregulation of 
surface antigens and their assembly proteins, viral defense pathways, and transcript and 
surface protein levels of PD- L1, the key checkpoint ligand targeted by pembrolizumab40,50. A 
recent study has demonstrated the effect of the demethylating agent, azacitidine, via 
upregulation of endogenous retroviruses which led to a growth-inhibiting tumor response72. 
These authors have shown a significantly increased efficacy of azacitidine plus anti-CTLA-4 
therapy compared to anti-CTLA-4 therapy alone in a murine melanoma model. 
 
The pharmacokinetics of azacitidine were studied in 6 myelodysplastic (MDS) patients 
following a single 75 mg/m2 SubQ dose and a single 75 mg/m2 IV dose. Azacitidine is rapidly 
absorbed after SubQ administration, and the bioavailability of SubQ azacitidine relative to IV 
azacitidine was approximately 89% based on area under the curve. It is FDA-approved for IV 
or SubQ administration in MDS. 
 
Azacitidine for subcutaneous injection is supplied as a lyophilized powder in 100 mg single-
dose vials. Each vial also contains 100 mg mannitol. For subcutaneous injection, reconstitute 


25 
 
azacitidine aseptically with 4 mL sterile water. Inject the diluent slowly into the vial. 
Vigorously shake or roll the vial until a uniform suspension is achieved. The suspension will 
be cloudy and should not be filtered after reconstituting since doing so could remove the active 
substance. The resulting suspension will contain azacitidine 25 mg/mL. 
 
For immediate SubQ administration, doses greater than 4 mL should be divided equally into 2 
syringes. The product may be held at room temperature for up to 1 hour, but must be 
administered within 1 hour after reconstitution. For delayed SubQ administration, the 
reconstituted product may be kept in the vial or drawn into a syringe. Doses greater than 4 mL 
should be divided equally into 2 syringes. The product must be refrigerated immediately. 
When azacitidine is reconstituted using water for injection that has not been refrigerated, the 
reconstituted product may be held under refrigerated conditions (2C - 8C , 36F - 46F) 
for up to 8 hours. When azacitidine is reconstituted using refrigerated (2C - 8C , 36F - 
46F) water for injection, the reconstituted product may be stored under refrigerated 
conditions (2C - 8C , 
 
36F - 46F) for up to 22 hours. After removal from refrigerated conditions, the suspension 
may be allowed to equilibrate to room temperature for up to 30 minutes prior to 
administration. To provide a homogeneous suspension, the contents of the dosing syringe must 
be re-suspended immediately prior to administration. 
 
Doses greater than 4 mL should be divided equally into 2 syringes and injected into 2 separate 
sites. Rotate sites for each injection (thigh, abdomen, or upper arm). New injections should be 
given at least one inch from an old site and never into areas where the site is tender, bruised, 
red, or hard. The recommended starting dose in MDS is 75 mg/m2 SubQ, however, lower doses 
have been shown to be effective in solid tumor patients in conjunction with other 
chemotherapeutic agents. In this protocol, we will utilize lower starting dose of azacitidine (50 
mg/m2 ) in conjunction with pembrolizumab. 
 
 
5. 
STUDY DESIGN 
 
5.1. General Design 
 
This is a single-arm, open-label, single site Phase II trial of azacitidine combined with 
pembrolizumab in previously systemically treated subjects with a histologically or 
cytologically confirmed diagnosis of pancreatic ductal adenocarcinoma. Pre-treatment biopsies 
will be required for those subjects without an archival sample. All subjects will be required to 
provide a tumor tissue sample, either from the primary or a metastatic site, for biomarker 
analysis after 8 weeks on treatment. Thirty-one evaluable subjects will be allocated to receive 
azacitidine 50 mg/m2 SubQ for 5 days every 28 days (Q4W) with single-agent pembrolizumab 
200 mg IV every 3 weeks (Q3W) beginning on week 3. 
 
The primary objective of this trial is to determine the PFS of pembrolizumab given in 
combination with a hypomethylating agent. Beginning with screening, all imaging assessments 
will be evaluated using RECIST 1.1. On-study imaging assessments will be performed every 8 


26 
 
weeks (Q8W) calculated from the date of allocation and independent of treatment delays. 
RECIST 1.1 will be used by the site for treatment decisions until the first radiologic evidence 
of progressive disease (PD). 
 
Following the first radiologic evidence of PD by RECIST 1.1, treatment decisions may be 
made by the adaptation of RECIST 1.1 as described in Section 13.5 termed immune-related 
RECIST (irRECIST) to accommodate the tumor response patterns seen with pembrolizumab 
treatment (e.g., tumor flare). This was first described by Nishino, et al. 201373 and is 
further modifie        d for the pembrolizumab program as described in Section 13.5. For a 
clinically stable subject with first radiologic evidence of PD, it is at the discretion of the 
principal investigator to continue treating the subject with pembrolizumab until PD is 
confirmed at least 4 weeks after the date of the first tumor imaging confirming PD per the 
principal investigator. If radiologic PD is confirmed by the subsequent tumor imaging, the 
subject should be discontinued from treatment unless, in the opinion of the investigator, the 
subject is achieving a clinically meaningful benefit; an exception for continued treatment may 
be considered following consultation with the PI. 
 
Subjects may continue to be treated with pembrolizumab until PD is confirmed by 
RECIST 1.1, unacceptable adverse events (AEs), intercurrent illness that prevents further 
administration of treatment, investigator’s decision to withdraw the subject, subject 
withdrawal of consent, pregnancy of the subject, noncompliance with trial treatment or 
procedure requirements, administrative reasons, or the subject has received 35 trial 
treatments (approximately 2 years) with pembrolizumab. Subjects who discontinue trial 
treatment for a reason other than disease progression will move into the Follow-Up Phase 
and should be assessed every 8 weeks (±7 days) by radiologic imaging to monitor disease 
status. 
 
Disease status will continue to be monitored until whichever of the following occurs 
first: the start of new anti-cancer treatment, disease progression, death, or the end of 
the study. All subjects will be followed by phone contact every 12 weeks (+/- 2 
weeks) for overall survival (OS) until death, withdrawal of consent from participation 
in the study, or the end of the study, whichever comes first. 
 
Subjects who attain a CR by 2 tumor imaging assessments at least 4 weeks apart and who 
have received at least 8 treatments (approximately 6 months of therapy) with 
pembrolizumab may discontinue treatment at the discretion of the investigator after 
receiving at least 2 treatments beyond the initial determination of a CR. Subjects who stop 
pembrolizumab after receiving 35 trial treatments (approx. 2 years) for reasons other than 
PD or intolerability or who stop after attaining a CR may be eligible for retreatment with up 
to an additional 17 treatments (second course of treatment, approximately 1 year) after they 
have experienced radiographic PD after consultation with the principal investigator. The 
decision to retreat will be at the discretion of the investigator only if no other cancer 
treatment was administered since the last dose of pembrolizumab, the subject still meets the 
parameters listed in the inclusion and exclusion criteria, and the trial remains open. 
 
Adverse events will be monitored throughout the trial and graded in severity according to 


27 
 
the guidelines outlined in the National Cancer Institute (NCI) Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 (Appendix 2). After the end of treatment, 
each subject will be followed for 30 days for AE monitoring. Serious adverse events (SAEs) 
will be collected for 90 days after the end of treatment or 30 days after the end of treatment 
if the subject initiates new anticancer therapy, whichever is earlier. 
 
This study will be conducted in conformance with Good Clinical Practices (GCP). 
 
Specific procedures to be performed during the trial, as well as their prescribed times and 
associated visit windows, are outlined in the Trial Flow Chart - Section 12.1. Details of each 
procedure are provided in Section 12.2 – Trial Procedures. 
 
5.2. Dose Limiting Toxicities 
 
All toxicities will be graded according to the NCI CTCAE version 4.0 and assessed for 
relationship to study medications. 
 
The incidence of DLT(s) assessed in the first 6 evaluable subjects during the first 6 weeks will 
be to initially determine whether the dose level of combination therapy is tolerable. A subject 
will be considered evaluable for DLT if they have received at least 1 dose of pembrolizumab 
after receiving the initial week of azacitidine. DLT should not be an AE considered by the 
investigator to be disease related. The following drug-related AE (whether related to one or 
both agents) will be considered a DLT: 
 
• Any Grade ≥ 3 drug-related non-hematological AE, including the following 
laboratory abnormalities 
- 
If a subject has baseline Grade ≤ 1 AST, ALT, or total bilirubin, a drug-related Grade 
≥ 3 toxicity will be considered a DLT 
- 
If a subject has baseline asymptomatic Grade 2 AST or ALT due to tumor 
infiltration in the liver, drug-related elevations in AST and/or ALT > 2x baseline or 
a maximum of > 8x ULN that does not resolve to Grade 2 or less within 48 hours 
(if symptomatic) or that does not resolve to Grade 1 or less within 3 weeks of onset 
(if asymptomatic) will be considered a DLT. 
 
• Any Grade ≥ 3 drug-related non-hematological laboratory abnormality with 
the following exceptions: 
- 
Grade 3 abnormal laboratory result that is asymptomatic and lasts no longer than 
72 hours. 
- 
Grade 4 lymphocytopenia not associated with symptoms or clinical 
manifestations 
 
• Any toxicity managed by discontinuation of pembrolizumab (see section 9.1). 
• Any toxicity managed by discontinuation of azacitidine (see section 9.2). 
• Grade ≥ 3 thrombocytopenia with bleeding, and febrile neutropenia of any Grade. 


28 
 
 
5.3. Number of Patients 
Thirty-one subjects who are evaluable for progression-free survival will be enrolled. 
Unevaluable patients (as defined in Section 13.1.1) will be replaced. 
 
 
6. 
SUBJECT SELECTION AND WITHDRAWAL 
 
Male and female subjects with advanced pancreatic ductal adenocarcinoma after progression 
on first-line systemic therapy who are considered incurable will be enrolled in this trial. 
 
6.1. Inclusion Criteria 
In order to be eligible for participation in this trial, the subject must: 
1. Be willing and able to provide written informed consent for the trial. In cases of partial 
impairment, impairment that fluctuates over time, or complete impairment due to dementia, 
stroke, traumatic brain injury, developmental disorders (including mentally disabled 
persons), serious mental illness, and delirium, a subject may be enrolled if the subject’s 
legally authorized representative consents on the subject’s behalf. 
▪ Age ≥18 years of age on day of signing informed consent. 
▪ Have histologically or cytologically confirmed diagnosis of pancreatic 
ductal adenocarcinoma 
▪ Have a predicted life expectancy of greater than 3 months. 
▪ Have measurable disease based on RECIST 1.1. 
▪ Have a performance status of 0 or 1 using the ECOG Performance Scale within 3 days 
of first dose of study drug. 
▪ Have documented radiographic progression to or documented intolerance of first line 
systemic chemotherapy which included at least gemcitabine or 5-FU based regimen 
(including capecitabine). 
▪ Subjects who have documented disease recurrence within 6 months of completing 
neoadjuvant or adjuvant chemotherapy for limited disease will be eligible for study 
provided they have not received an additional line of systemic therapy. Subjects who 
recur greater than 6 months after completing adjuvant or neoadjuvant chemotherapy 
will not be eligible unless they receive additional chemotherapy for advanced disease. 
 
▪ Have a negative urine or serum pregnancy test within 72 hours prior to receiving 
the first dose of study medication (Cycle 1, Day 1) (female subjects of 
childbearing potential). If the urine test is positive or cannot be confirmed as 
negative, a serum pregnancy test will be required. 
• Be willing to use an adequate method of contraception for the course of the study 
through 120 days after the last dose of study medication (male and female subjects 
of childbearing potential [see Section 8.5.2]). 


29 
 
• Demonstrate adequate organ function as defined in Table 1. 
 
Table 1. 
Adequate Organ Function Laboratory Values 
 
 
 
6.2. Exclusion Criteria 
The subject must be excluded from participating in the trial if the subject: 
▪ Is currently participating and receiving study therapy or has participated in a 
study of an investigational agent and received study therapy, or 
herbal/complementary oral or IV medicine within 2 weeks of the first dose of 
treatment. 
▪ All toxicities attributed to prior anti-cancer therapy other than alopecia and 
fatigue must have resolved to Grade 1 (NCI-CTCAE Version 4.0) or baseline 
prior to administration of first dose of study drug. Subjects with toxicities 
attributed to prior anti-cancer therapy that are not expected to resolve and result 
in long-lasting sequelae, such as chronic neuropathy after platinum based 
therapy, are permitted to enroll 
▪ Has received chemotherapy or radiotherapy within 14 days of first dose of 
study medication. 
▪ Had a solid organ or hematologic transplant. 
System 
Laboratory Value 
Hematological 
Leukocytes 
≥2,000/mcL 
Absolute neutrophil count (ANC) 
≥1,500 /mcL 
Platelets 
≥100,000 / mcL 
Hemoglobin 
≥9 g/dL without transfusion or EPO dependency within 7 days 
Renal 
Creatinine OR 
Measured or calculateda  creatinine clearance 
(GFR can also be used in place of creatinine or CrCl) 
≤1.5 X upper limit of normal (ULN) OR 
≥60 mL/min for subject with creatinine levels > 1.5 X 
institutional ULN 
Hepatic 
Total bilirubin 
≤ 2 mg/dL or direct bilirubin ≤ ULN for those with total 
bilirubin >2xULN 
Subjects with Gilbert Syndrome will be eligible if total bilirubin 
is < 3.0 mg/dL. 
AST (SGOT) and ALT (SGPT) 
≤ 2.5 X ULN OR 
≤ 5 X ULN for subjects with liver metastases 
Albumin 
>3.0 mg/dL 
Amylase and Lipase 
≤1.5 ULN. Subjects with Amylase or Lipase > 1.5 ULN may 
enroll if there are neither clinical nor radiographic signs of 
pancreatitis 
Coagulation 
INR or PT 
aPTT 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or aPTT is within therapeutic range of intended 
use of anticoagulants 


30 
 
▪ Has experienced weight loss >10% over 2 months prior to first dose of study therapy. 
▪ Has active autoimmune disease that has required systemic treatment in past 2 years 
(i.e. with use of disease-modifying agents, corticosteroids, or immunosuppressive 
drugs). Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid 
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a 
form of systemic treatment. 
▪ Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy (at a 
dose greater than 10mg/day of Prednisone equivalent) or any other form of 
immunosuppressive therapy within 7 days prior to the first dose of trial treatment. 
▪ Has a diagnosed additional malignancy within 2 years prior to first dose of trial 
treatment with the exception of curatively treated basal cell carcinoma of the skin, 
squamous cell carcinoma of the skin or curatively resected in situ breast cancers. 
Subjects with another malignancy diagnosed >2 years prior to the first dose of trial 
medication who were treated with curative intent and are not undergoing active 
therapy will be eligible. 
▪ Has a known history of, or any evidence of, interstitial lung disease or active 
non- infectious pneumonitis. 
▪ Has an active infection requiring systemic therapy. 
▪ Has clinically relevant ascites at baseline (defined as requiring paracentesis) or 
with moderate radiographic ascites. A minimal amount of radiographic ascites is 
allowed. 
▪ Has a history of current evidence of any condition, therapy, or laboratory 
abnormality that might confound the results of the trial, interfere with the subject’s 
participation for the full duration of the trial, or is not in the best interest of the 
subject to participate, in the opinion of the treating investigator, including dialysis. 
▪ Has known psychiatric or substance abuse disorders that would interfere with 
cooperation with the requirements of the trial. 
▪ Is pregnant or breastfeeding, or expecting to conceive or father children within the 
projected duration of the trial, starting with the screening visit through 120 days after 
the last dose of trial treatment. 
▪ Has received prior therapy with anti–PD-1, anti–PD-L1, or anti–PD-L2 agents, or 
if the subject has previously participated in Merck pembrolizumab clinical trials. 
▪ Has a known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies). 
▪ Has known chronic or acute Hepatitis B (e.g., HBsAg reactive) or Hepatitis C 
infection (e.g., HCV RNA [qualitative] is detected). 
• Note: To qualify for enrollment, antiviral therapy for HBV must be given for at 
least 3 months, and HBV viral load must be less than 100 IU/mL prior to first dose 
of study 
 
drug. Those on active HBV therapy with viral loads under 100 IU/mL should stay on 


31 
 
the same therapy throughout trial treatment. Those subjects who are anti-HBc (+), and 
negative for HBsAg, and negative for anti-HBs, and have an HBV viral load under 
100 IU/mL do not require HBV anti-viral prophylaxis, but need close monitoring. 
▪ Has dual infection with HBV/HCV or other hepatitis combinations at study entry. 
▪ Has received a live vaccine within 30 days of planned start of study therapy 
(Cycle 1, Day 1). 
• Note: The killed virus vaccines used for seasonal influenza vaccines for injection 
are allowed; however intranasal influenza vaccines (e.g., FluMist®) are live 
attenuated vaccines and are not allowed. 
 
6.3. Inclusion of Women and Minorities 
Both men and women of all races and ethnic groups are eligible for this trial.  
Table 2. 
Inclusion of Women and Minorities 
Accrual Targets 
Ethnic Category 
Sex/Gender 
Females 
Males 
Total 
Hispanic or Latino 
4 
+ 
4 
= 
8 
Not Hispanic or Latino 
11 + 
12 = 
23 
Ethnic Category: Total of all 
subjects 
15 
+ 
16 = 
31 
Racial Category 
Asian 
2 
+ 
2 
= 
4 
Black or African American 
2 
+ 
2 
= 
4 
White 
11 + 
12 = 
23 
Racial Category: Total of all 
subjects 
15 
+ 
16 = 
31 
 
 
6.4. Subject Recruitment 
This study will be conducted at Columbia University Medical Center. Thirty-one patients will 
be needed to meet the primary study endpoint. . The amount of time required to complete this 
trial will depend on the rapidity of accrual. We estimate evaluation of 3-5 subjects a month in 
our center with enrollment of 2 subjects a month to complete accrual over 16-18 months with 
an anticipated 4-6 week pause after enrolling the 6th subject for safety analysis. If the first 
dose level is deemed intolerable (≥ 2 DLTs), we will accrue 6 subjects at a lower dose level 
and complete 31 subjects (25 additional) at that dose level. Thus the maximum number of 
subjects enrolled in this study will be 37. 
 
Participation is voluntary. The patient must be aware of the neoplastic nature of his/her 
disease and willingly consent after being informed of the procedures to be followed, the 


32 
 
experimental nature of the therapy, alternatives, potential benefits, side effects, risks, and 
discomforts. The investigator will make certain that an appropriate informed consent process 
is in place to ensure that potential research subjects, or their authorized representatives, are 
fully informed about the nature and objectives of the clinical study, the potential risks and 
benefits of study participation and their rights as research subjects. 
 
6.5. Early Withdrawal of Subjects 
When a subject discontinues/withdraws prior to trial completion, all applicable activities 
scheduled for the final trial visit should be performed at the time of discontinuation. Any 
adverse events which are present at the time of discontinuation/withdrawal should be followed 
in accordance with the safety requirements outlined in Section 10.6 - Assessing and Recording 
Adverse Events. Subjects who discontinue for toxicity but do not withdraw consent from the 
study will continue to be followed for post-study treatment and survival as described. Subjects 
who a) attain a CR or b) complete 24 months of treatment with pembrolizumab may 
discontinue treatment with the option of restarting treatment in the future after consultation 
with the sponsor. After discontinuing treatment following assessment of CR, these subjects 
should return to the site for a Safety Follow-up Visit (described in Section 6.6.1 and then 
proceed to the Follow-Up Period of the study (described in Section 6.6.2). 
 
6.5.1 
When and How to Withdraw Subjects 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the 
discretion of the investigator should any untoward effect occur. In addition, a subject may be 
withdrawn by the investigator or the Sponsor if enrollment into the trial is inappropriate, the 
trial plan is violated, or for administrative and/or other safety reasons. 
 
A subject must be discontinued from the trial for any of the following reasons: 
• The subject or legal representative withdraws consent. 
• Confirmed radiographic disease progression 
o Note: A subject may be granted an exception to continue on treatment with 
confirmed radiographic progression if clinically stable or clinically 
improved. 
• Unacceptable adverse experiences 
• Intercurrent illness that prevents further administration of treatment 
• Investigator’s decision to withdraw the subject 
• The subject has a confirmed positive serum pregnancy test 
• Noncompliance with trial treatment or procedure requirements 
• The subject is lost to follow-up 
• Completed 24 months of uninterrupted treatment with pembrolizumab or 
35 administrations of study medication, whichever is later. 
o Note: 24 months of study medication is calculated from the date of first dose. 
Subjects who stop pembrolizumab after 24 months may be eligible for up to 
one year of additional study treatment if they progress after stopping study 
treatment after consultation with the sponsor. 


33 
 
• Administrative reasons 
 
6.5.2 
Data Collection and Follow-up for Withdrawn Subjects 
The End of Treatment and Follow-up visit procedures are listed in Section 12.1 (Trial Flow Chart) 
and Section 12.3 (Administrative Procedures). After the end of treatment, each subject will 
be followed for 30 days for adverse event monitoring (serious adverse events will be collected 
for 90 days after the end of treatment as described in Section 10). Subjects who discontinue for 
reasons other than progressive disease will have post-treatment follow-up for disease status until 
disease progression, initiating a non-study cancer treatment, withdrawing consent or 
becoming lost to follow-up. After documented disease progression each subject will be followed 
by telephone for overall survival until death, withdrawal of consent, or the end of the study, 
whichever occurs first. 
 
6.6. Post-Treatment Visits 
 
6.6.1 
Safety Follow-Up Visits 
The mandatory Safety Follow-up Visit should be conducted approximately 30 days after the last 
dose of trial treatment or before the initiation of a new anti-cancer treatment, whichever comes 
first. 
 
All AEs that occur prior to the Safety Follow-Up Visit should be recorded. Subjects with an 
AE of Grade >1 will be followed until the resolution of the AE to Grade 0-1 or until the 
beginning of a new anti-cancer therapy, whichever occurs first. SAEs that occur within 90 
days of the end of treatment or before initiation of a new anti-cancer treatment should also be 
followed and recorded. 
 
Subjects who are eligible for retreatment with pembrolizumab may have up to two safety 
follow- up visits, one after the Initial Treatment Period and one after the Second Course 
Treatment Phase. 
 
6.6.2 
Follow-Up Visits 
Subjects who discontinue trial treatment for reasons other than disease progression will move 
into the Follow-up Phase and should be assessed Q8W by radiologic imaging to monitor 
disease status. Every effort should be made to collect information regarding disease status 
until the start of a new anti-cancer therapy, disease progression, death, or the end of the study. 
 
Information regarding post-study anti-cancer treatment will be collected if new treatment is 
initiated. 
 
6.6.3 
Survival Follow-Up 
Subjects, who experience disease progression (by site assessment) or start a new anti –
cancer therapy, will move into the Survival Follow-Up Phase. Subjects should be 
contacted (e.g., by telephone or visit) every 12 weeks to assess for survival status until 
death, withdrawal of consent, or the end of the study, whichever occurs first Post-study 
anti-cancer therapy will be collected during survival follow-up. 
 


34 
 
 
7. 
REGISTRATION PROCEDURES 
 
7.1. CUMC Research Participant Registration 
 
Confirm eligibility as defined in the section entitled Criteria for Subject Eligibility. 
 
Obtain informed consent, by following procedures defined in section entitled Informed 
Consent Procedures, along with applicable institutional policies and federal regulations. 
 
Only Investigators/Research personnel properly trained and delegated to consent subjects for 
this protocol will participate in the consenting process. Furthermore, properly delegated/trained 
Physician Investigators (e.g., MD, MD PhD) are required to sign/verify a protocol specific 
Eligibility Checklist for each subject enrolled on the study, in addition to providing the 
relevant source documentation confirmation subject eligibility. 
 
All participants must be centrally registered through the Central Registration Office within 
Herbert Irving Comprehensive Cancer Center at CUMC prior to initiation of study treatment. 
Registration hours are available Monday through Friday from 9:00am – 5:00pm EST 
(excluding holidays and weekends). Same day patient registrations (and after hour 
registrations) will be accommodated on a case by case basis provided that the study team has 
expressed all time sensitive registration concerns/cases in a timely manner to the Central 
Registration Office. 
 
CPDM Central Registration Procedures: 
Within 48 hours of obtaining consent (excluding holidays and weekends), a completed/signed 
IRB approved informed consent HIPAA form, and demographics forms must be submitted to 
the CPDM Central Registration Office via an email to 
CPDMRegistration@cumc.columbia.edu or fax to 212.305.5292, with the subject line 
“AAAxxxxx Pending Subject Registration Request (PHI)”. 
Upon receipt, applicable subject information as well as a “pending eligibility” status will be 
entered into HICCC’s institutional database. This status will remain until further source 
documentation is made available to confirm overall patient eligibility. Required materials for 
all pending registration submissions are as follows: 
 
• Completed/signed IRB approved/stamped Informed Consent Forms, including 
additional study ICFs (e.g., tissue, DNA, etc.), as applicable. 
• The completed/signed IRB approved HIPAA Authorization form 
• Completed/signed CPDM ICF checklist 
• Completed/signed HICCC personal census form 
• Completed/signed CPDM Demographics Note to File 
 
In order to confirm eligibility status, Investigators/designees (e.g., study specific Clinical 
Research Coordinator/Research Nurse, etc.) must submit the following documentation to the 


35 
 
Central Registration Office via email or fax: 
 
• The completed/signed study specific Eligibility Checklist (signed by an Physician level 
Investigator) 
 
• Copies of source documentation necessary for each item to be verified on the 
CPDM specific Eligibility Checklist, including but not limited to: 
o Copy of required laboratory test and procedure reports (e.g., hematology, 
serum chemistry, pregnancy test when applicable, MRI reports, CT/bone 
scans, etc.) 
o Copy of pathology and surgical reports 
o Copy of clinic note(s) or other appropriate medical records capturing the 
consent process information, along with providing source documentation of 
any other items needed for screening/eligibility that are not captured in other 
source document forms (e.g., positive investigator statements of unique 
eligibility items not captured via other direct source documentation, 
concomitant medication lists, etc.) 
o Protocol deviation/waiver approvals (if applicable) 
• Please note: subject line of email or fax should include the 
following: “AAAR3554 Complete Subject Registration Request 
(PHI)”. 
Upon receipt of the above mentioned documentation, participant eligibility information will 
be verified by a qualified Central Registration Registrar. If any questions arise during the 
review process, queries in the form of emails will be addressed to the applicable study team 
personnel for clarification prior to enrollment. All applicable finalized 
registration/eligibility information will then be entered into HICCC’s institutional CTMS 
database by the Central Registration Registrar. Upon completion, an official subject 
registration notification email will be sent to the PI/research team which will include 
eligibility/enrollment status, as well as subject ID information. Protocol therapy may not be 
initiated prior to receipt of this notification from the Central Registration Office. 
 
All screen fail/ineligible subjects, as well as subject’s who withdraw consent prior to 
enrollment/initiation of protocol therapy must be submitted to the Central Registration 
office in a manner analogous to the procedures noted above. Applicable source 
documentation will be required within the corresponding submissions. 
 
 
8. 
TREATMENT PLAN 
 
8.1. Agent Administration 
 
Treatment will be administered on an outpatient basis. Reported adverse events and 
potential risks for Pembrolizumab and Azacitidine are described in Section 10. There are no 


36 
 
dose modifications for Pembrolizumab. No investigational or commercial agents or 
therapies other than those described below may be administered with the intent to treat the 
patient's malignancy. The treatment to be used in this trial is outline below in Table 3. 
 
 
Table 3 
Trial Treatment Schedule 
Drug 
Dose/Potency 
Dose Frequency 
Route of 
Administration 
Regimen 
Use 
 
Pembrolizumab 
200 mg 
Q3W 
IV Infusion 
Dosed every 21 
days beginning 
in week 3 of 
study. 
Experimental 
Azacitidine 
50 mg/m2 
Q4W 
SubQ 
Day 1 to 5 of on 
a 28-day cycle 
Experimental 
 
The investigator shall take responsibility for and shall take all steps to maintain appropriate 
records and ensure appropriate supply, storage, handling, distribution, and usage of trial 
treatments in accordance with the protocol and any applicable laws and regulations. 
 
8.2. Dose Selection/Modification 
8.2.1 
Dose Selection 
The rationale for selection of doses to be used in this trial is provided in Section 4 
Background and Rationale. 
 
Details on preparation and administration of pembrolizumab (MK-3475) are provided in the 
Pharmacy manual. Preparation and administration of azacitidine should be completed as per 
the approved product label. See Section 8.1 for general recommendations for 
administration. 
 
Body surface area (BSA) in m2  should be calculated per local guidance. 
 
8.2.2 
Dose Modification (Escalation/Titration/Other) 
The Common Terminology Criteria for Adverse Events version 4.0 (CTCAE 4.0) must be 
used to grade the severity of adverse events. 
 
If appropriate, the investigators may attribute each toxicity event to either one of the 
investigational agents and use stepwise dose modifications according to Table 5. 
Pembrolizumab dose reductions are not permitted. Pembrolizumab treatment may be 
interrupted or discontinued due to toxicity. 
 
If a dose level reduction for toxicity occurs with azacitidine, the dose may not be re-
escalated. Dose modifications are always based on the previous cycle. 
 
Subjects may have up to 1 dose level reductions of azacitidine as described in Table 6. If 
further toxicity occurs or the criteria for resuming treatment are not met, the subject must be 
discontinued from treatment. 


37 
 
 
If a toxicity is not otherwise specified, investigators should refer to the label or local standard 
of care for dose adjustments. At the investigator’s discretion, dose modification according 
to Table 5 is allowed for intolerable Grade 2-3 toxicities that are not specified in the tables 
below. 
 
8.3. Pembrolizumab 
8.2.3 
General Concomitant Medication and Supportive Care Guidelines 
 
8.2.4 
Concomitant Medications/Vaccinations (allowed & prohibited) 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial. If there is a clinical indication for one of these or other medications 
or vaccinations specifically prohibited during the trial, discontinuation from trial therapy or 
vaccination may be required.  The investigator should discuss any questions regarding this 
with the Merck Clinical team. The final decision on any supportive therapy or vaccination 
rests with the investigator and/or the subject's primary physician. However, the decision to 
continue the subject on trial therapy or vaccination schedule requires the mutual agreement 
of the investigator, Sponsor-Investigator, and the subject. 
 
8.2.5 
Acceptable Concomitant Medications 
All treatments that the investigator considers necessary for a subject’s welfare may be 
administered at the discretion of the investigator in keeping with the community standards of 
medical care. All concomitant medication will be recorded on the case report form (CRF) 
including all prescription, over-the-counter (OTC), herbal supplements, and IV medications and 
fluids. If changes occur during the trial period, documentation of drug dosage, frequency, 
route, and date may also be included on the CRF. 
All concomitant medications received within 28 days before the first dose of trial treatment and 
30 days after the last dose of trial treatment should be recorded. Concomitant medications 
administered after 30 days after the last dose of trial treatment should be recorded for SAEs and 
ECIs as defined in Section 10. 
 
8.2.6 
Prohibited Concomitant Medications 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase (including retreatment for post-complete response relapse) of this trial: 
 
• Antineoplastic systemic chemotherapy or biological therapy 
• Immunotherapy not specified in this protocol 
• Chemotherapy not specified in this protocol 
• Investigational agents other than pembrolizumab 
• Radiation therapy 
o Note: Radiation therapy to a symptomatic solitary lesion or to the brain may be 
allowed at the investigator’s discretion. 
• Live vaccines within 30 days prior to the first dose of trial treatment and while 
participating in the trial. Examples of live vaccines include, but are not limited to, 


38 
 
the following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and 
typhoid vaccine. 
• Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
event of clinical interest of suspected immunologic etiology. The use of physiologic 
doses of corticosteroids may be approved after consultation with the PI. 
 
Subjects who, in the assessment by the investigator, require the use of any of the aforementioned 
treatments for clinical management should be removed from the trial. Subjects may receive other 
medications that the investigator deems to be medically necessary. 
 
The Exclusion Criteria describes other medications which are prohibited in this trial. 
There are no prohibited therapies during the Post-Treatment Follow-up Phase. 
8.2.7 
Rescue Medications 
No rescue medications are specified to be used in this trial. 
 
8.2.8 
Supportive Care Guidelines 
Subjects should receive appropriate supportive care measures as deemed necessary by the 
treating investigator. Suggested supportive care measures for the management of adverse 
events with potential immunologic etiology are outlined below. Toxicities associated or 
possibly associated with pembrolizumab should be managed according to standard medical 
practice. Additional tests, such as autoimmune serology or biopsies, should be used to 
evaluate for a possible immunogenic etiology. Attempts should be made to rule out other 
causes such as metastatic disease or bacterial or viral infection, which might require additional 
supportive care. 
 
Although most immune-related adverse events observed with immunomodulatory agents have 
been mild and self-limiting, such events should be recognized early and treated promptly to 
avoid potential major complications. Discontinuation of pembrolizumab may not have an 
immediate therapeutic effect, and in severe cases, immune-related toxicities may require acute 
management with topical steroids, systemic corticosteroids, or other immunosuppressive 
agents. The treatment guidelines are intended to be applied when the investigator determines 
the events to be related to trial treatment. 
 
Note: if after the evaluation the event is determined not to be related, the investigator does not 
need to follow the treatment guidance (as outlined below). 
 
MANAGEMENT GUIDELINES 
▪ Immune-related hepatitis 
Immune-related hepatitis has been associated with the administration of 
pembrolizumab. Patients with right upper quadrant pain and/or unexplained nausea or 
vomiting should have liver function tests (LFTs) performed immediately and reviewed 
before administration of the next dose of study drug. 
 


39 
 
For patients with elevated LFTs, concurrent medication, viral hepatitis, biliary 
obstruction, and toxic or neoplastic etiologies should be considered and addressed, as 
appropriate.  
 
o For Grade 1 events, continue pembrolizumab and monitor LFTs until values 
resolve to within normal limits or to baseline values. 
 
o For Grade 2 events of >5 days’ duration:  
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. The 
acceptable length of the extended period of time will be determined by 
the investigator. 
▪ Initiate treatment with systemic corticosteroids equivalent to 1-2 
mg/kg/day oral prednisone. 
▪ Monitor liver function tests more frequently until returned to baseline 
values (consider weekly). 
▪ If event resolves to Grade 1 or less, resume pembrolizumab. If 
corticosteroids have been initiated, they must be tapered over no less 
than 4 weeks to the equivalent of 10 mg/day oral prednisone or less 
before pembrolizumab may be resumed. 
 
o For Grade 3-4 events: 
▪ Permanently discontinue pembrolizumab. 
▪ Consider referral to gastrointestinal specialist for evaluation and liver 
biopsy to establish etiology of hepatic injury. 
▪ Initiate treatment with systemic corticosteroids equivalent to 1-2 
mg/kg/day oral prednisone. 
▪ If the event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent.  
▪ If event resolves to Grade 1 or better, taper corticosteroids over no less 
than 4 weeks. 
 
▪ Immune-related pneumonitis 
Dyspnea, cough, fatigue, hypoxia, pneumonitis, and pulmonary infiltrates have been 
associated with the administration of pembrolizumab. Patients will be assessed for 
pulmonary signs and symptoms throughout the study and will have computed 
tomography (CT) scans of the chest performed at every tumor assessment. 
 
All pulmonary events should be thoroughly evaluated for other commonly reported 
etiologies such as pneumonia or other infection, lymphangitic carcinomatosis, 


40 
 
pulmonary embolism, heart failure, chronic obstructive pulmonary disease, or 
pulmonary hypertension.  
 
Management guidelines for pulmonary events, including pneumonitis: 
o For Grade 1 events, continue pembrolizumab and monitor closely. Re-
evaluate on serial imaging and consider referral to a pulmonary specialist. 
 
o For Grade 2 events:  
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone.  
▪ Initiate treatment with systemic corticosteroids equivalent to 1-2 
mg/kg/day oral prednisone.  
▪ Refer patient to pulmonary specialist and consider bronchoscopic 
alveolar lavage.  
▪ When symptoms improve to Grade 1 or less, resume pembrolizumab. 
Steroid taper should be started and continued over no less than 4 weeks.  
 
o For Grade 3-4 events: 
▪ Permanently discontinue pembrolizumab. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day 
oral prednisone.  
▪ If the event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent.  
▪ If event resolves to Grade 1 or better, taper corticosteroids over no 
less than 4 weeks. 
 
o Add prophylactic antibiotics for opportunistic infections in the case of 
prolonged steroid administration. 
 
▪ Immune-related colitis 
Subjects should be carefully monitored for signs and symptoms of enterocolitis (such as 
diarrhea, abdominal pain, blood or mucus in stools, with or without fever) and of bowel 
perforation (such as peritoneal signs and ileus). 
 
All events of diarrhea or colitis should be thoroughly evaluated for other more common 
etiologies. For events of significant duration or magnitude or associated with signs of 
systemic inflammation or acute-phase reactants (e.g. increased C-reactive protein, 
platelet count, or bandemia): Perform sigmoidoscopy (or colonoscopy, if appropriate) 
with colonic biopsy, with three to five specimens for standard paraffin block to check 


41 
 
for inflammation and lymphocytic infiltrates to confirm colitis diagnosis. 
 
o All subjects who experience diarrhea/colitis should be advised to drink liberal 
quantities of clear fluids. If sufficient oral fluid intake is not feasible, fluid and 
electrolytes should be substituted via IV infusion.  
 
o For Grade 1 diarrhea or colitis, continue pembrolizumab. If symptoms persist 
>7 days, endoscopy is recommended. 
 
o For Grade 2 diarrhea or colitis:  
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer to GI specialist for evaluation and confirmatory biopsy. 
▪ For recurrent events or events that persist >5 days, initiate treatment 
with corticosteroids equivalent to 1-2 mg/kg/day oral prednisone.  
▪ If symptoms improve to Grade 1 or less, resume pembrolizumab. If 
corticosteroids have been initiated, they must be tapered over no less 
than 4 weeks to the equivalent of 10 mg/day oral prednisone or less 
before pembrolizumab may be resumed. 
 
o For Grade 3 diarrhea or colitis: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer to GI specialist for evaluation and confirmatory biopsy. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement.  
▪ If symptoms improve to Grade 1 or less, resume pembrolizumab. If 
corticosteroids have been initiated, they must be tapered over no less 
than 4 weeks to the equivalent of 10 mg/day oral prednisone or less 
before pembrolizumab may be resumed. 
 
o For Grade 4 diarrhea or colitis:  
▪ Permanently discontinue pembrolizumab. 
▪ Refer to GI specialist for evaluation and confirmatory biopsy. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement.  
▪ If the event does not improve within 48 hours after initiating corticosteroids, 


42 
 
consider adding an immunosuppressive agent. 
▪ If the event resolves to Grade 1 or better, taper corticosteroids over no less than 4 
weeks. 
 
▪ Immune-related type 1 diabetes mellitus (if new onset, including diabetic 
ketoacidosis [DKA] or ≥ Grade 3 Hyperglycemia, if associated with ketosis (ketonuria) 
or metabolic acidosis (DKA) 
 
o For new onset T1DM or Grade 3-4 Hyperglycemia 
▪ Withhold pembrolizumab 
▪ Insulin replacement therapy is recommended for T1DM and for Grade 
3-4 hyperglycemia associated with metabolic acidosis or ketonuria. 
▪ Monitor for glucose control. 
▪ Evaluate patients with plasma glucose and a metabolic panel, 
urine ketones, HbA1c, and C-peptide. 
▪ Resume pembrolizumab when symptoms resolve and glucose 
levels are stable. 
 
▪ Immune-related hypophysitis 
Patients with unexplained symptoms such as headache, fatigue, myalgias, impotence, 
constipation, or mental status change should be investigated for the presence of thyroid, 
pituitary, or adrenal endocrinopathies. The patient should be referred to an 
endocrinologist if an endocrinopathy is suspected. Thyroid-stimulating hormone (TSH) 
and free triiodothyronine and thyroxine levels should be measured to determine whether 
thyroid abnormalities are present. Pituitary hormone levels and function tests (e.g. TSH, 
growth hormone, luteinizing hormone, follicle-stimulating hormone, testosterone, 
prolactin, adrenocorticotropic hormone [ACTH] levels, and ACTH stimulation test) and 
magnetic resonance imaging (MRI) of the brain (with detailed pituitary sections) may 
help to differentiate primary pituitary insufficiency from primary adrenal insufficiency. 
 
o For Grade 2 or 3 events:  
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to endocrinologist. 
▪ Perform brain MRI (pituitary protocol). 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement.  
▪ Initiate hormone replacement if clinically indicated.  


43 
 
▪ If symptoms improve to Grade 1 or less, resume pembrolizumab. If 
corticosteroids have been initiated, they must be tapered over no less 
than 4 weeks to the equivalent of 10 mg/day oral prednisone or less 
before pembrolizumab may be resumed. 
▪ For recurrent hypophysitis, treat as Grade 4 event. 
 
o For Grade 4 event:  
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to endocrinologist. 
▪ Perform brain MRI (pituitary protocol). 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement.  
▪ Initiate hormone replacement if clinically indicated.  
 
▪ Immune-related hyperthyroidism or hypothyroidism 
Patients with unexplained symptoms such as headache, fatigue, myalgias, impotence, 
constipation, or mental status change should be investigated for the presence of thyroid, 
pituitary, or adrenal endocrinopathies. The patient should be referred to an 
endocrinologist if an endocrinopathy is suspected. Thyroid-stimulating hormone (TSH) 
and free triiodothyronine and thyroxine levels should be measured to determine whether 
thyroid abnormalities are present. Pituitary hormone levels and function tests (e.g. TSH, 
growth hormone, luteinizing hormone, follicle-stimulating hormone, testosterone, 
prolactin, adrenocorticotropic hormone [ACTH] levels, and ACTH stimulation test) and 
magnetic resonance imaging (MRI) of the brain (with detailed pituitary sections) may 
help to differentiate primary pituitary insufficiency from primary adrenal insufficiency. 
 
Thyroid disorders can occur at any time during treatment. Monitor patients for changes 
in thyroid function (at the start of treatment, periodically during treatment, and as 
indicated based on clinical evaluation) and for clinical signs and symptoms of thyroid 
disorders. 
 
o Asymptomatic hypothyroidism: 
▪ Continue pembrolizumab 
▪ Initiate treatment with thyroid replacement hormone per standard of 
care 
 
o Symptomatic hypothyroidism: 
▪ Withhold pembrolizumab 
▪ Initiate treatment with thyroid replacement hormone per standard of 
care 
▪ Consider referral to endocrinology 


44 
 
▪ Resume pembrolizumab when symptoms are controlled and thyroid 
function is normal. 
 
o Asymptomatic hyperthyroidism: 
▪ TSH  0.1 mU/L and  0.5 mU/L 
• 
Continue pembrolizumab 
• 
Monitor TSH every 4 weeks 
▪ TSH <0.1 mU/L: 
• 
Follow guidelines for symptomatic hyperthyroidism. 
 
o Symptomatic hyperthyroidism: 
▪ Withhold pembrolizumab 
▪ Initiate treatment with anti-thyroid drug such as methimazole or 
carbimazole as needed 
▪ Consider referral to endocrinology 
▪ Resume pembrolizumab when symptoms are controlled and thyroid 
function is normal. 
 
▪ Immune-related adrenal insufficiency 
Patients with unexplained symptoms such as headache, fatigue, myalgias, impotence, 
constipation, or mental status change should be investigated for the presence of thyroid, 
pituitary, or adrenal endocrinopathies. The patient should be referred to an 
endocrinologist if an endocrinopathy is suspected. Thyroid-stimulating hormone (TSH) 
and free triiodothyronine and thyroxine levels should be measured to determine whether 
thyroid abnormalities are present. Pituitary hormone levels and function tests (e.g. TSH, 
growth hormone, luteinizing hormone, follicle-stimulating hormone, testosterone, 
prolactin, adrenocorticotropic hormone [ACTH] levels, and ACTH stimulation test) and 
magnetic resonance imaging (MRI) of the brain (with detailed pituitary sections) may 
help to differentiate primary pituitary insufficiency from primary adrenal insufficiency. 
 
o Symptomatic adrenal insufficiency, Grade 2-4: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to endocrinologist. 
▪ Perform appropriate imaging. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement.  
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 


45 
 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
 
▪ Immune-mediated nephritis 
Patients with abnormal renal function should be evaluated and treated for other more 
common etiologies (including prerenal and postrenal causes, and concomitant 
medications such as non-steroidal anti-inflammatory drugs). Refer the patient to a renal 
specialist if clinically indicated. A renal biopsy may be required to enable a definitive 
diagnosis and appropriate treatment. 
 
o For Grade 1 events: Continue pembrolizumab and monitor kidney function 
closely until values resolve to within normal limits or to baseline values. 
 
o Grade 2 events: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to a renal specialist. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day 
oral prednisone.  
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
 
o For Grade 3 or 4 events: 
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to a renal specialist. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day 
oral prednisone.  
▪ If the event does not improve within 48 hours after initiating corticosteroids, 
consider adding an immunosuppressive agent. 
▪ If event resolves to Grade 1 or better, taper corticosteroids over no less 
than 4 weeks. 
 
▪ Immune-mediated dermatologic events 
The majority of rashes are mild and self-limited, with or without pruritus. A 
dermatologist should evaluate persistent and/or severe rash or pruritus. A biopsy should 
be considered unless contraindicated. 
 
o Grade 1:  
▪ Continue pembrolizumab. 


46 
 
▪ Consider treatment with topical corticosteroids and/or other 
symptomatic therapy (e.g., antihistamines).  
 
o Grade 2: 
▪ Continue pembrolizumab. 
▪ Consider patient referral to a dermatologist. 
▪ Initiate treatment with topical corticosteroids. 
▪ Consider treatment with higher-potency topical corticosteroids if event 
does not improve. 
 
o Grade 3:  
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to a dermatologist. 
▪ Initiate treatment with corticosteroids equivalent to 10 mg/day oral 
prednisone, increasing dose to 1-2 mg/kg/day if event does not improve 
within 48-72 hours. 
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
 
o Grade 4: 
▪ Permanently discontinue pembrolizumab. 
 
▪ Immune-mediated ocular events  
An ophthalmologist should evaluate visual complaints (e.g. uveitis, retinal events).  
 
o Grade 1:  
▪ Continue pembrolizumab. 
▪ Referral to an ophthalmologist is strongly recommended. 
▪ Initiate treatment with topical corticosteroid eye drops and topical 
immunosuppressive therapy. 
▪ If symptoms persist, treat as a Grade 2 event. 
 
o Grade 2:  
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 


47 
 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Referral to an ophthalmologist is strongly recommended. 
▪ Initiate treatment with topical corticosteroid eye drops and topical 
immunosuppressive therapy. 
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
 
o Grade 3 or 4: 
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to an ophthalmologist. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day oral 
prednisone. 
▪ If event resolves to Grade 1 or better, taper corticosteroids over no less 
than 4 weeks. 
 
▪ Immune-related pancreatitis 
Symptoms of abdominal pain associated with elevations of amylase and lipase, 
suggestive of pancreatitis, have been associated with the administration of 
pembrolizumab. The differential diagnosis of acute abdominal pain should include 
pancreatitis. Appropriate work up should include an evaluation for ductal obstruction, 
as well as serum amylase and lipase tests.  
 
o Amylase and/or lipase elevation, Grade 2: 
▪ Amylase and/or lipase >1.5-2.0x ULN 
• 
Continue pembrolizumab 
• 
Monitor amylase and lipase weekly 
• 
For prolonged elevation (e.g., >3 weeks), consider treatment 
with corticosteroids equivalent to 10 mg/day oral prednisone. 
▪ Asymptomatic with amylase and/or lipase >2.0-5.0x ULN 
• 
Treat as a Grade 3 event 
 
o Amylase and/or lipase elevation, Grade 3 or 4: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to a GI specialist. 
▪ Monitor amylase and lipase every other day. 
▪ If no improvement, consider treatment with corticosteroids equivalent 


48 
 
to 1-2 mg/kg/day oral prednisone. 
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
▪ For recurrent events, permanently discontinue pembrolizumab. 
 
o Immune-related pancreatitis, Grade 2 or 3: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to a GI specialist. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement.  
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
▪ For recurrent events, permanently discontinue pembrolizumab. 
 
o Immune-related pancreatitis, Grade 4: 
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to a GI specialist. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement.  
▪ If the event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
▪ If event resolves to Grade 1 or better, taper corticosteroids over no less 
than 4 weeks. 
 
▪ Immune-related myocarditis 
Immune-related myocarditis should be suspected in any patient presenting with signs 
or symptoms suggestive of myocarditis, including, but not limited to dyspnea, chest 
pain, fatigue, decreased exercise tolerance, or syncope. Immune-related myocarditis 
needs to be distinguished from myocarditis resulting from infection (commonly viral, 
e.g., in a patient who reports a history of gastrointestinal illness), ischemic events, 
underlying arrhythmias, exacerbation of preexisting cardiac conditions, or progression 
of malignancy. 


49 
 
 
All patients with possible myocarditis should be urgently evaluated by performing 
cardiac enzyme assessment, an ECG, a chest X-ray, an echocardiogram, and a cardiac 
MRI as appropriate per institutional guidelines. A cardiologist should be consulted. An 
endomyocardial biopsy may be considered to enable a definitive diagnosis and 
appropriate treatment, if clinically indicated.  
 
o For Grade 2 events: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to a cardiologist. 
▪ Initiate treatment as per institutional guidelines. 
▪ Consider treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement. 
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
 
o For Grade 3 or 4 events: 
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to a cardiologist. 
▪ Initiate treatment as per institutional guidelines. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement. 
▪ If the event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
▪ If event resolves to Grade 1 or better, taper corticosteroids over no less 
than 4 weeks. 
 
▪ Immune-related neuropathies (i.e. myasthenic syndrome/myasthenia gravis, 
Guillain-Barre syndrome) 
Patients may present with signs and symptoms of sensory and/or motor neuropathy. 
Diagnostic work up is essential for an accurate characterization to differentiate between 
alternative etiologies. 
 
o Immune-related neuropathy, Grade 1: Continue pembrolizumab and 
investigate etiology. 


50 
 
 
o Immune-related neuropathy, Grade 2:  
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Investigate etiology. 
▪ Initiate treatment as per institutional guidelines. 
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
 
o Immune-related neuropathy, Grade 3 or 4: 
▪ Permanently discontinue pembrolizumab. 
▪ Initiate treatment as per institutional guidelines. 
 
o Myasthenia gravis and Guillain-Barre syndrome (any grade): 
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to a neurologist. 
▪ Initiate treatment as per institutional guidelines. 
▪ Consider treatment with corticosteroids equivalent to 1-2 mg/kg/day oral 
or IV prednisone. 
 
▪ Immune-related meningoencephalitis 
Immune-related meningoencephalitis should be suspected in any patient presenting 
with signs or symptoms suggestive of meningitis or encephalitis, including, but not 
limited to, headache, neck pain, confusion, seizure, motor or sensory dysfunction, and 
altered or depressed level of consciousness. Encephalopathy from metabolic or 
electrolyte imbalances needs to be distinguished from potential meningoencephalitis 
resulting from infection (bacterial, viral, or fungal) or progression of malignancy, or 
secondary to a paraneoplastic process. 
 
All patients being considered for meningoencephalitis should be urgently evaluated 
with a CT scan and/or MRI scan of the brain to evaluate for metastasis, inflammation, 
or edema. If deemed safe by the treating physician, a lumbar puncture should be 
performed and a neurologist should be consulted. 
 
Patients with signs and symptoms of meningoencephalitis, in the absence of an 
identified alternate etiology, should be treated according to the guidelines. 
 
o Immune-related meningoencephalitis (all grades): 


51 
 
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to a neurologist. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement. 
▪ If the event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
▪ If event resolves to Grade 1 or better, taper corticosteroids over no less 
than 4 weeks. 
 
▪ Myositis 
Myositis or inflammatory myopathies are a group of disorders sharing the common 
feature of inflammatory muscle injury; dermatomyositis and polymyositis are among 
the most common disorders. Initial diagnosis is based on clinical (muscle weakness, 
muscle pain, skin rash in dermatomyositis), biochemical (serum creatine kinase 
increase), and imaging (electromyography/MRI) features, and is confirmed with a 
muscle biopsy. 
 
o For Grade 1 events: Continue pembrolizumab, refer patient to a rheumatologist 
or neurologist, and initiate treatment as per institutional guidelines. 
 
o For Grade 2 events: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to a rheumatologist or neurologist. 
▪ Initiate treatment as per institutional guidelines. 
▪ Consider treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone and convert to 1-2 mg/kg/day oral prednisone or 
equivalent upon improvement. 
▪ If corticosteroids are initiated and the event does not improve within 48 
hours after initiating corticosteroids, consider adding an 
immunosuppressive agent. 
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
 
o For Grade 3 events: 
▪ Withhold pembrolizumab for up to 12 weeks after event onset. 


52 
 
Pembrolizumab may be withheld for a longer period of time (i.e. >12 
weeks after event onset) to allow for corticosteroids (if initiated) to be 
reduced to the equivalent of 10 mg/day or less of oral prednisone. 
▪ Refer patient to a rheumatologist or neurologist. 
▪ Initiate treatment as per institutional guidelines. Respiratory support 
may be required in more severe cases. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone, or higher-dose bolus if patient is severely 
compromised (e.g., cardiac or respiratory symptoms, dysphagia, or 
weakness that severely limits mobility); convert to 1-2 mg/kg/day oral 
prednisone or equivalent upon improvement. 
▪ If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
▪ If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume pembrolizumab. If corticosteroids have 
been initiated, they must be tapered over no less than 4 weeks to the 
equivalent of 10 mg/day oral prednisone or less before pembrolizumab 
may be resumed. 
▪ For recurrent events, treat as a Grade 4 event. 
 
o For Grade 4 events: 
▪ Permanently discontinue pembrolizumab. 
▪ Refer patient to a rheumatologist or neurologist. 
▪ Initiate treatment as per institutional guidelines. Respiratory support 
may be required in more severe cases. 
▪ Initiate treatment with corticosteroids equivalent to 1-2 mg/kg/day IV 
methylprednisolone, or higher-dose bolus if patient is severely 
compromised (e.g., cardiac or respiratory symptoms, dysphagia, or 
weakness that severely limits mobility); convert to 1-2 mg/kg/day oral 
prednisone or equivalent upon improvement. 
▪ If the event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
▪ If event resolves to Grade 1 or better, taper corticosteroids over no less 
than 4 weeks. 
 
▪ Infusion-related reactions 
 
Signs and symptoms usually develop during or shortly after drug infusion and 
generally resolve completely within 24 hours of completion of infusion. No 
premedication is indicated for the administration of Cycle 1 of pembrolizumab. 
However, patients who experience an IRR with Cycle 1 of pembrolizumab may 
receive premedication with antihistamines or antipyretics/analgesics (e.g., 
acetaminophen) for subsequent infusions. 


53 
 
 
Table 4 
Infusion Reaction Treatment Guidelines 
 
NCI CTCAE Grade 
Treatment 
Premedication at subsequent 
dosing 
Grade 1 
Mild reaction; infusion interruption 
not indicated; intervention not 
indicated 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
None 
Grade 2 
Requires infusion interruption but 
responds promptly to symptomatic 
treatment (e.g., antihistamines, 
NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated for 
< =24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
If symptoms resolve within one hour of stopping 
drug infusion, the infusion may be restarted at 
50% of the original infusion rate (e.g., from 100 
mL/hr to 50 mL/hr). Otherwise dosing will be 
held until symptoms resolve and the subject 
should be premedicated for the next scheduled 
dose. 
Subjects who develop Grade 2 toxicity despite 
adequate premedication should be 
permanently discontinued from further trial 
treatment administration. 
Subject may be premedicated 1.5h 
(± 30 minutes) prior to infusion of 
pembrolizumab (MK-3475) with: 
Diphenhydramine 50 mg po (or 
equivalent dose of antihistamine). 
Acetaminophen 500-1000 mg po 
(or equivalent dose of antipyretic). 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly responsive 
to symptomatic medication and/or 
brief interruption of infusion); 
recurrence of symptoms following 
initial improvement; hospitalization 
indicated for other clinical sequelae 
(e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or ventilatory 
support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued from 
further trial treatment administration. 
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period of drug 
administration. 
 
8.4. Azacitidine 
Azacitidine is supplied as a lyophilized powder in a single-dose vial. Each vial contains 100 
mg of azacitidine. Azacitidine is administered at a dose of 50 mg/m2 by SubQ injection, in 
rotating sites (thigh, abdomen, or upper arm) repeated for 5 consecutive business days. This 
cycle should be repeated after 4 weeks. Patients should be premediated with standard anti-
emetic therapy. 
 
Contraindications to the administration of azaciditine include advanced malignant hepatic 
tumors and hypersensitivity to azacitidine or mannitol. Patients with severe preexisting hepatic 


54 
 
impairment are at higher risk for toxicity. Azacitidine is primarily excreted by the kidneys. No 
formal drug interaction studies with azacitidine have been conducted. Whether azacitidine 
metabolism may be affected by known microsomal enzyme inhibitors or inducers in the liver 
has not yet been studied. In vitro studies have shown that azacitidine does not cause inhibition 
of CYP2B6 and CYP2C8 but the potential of azacitidine to inhibit other cytochrome P450 
enzymes is not known. Other in vitro studies indicate that azacitidine does not induce CYP 
1A2, 2C19, or 3A4/5. 
 
8.5. Diet/Activity/Other Considerations 
8.2.9 
Diet 
Subjects should maintain a normal diet unless modifications are required to manage an 
adverse event such as diarrhea, nausea, or vomiting. 
 
8.2.10 
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 a high follicle-stimulating 
hormone [FSH] level in the postmenopausal range may be used to confirm a 
post- menopausal state in women not using hormonal contraception or 
hormonal replacement therapy. In the absence of 12 months of amenorrhea, at 
least two FSH measurements should be obtained); 
• OR 
 
 
• OR 
 
(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy, or 
bilateral tubal ligation/occlusion at least 6 weeks prior to screening; 
 
(3) has a congenital or acquired condition that prevents childbearing. 
 
Female and male subjects of reproductive potential must agree to avoid becoming pregnant or 
impregnating a partner, respectively, while receiving pembrolizumab and for 120 days after 
the last dose. Subjects must comply with one of the following: 
(1) practice abstinence* from heterosexual activity; 
• OR 


55 
 
 
(2) use (or have their partner use) acceptable contraception during heterosexual activity. 
Acceptable methods of contraception are**: 
• Single method (one of the following is acceptable): 
 
▪ intrauterine device (IUD) 
▪ vasectomy of a female subject’s sole 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 
*Abstinence (relative to heterosexual activity) can be used as the sole method of contraception 
if it is consistently employed as the subject’s preferred and usual lifestyle and if considered 
acceptable by local regulatory agencies and ERCs/IRBs. Periodic abstinence (e.g. calendar, 
ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are not acceptable 
methods of contraception. 
 
**If a contraceptive method listed above is restricted by local regulations/guidelines, then it 
does not qualify as an acceptable method of contraception for subjects participating at sites in 
this country/region. 
 
Subjects should be informed that taking the study 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 trial treatment [Cycle 1 Day 1] for oral contraception) throughout the study period up to 120 
days after the last dose of trial therapy. If there is any question that a subject of childbearing 
potential will not reliably comply with the requirements for contraception, that subject should 
not be entered into the study. 
 
8.2.11 
Use in Pregnancy 
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab, the 
subject will immediately be removed from the study. The site will contact the subject at least 
monthly and document the subject’s status until the pregnancy has been completed or 
terminated. The outcome of the pregnancy will be reported to the Sponsor-Investigator and to 
Merck without delay and within 24 hours to the Sponsor-Investigator and within 2 working 
days to Merck if the outcome is a serious adverse experience (e.g., death, abortion, congenital 


56 
 
anomaly, or other disabling or life-threatening complication to the mother or newborn). 
 
The study investigator will make every effort to obtain permission to follow the outcome of the 
pregnancy and report the condition of the fetus or newborn to the Sponsor. If a male subject 
impregnates his female partner the study personnel at the site must be informed immediately 
and the pregnancy reported to the Sponsor-Investigator. 
 
8.2.12 
Use in Nursing 
It is unknown whether pembrolizumab is excreted in human milk. Since many 
drugs are excreted in human milk, and because of the potential for serious adverse 
reactions in the nursing infant, subjects who are breast-feeding are not eligible for 
enrollment. 
 
8.6. Duration of Therapy 
In the absence of treatment delays due to adverse events, treatment may 
continue for up to 2 years (35 cycles of pembrolizumab) or until one of the 
following criteria applies: 
• Disease progression 
• Intercurrent illness that prevents further administration of treatment 
• Unacceptable adverse events(s) 
• Patient decides to withdraw from the study 
• General or specific changes in the patient's condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
8.7. Duration of Follow Up 
Patients will be followed for 4 weeks after completion or removal from study 
or until death, whichever occurs first. Patients removed from study for 
unacceptable adverse events will be followed until resolution or stabilization 
of the adverse event.. 
 
8.8. Criteria for Removal from Study 
Patients will be removed from study when any of the criteria listed in Section 6.5.1 
applies. The reason for study removal and the date the patient was removed will be 
documented in the Case Report Form. 
 
 
9. 
DOSING DELAYS/DOSE MODIFICATIONS 
 
9.1. Dose Modification for Pembrolizumab 
 
Adverse events (both non-serious and serious) associated with pembrolizumab 
exposure may represent an immunologic etiology. These adverse events may 
occur shortly after the first dose or several months after the last dose of 
treatment. Pembrolizumab must be withheld for drug- related toxicities and 


57 
 
severe or life-threatening AEs as per Table 5 below. See Section 8.3.6 for 
supportive care guidelines, including use of corticosteroids. 
 
 
Table 5 
Dose Modification Guidelines for Pembrolizumab-Related Adverse Events 
 
Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting Treatment 
Treatment Discontinuation 
Diarrhea/Colitis 
2-3 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
4 
Permanently discontinue 
Permanently discontinue 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose 
AST, ALT, or 
Increased Bilirubin 
3-4 
Permanently discontinue 
(see exception below)a 
Permanently discontinue 
Toxicity 
Hold 
Treatment 
For Grade 
Timing for Restarting Treatment 
Treatment Discontinuation 
Type 1 diabetes 
mellitus (if new 
onset) or 
Hyperglycemia 
T1DM or 
3-4 
Hold pembrolizumab for new onset Type 
1 diabetes mellitus or Grade 3-4 
hyperglycemia associated with evidence of 
beta cell failure 
Resume pembrolizumab when patients are clinically and 
metabolically stable 
Hypophysitis 
2-4 
Toxicity resolves to Grade 0-1. Therapy 
with pembrolizumab can be continued 
while endocrine replacement therapy is 
instituted 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
Hyperthyroidism 
3 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability to 
reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
4 
Permanently discontinue 
Permanently discontinue 
Hypothyroidism 
Therapy with pembrolizumab can be 
continued while thyroid replacement 
therapy is instituted 
Therapy with pembrolizumab can be continued while thyroid 
replacement therapy is instituted 
Infusion Reaction 
2b 
Toxicity resolves to Grade 0-1 
Permanently discontinue if toxicity develops despite adequate 
premedication 
3-4 
Permanently discontinue 
Permanently discontinue 
Pneumonitisc 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
3-4 
Permanently discontinue 
Permanently discontinue 
Renal Failure or 
Nephritis 
2 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability to 
reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
3-4 
Permanently discontinue 
Permanently discontinue 
All Other Drug- 
Related Toxicityd 
3 or Severe 
Toxicity resolves to Grade 0-1 
Toxicity does not resolve within 12 weeks of last dose or inability 
to reduce corticosteroid to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
4 
Permanently discontinue 
Permanently discontinue 
Note: Permanently discontinue for any severe or Grade 3 drug-related AE that recurs or any life-threatening event. 
a For patients with liver metastasis who begin treatment with Grade 2 AST or ALT, if AST or ALT increases by greater than or equal to 50% relative to baseline 
and lasts for at least 1 week then patients should be discontinued. 
b If symptoms resolve within one hour of stopping drug infusion, the infusion may be restarted at 50% of the original infusion rate (e.g., from 100 mL/hr to 50 
mL/hr). Otherwise dosing will be held until symptoms resolve and the subject should be premedicated for the next scheduled dose; Refer to Table 4– Infusion 
Treatment Guidelines for further management details. 
c For grade 2 pneumonitis, should this recur, pembrolizumab should be discontinued. 
d Patients with intolerable or persistent Grade 2 drug-related AE may hold study medication at physician discretion. Permanently discontinue study drug for 
persistent Grade 2 adverse reactions for which treatment with study drug has been held, that do not recover to Grade 0-1 within 12 weeks of the last dose. 
 


58 
 
Dosing interruptions are permitted in the case of medical / surgical events or 
logistical reasons not related to study therapy (e.g., elective surgery, unrelated 
medical events, patient vacation, and/or holidays). Subjects should be placed 
back on study therapy within 3 weeks of the scheduled interruption, unless 
otherwise discussed with the Sponsor. The reason for interruption should be 
documented in the patient's study record. 
 
9.2 
Dose Modification for Azacitidine 
If myelosuppression is present, subsequent treatment cycles of azacitidine 
should be delayed until there is hematologic recover (ANC ≥ 1,000/μL, platelets 
≥ 50,000/μL). Following the first cycle of azacitidine treatment, if any of the 
following non-hematologic toxicities are present, azacitidine treatment should 
not be restarted until the toxicity is resolved: 1) serum bicarbonate level < 20 
mEq/L, 2) serum creatinine ≥ 2 mg/dL; 3) SGPT, total bilirubin ≥ 2 times ULN; 
4) 
and active or uncontrolled infection. Subjects will continue taking pembrolizumab 
on schedule if toxicity is not related to this agent. 
 
 
Table 6 
Dose Levels for Trial Medications 
Drug 
Starting Dose 
Dose Level -1 
Dose Level -2 
Pembrolizumab 
200 mg fixed 
dose 
No dose 
reductions are 
permitted 
No dose 
reductions are 
permitted 
Azacitidine 
50 mg/m2 
40 mg/m2 
Discontinue 
 
 
10. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS 
 
10.1. Definition of an Overdose for this Protocol and Reporting of Overdose to Sponsor- 
Investigator and to Merck 
 
For purposes of this trial, an overdose of: 
• pembrolizumab will be defined as any dose of 1,000 mg or greater (≥5 times 
the indicated dose). 
• Azacitidine will be defined as any dose >/= 20% over the prescribed dose. 
 
No specific information is available on the treatment of overdose of pembrolizumab. In the 
event of overdose, the subject should be observed closely for signs of toxicity. Appropriate 
supportive treatment should be provided if clinically indicated. 
 
There is no known specific antidote for azacitidine overdosage. In the event of an overdose 
of azacitidine, the patient will be monitored with appropriate blood counts and will receive 
supportive treatment as necessary.. 
 


59 
 
If an adverse event(s) is associated with (“results from”) the overdose of a Merck product, 
the adverse event(s) is reported as a serious adverse event, even if no other seriousness 
criteria are met. 
 
If a dose of Merck’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-Investigator and within 2 working days hours to Merck Global Safety. (Attn: 
Worldwide Product Safety; FAX 215 993-1220) 
 
10.2. Anticipated Adverse Events 
 
Pembrolizumab: Refer to section 8.3.6 for specific adverse events related to pembrolizumab. 
 
Azacitidine: The primary toxicities of azacitidine include bone marrow suppression, nausea 
and vomiting, diarrhea, constipation, injection site erythema, pyrexia, and ecchymosis. 
 
10.3. Adverse Events Definitions: 
10.2.1 
Adverse Event: 
An adverse event (AE) is any untoward or unfavorable medical occurrence in a human subject, 
including abnormal sign, symptom or disease, temporally associated with the subject’s 
participation in research, whether or not considered related to the subject’s participation in 
the research. Abnormal results of diagnostic procedures are considered to be adverse events 
if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
10.2.2 
Serious Adverse Event: 
A serious adverse event is any adverse event occurring at any dose or during any use of the 
Sponsor’s product that is: 
• fatal 
• life-threatening 
• requires inpatient hospitalization/prolongation of existing hospitalization, unless: 
o routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition (procedures such as central line placements, 
paracentesis, pain control) 
o elective or pre-planned treatment for a pre-existing condition that is unrelated to 
the indication under study and has not worsened since the start of study drug 
o treatment on an emergency outpatient basis for an event not fulfilling any of 
the definitions of an SAE given above/below and not resulting in hospital 


60 
 
admissions 
o social reasons and respite care in the absence of any deterioration in the 
patient’s general condition 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly 
of major clinical significance. They may jeopardize the subject, and may require intervention to 
prevent one of the other serious outcomes noted above. For example, drug overdose or abuse, 
a seizure that did not result in in-patient hospitalization or intensive treatment of bronchospasm 
in an emergency department would typically be considered serious. 
 
All adverse events that do not meet any of the criteria for serious events should be regarded 
as non-serious adverse events. 
 
Progression of the cancer under study is not considered an adverse event. 
 
 
10.2.3 
Unanticipated Problem: 
An unanticipated problem is any incident, experience or outcome involving risks to subjects or 
others in any human subjects research that meets all of the following criteria: 
• Unexpected (in terms of nature, severity or frequency) given (a) the research 
procedures that are described in the IRB-approval protocol and informed consent 
document, and (b) the characteristics of the subject population being studied; 
• Related or possibly related to participation in such research (e.g., there is a reasonable 
possibility that the incident, experience or outcome may have been caused by the 
procedures involved in such research); and 
• Suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic or social harm) than was previously 
known or recognized. 
10.4. Events of Clinical Interest 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest 
(ECI) and must be reported within 24 hours to the Sponsor-Investigator and within 2 working 
days to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-1220). 
 
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, any ECI, or follow up to an ECI, that occurs to any subject must be 
reported within 24 hours to the Sponsor-Investigator and within 2 working days to Merck 
Global Safety if it causes the subject to be excluded from the trial, or is the result of a protocol-
specified intervention, including but not limited to washout or discontinuation of usual 
therapy, diet, placebo treatment or a procedure. 
For the time period beginning at treatment allocation/randomization through 90 days following 
cessation of treatment, or 30 days following cessation of treatment if the subject initiates new 


61 
 
anticancer therapy, whichever is earlier, any ECI, or follow up to an ECI, whether or not 
related to Merck product, must be reported within 24 hours to the Sponsor and within 24 hours 
to Merck Global Safety. 
Events of clinical interest for this trial include: 
 
• An overdose of Merck product, as defined in Section 10.1 - Definition of an Overdose 
for This Protocol and Reporting of Overdose to the Sponsor-Investigator, that is not 
associated with clinical symptoms or abnormal laboratory results. 
• An elevated AST or ALT lab value that is greater than or equal to 3X the upper limit of 
normal and an elevated total bilirubin lab value that is greater than or equal to 2X the 
upper limit of normal and, at the same time, an alkaline phosphatase lab value that is 
less than 2X the upper limit of normal, as determined by way of protocol-specified 
laboratory testing or unscheduled laboratory testing.* 
 
• *Note: These criteria are based upon available regulatory guidance documents. The 
purpose of the criteria is to specify a threshold of abnormal hepatic tests that may 
require an additional evaluation for an underlying etiology. 
10.5. Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the 
period from the initiation of any study procedures (e.g., after the first dose of study treatment) 
to the end of the study treatment (e.g., last dose of study treatment) and/or follow-up. For this 
study, the study treatment follow-up is defined as 30 days following the last administration of 
study treatment, or 30 days following the decision to remove the subject from study treatment, 
whichever is earliest. 
 
10.2.4 
Baseline/Preexisting Condition 
A baseline/preexisting condition is one that is present at the start of the study. A preexisting 
condition should be recorded as an adverse event if the frequency, intensity, or if the character 
of the condition worsens during the study period. 
 
10.2.5 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting 
condition. At the end of the study, any new clinically significant findings/abnormalities that 
meet the definition of an adverse event must also be recorded and documented as an adverse 
event. 
 
10.2.6 
Post-study Adverse Event 
All unresolved adverse events should be followed by the investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained. At the 
last scheduled visit, the investigator should instruct each subject to report any subsequent 
event(s) that the subject, or the subject’s personal physician, believes might reasonably be 
related to participation in this study. 
 


62 
 
10.2.7 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the 
following conditions is met: 
• 
The laboratory abnormality is not otherwise refuted by a repeat test to confirm 
the abnormality 
• 
The abnormality suggests a disease and/or organ toxicity 
• 
The abnormality is of a degree that requires active management (e.g., change of 
dose, discontinuation of the drug, more frequent follow-up assessments, further 
diagnostic investigation, etc.). 
10.2.8 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in 
 
this protocol. Any condition responsible for surgery should be documented as an adverse 
event if the condition meets the criteria for an adverse event. 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an 
adverse event in the following circumstances: 
• 
Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition. Surgery should not be reported as an outcome 
of an adverse event if the purpose of the surgery was elective or diagnostic and the 
outcome was uneventful. 
• 
Hospitalization or prolonged hospitalization required to allow efficacy measurement 
for the study. 
• 
Hospitalization or prolonged hospitalization for therapy of the target disease of the 
study, unless it is a worsening or increase in frequency of hospital admissions as 
judged by the clinical investigator. 
 
10.6. Assessing and Recording of Adverse Events 
An adverse event is defined as any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and which does not necessarily 
have to have a causal relationship with this treatment. An adverse event can therefore be any 
unfavorable and unintended sign (including an abnormal laboratory finding, for example), 
symptom, or disease temporally associated with the use of a medicinal product or protocol- 
specified procedure, whether or not considered related to the medicinal product or protocol- 
specified procedure. Any worsening (i.e., any clinically significant adverse change in 
frequency and/or intensity) of a preexisting condition that is temporally associated with the use 
of the Merck’s product, is also an adverse event. 
 
All adverse events that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be 
excluded from the trial, or are the result of a protocol-specified intervention, including but not 
limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. 
 


63 
 
From the time of treatment allocation/randomization through 30 days following cessation of 
treatment, all adverse events must be reported by the investigator. Such events will be 
recorded at each examination on the Adverse Event case report forms/worksheets. The 
reporting timeframe for adverse events meeting any serious criteria is described in section 
10.8. The investigator will make every attempt to follow all subjects with non-serious adverse 
events for outcome. 
 
Adverse events will not be collected for subjects during the pre-screening period (for 
determination of archival tissue status) as long as that subject has not undergone any 
protocol- specified procedure or intervention. If the subject requires a blood draw, fresh 
tumor biopsy, etc., the subject is first required to provide consent to the main study and AEs 
will be captured according to guidelines for standard AE reporting. 
 
10.7. Evaluating Adverse Events 
An investigator who is a qualified physician will evaluate all adverse events according to the 
NCI Common Terminology for Adverse Events (CTCAE), version 4.0. Any adverse event 
which changes CTCAE grade over the course of a given episode will have each change of 
grade recorded on the adverse event case report forms/worksheets. 
 
All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 
Table 7 
Evaluating Adverse Events 
V4.0 CTCAE 
Grading 
Grade 1 
Mild; asymptomatic or mid symptoms; clinical or diagnostic observations only; 
intervention not indicated. 
Grade 2 
Moderate; minimal, local or noninvasive intervention indicated; limiting age-
Grade 3 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation or hospitalization indicated; disabling; 
Grade 4 
Life threatening consequences; urgent intervention indicated. 
Grade 5 
Death related to AE 
Seriousness 
A serious adverse event is any adverse event occurring at any dose or during any use of Merck product that: 
†Results in death; or 
†Is life threatening; or places the subject, in the view of the investigator, at immediate risk of death 
from the event as it occurred (Note: This does not include an adverse event that, had it occurred in a 
†Results in a persistent or significant disability/incapacity (substantial disruption of one’s ability to 
†Results in or prolongs an existing inpatient hospitalization (hospitalization is defined as an inpatient 
admission, regardless of length of stay, even if the hospitalization is a precautionary measure for 
continued observation. (Note: Hospitalization for an elective procedure to treat a pre-existing condition 
that has not worsened is not a serious adverse event. A pre-existing condition is a clinical condition that 
†Is a congenital anomaly/birth defect (in offspring of subject taking the product regardless of time to 
Is a new cancer (that is not a condition of the study) (although not serious per ICH definition, is 
reportable to the Sponsor within 24 hours and to Merck within 2 working days to meet certain local 
Is an overdose (whether accidental or intentional). Any adverse event associated with an overdose is 
considered a serious adverse event for collection purposes. An overdose that is not associated with an 
adverse event is considered a non-serious event of clinical interest and must be reported within 24 hours to 
Other important medical events that may not result in death, not be life threatening, or not require 
hospitalization may be considered a serious adverse event when, based upon appropriate medical judgment, 
the event may jeopardize the subject and may require medical or surgical intervention to prevent one of the 
Duration 
Record the start and stop dates of the adverse event. If less than 1 day, indicate the appropriate length of time 
Action taken 
Did the adverse event cause Merck product to be discontinued? 


64 
 
Relationship to 
Merck Product 
Did Merck product cause the adverse event? The determination of the likelihood that Merck product 
caused the adverse event will be provided by an investigator who is a qualified physician. The 
investigator’s signed/dated initials on the source document or worksheet that supports the causality noted 
on the AE form, ensures that a medically qualified assessment of causality was done. This initialed 
document must be retained for the required regulatory time frame. The criteria below are intended as 
reference guidelines to assist the investigator in assessing the likelihood of a relationship between the test 
drug and the adverse event based upon the available information. 
Exposure 
Is there evidence that the subject was actually exposed to Merck product such as: 
reliable history, acceptable compliance assessment (pill count, diary, etc.), expected 
Time Course 
Did the AE follow in a reasonable temporal sequence from administration of Merck 
product? 
Likely Cause 
Is the AE not reasonably explained by another etiology such as underlying disease, other 
 
 
46 
10.8. Reporting of Serious Adverse Events 
10.2.9 
IRB Notification by Sponsor-Investigator 
Reports of all events (including follow-up information) that meet the definition of an 
unanticipated problem posing risk to subjects or others must be submitted to the IRB within one 
week (5 business days) following the occurrence of the unanticipated problem or the principal 
investigator’s acquiring knowledge of the unanticipated problem in accordance with IRB policy. 
Additionally, the sponsor-investigator will submit a summary of all Unanticipated problems that 
occurred since the beginning of the study at the time of continuing review. Copies of each report 
and documentation of IRB notification and receipt will be kept in the Regulatory binder. 
 
10.2.10 
FDA Notification by Sponsor-Investigator 
The Columbia University Medical Center Sponsor-Investigator, as holder of the IND, will be 
responsible for all communication with the FDA. Columbia University Medical Center 
Principal Investigator will report to the FDA, regardless of the site of occurrence, any adverse 
event that is serious, unexpected and there is evidence to suggest a causal relationship between 
the drug and the adverse event. These must be reported to the FDA and any affiliate sites as 
soon as possible, but in no case later than 15 calendar days after the sponsor determines that 
the information qualifies for reporting. The Sponsor-Investigator will also submit an IND 
annual report to the FDA in accordance with 21.CFR 312.33. 
 
The Columbia University Medical Center Sponsor Investigator must report to the FDA and any 
affiliate site investigators as follows: 
 
• 
Any unexpected fatal or life-threatening event must be reported as soon as possible, 
but no later than 7 calendar days after the sponsor investigator initial receipt of the 
information 
• Any findings from epidemiological studies, pooled analysis of multiple 
studies, or clinical studies, whether or not conducted under an IND, and 
whether or not conducted by the sponsor-investigator, that suggest a 
significant risk in humans exposed to the drug must be reported as soon 
as possible but no later than 15 calendar days after the sponsor-
investigator determines that the information qualifies for reporting 
• Any findings from animal or in vitro testing whether or not conducted 


65 
 
under an IND, and whether or not conducted by the sponsor-investigator, 
that suggest a significant risk in humans exposed to the drug must be 
reported as soon as possible but no later than 15 calendar days after the 
sponsor- investigator determines that the information qualifies for 
reporting 
• Any clinically important increase in the rate of a serious suspected 
adverse reactions over that listed in the protocol or Investigator 
Brochure 
• Expected SAEs and AEs will be included in the IND Annual Reports. 
 
Follow-up information to a safety report should be submitted as soon as the relevant 
information is available. However, if the results of a sponsor’s investigation show that an 
adverse drug experience not initially determined to be reportable are so reportable, the sponsor 
investigator 
 
47 
 
must report such experience as soon as possible, but no later than 15 calendar 
days after the determination is made. 
 
All other serious unexpected experiences associated with the use of the study 
treatment will be reported to FDA as soon as possible but in no event later than 
15 calendar days after initial receipt of the information. 
 
10.2.11 
DSMC Reporting by the Sponsor Investigator 
Serious adverse events not constituting unanticipated problems are to be 
reported to the HICCC DSMC. Reporting should occur within 24 hours of 
knowledge of the SAE occurring at our institution or affiliate sites. 
 
10.2.12 
Reporting to Drug Manufacturer by Sponsor-Investigator 
The Sponsor-Investigator will report to investigational agent manufacturer any 
serious adverse events that meet the reporting criteria to the Institutional 
Review Board as described in section 
10.8.1 and/or to the FDA as described in section 10.8.2 within 72 hours of 
becoming aware of it, so that these reports can be evaluated and included in the 
Investigator’s Brochure and for IND safety submissions per regulations. 
Reporting will occur by sending the reporting form along with any additional 
documentation sent to the regulatory authorities. 
 
At the time of IRB renewal or at the request of the manufacturer, the Sponsor- 
Investigator will submit a summary of all Serious Adverse Events that have 
occurred inclusive of all sites to manufacturer. 
 
10.9 
Reporting Process 
Adverse events may be submitted on FDA Form 3500A, the HICCC DSMC 
Serious Adverse Event Reporting Form, or in a narrative format. 


66 
 
 
11. 
 
11.1 
11. 
PHARMACEUTICAL INFORMATION 
 
11.1. Pembrolizumab 
 
The investigator shall take responsibility for and shall take all steps to maintain 
appropriate records and ensure appropriate supply, storage, handling, 
distribution and usage of investigational product in accordance with the 
protocol and any applicable laws and regulations. 
 
Clinical Supplies will be provided by the Sponsor as summarized in Table 8. 
 
Clinical supplies will be packaged to support enrollment and replacement 
subjects as required. When a replacement subject is required, the Sponsor or 
designee needs to be contacted prior to dosing the replacement supplies. 
 
 
Table 8 
Product Description- Pembrolizumab 
Product Name & Potency 
Dosage Form 
Additional Information 
Pembrolizumab 50 mg/vial 
Lyophilized powder for 
injection 
Provided centrally by the 
Sponsor 
 
All supplies indicated in Table 8 will be provided per the Additional Information 
field depending on local country operational or regulatory requirements. 
 
Any commercially available product not included in Table 8 (i.e. azacitidine) will 
be provided by the trial site, subsidiary or designee. Every attempt should be made 
to source these supplies from a single lot/batch number. 
 
The trial site is responsible to record the lot number, manufacturer and expiration 
date for any locally purchased product as per local guidelines unless otherwise 
instructed by the Sponsor. 
 
11.2. Packing and Labeling Information 
Clinical supplies will be affixed with a clinical label in accordance with 
regulatory requirements. Subjects will receive open label vials and/or kits for 
every 3-week dosing. 
 
11.3. Clinical Supplies Disclosure 
This trial is open-label; therefore, the subject, the trial site personnel, the 
Sponsor and/or designee are not blinded. Treatment (name, strength or potency) 


67 
 
is included in the label text; random code/disclosure envelopes or lists are not 
provided. 
 
11.4. Storage and Handling Requirements 
Clinical supplies must be stored in a secure, limited-access location under the 
storage conditions specified on the label. Receipt and dispensing of trial 
medication must be recorded by an authorized person at the trial site. Clinical 
supplies may not be used for any purpose other than that stated in the protocol. 
 
11.5. Discard/Destruction/Returns and Reconciliation 
The investigator is responsible for keeping accurate records of the clinical 
supplies received from the Sponsor or designee, the amount dispensed to and 
returned by the subjects and the amount remaining at the conclusion of the trial. 
For all trial sites, the local country Sponsor personnel or designee will provide 
appropriate documentation that must be completed for drug accountability and 
return, or local discard and destruction if appropriate. Where local discard and 
destruction is appropriate, the investigator is responsible for ensuring that a local 
discard/destruction procedure is documented. 
 
11.6. Standard Policies 
Trial site personnel will have access to a central electronic randomization system 
(IVRS/IWRS system) to allocate subjects, to assign treatment to subjects and to 
manage the distribution of clinical supplies. Each person accessing the IVRS 
system must be assigned an individual unique PIN. They must use only their 
assigned PIN to access the system, and they must not share their assigned PIN 
with anyone. 
 
11.7. Other Agent: Azacitidine 
Product description: Azacitidine (Vidaza) at a dose of 50 mg/m2 by SubQ 
injection repeated daily for 5 days. Repeat cycle after 4 weeks. 
 
Solution preparation (how the dose is to be prepared): Azacitidine should be 
aseptically reconstituted with 4 mL of Sterile Water for Injection (USP); upon 
reconstitution, the resulting suspension will contain azacitidine 25 mg/mL. The 
reconstituted product may be kept in the vial or drawn into a syringe. Doses 
greater than 4 mL should be divided equally into 2 syringes. 
 
Storage requirements: The reconstituted product may be held at room 
temperature for up to 1 hour, but must be administered within 1 hour after 
reconstitution. If the preparation is for delayed SubQ administration, the product 
must be refrigerated immediately. When azacitidine is reconstituted using water 
for injection that has not been refrigerated, the reconstituted product may be 
held under refrigerated conditions (2°C – 8°C, 36°F – 46°F) for up to 8 hours. 
When azacitidine is reconstituted using refrigerated (2°C – 8°C, 36°F – 46°F) 
water for injection, the reconstituted product may be stored under refrigerated 


68 
 
conditions (2°C – 8°C, 36°F – 46°F) for up to 22 hours. After removal from 
refrigerated conditions, the suspension may be allowed to equilibrate to room 
temperature for up to 30 minutes prior to administration. 
 
Stability: Azacitidine reconstituted with non-refrigerated water for injection for 
SubQ administration may be stored for up to 1 hour at 25°C (77°F) or for up to 8 
hours between 2°C and 8°C (36°F and 46°F); when reconstituted with 
refrigerated (2°C – 8°C, 36°F – 46°F) water for injection, it may be stored for 22 
hours between 2°C and 8°C (36°F and 46°F). 
 
Route of administration: Azacitidine is administered at a dose of 50 mg/m2 by 
SubQ injection, rotating sites for each injection (thigh, abdomen, or upper arm), 
repeated daily for 5 consecutive business days. This cycle should be repeated 
after 4 weeks.  On the days when azacitidine is given with pembrolizumab, the 
pembrolizumab will be administered first followed by azacitidine. 
 
 
12. 
STUDY CALENDAR 
 
12.1. Trial Flow Chart 
 
Baseline evaluations are to be conducted according to the trial flow chart below 
(Section 12.1). Scans and x-rays must be done < 4 weeks prior to the start of 
therapy. In the event that the patient’s condition is deteriorating, laboratory 
evaluations should be repeated within 48 hours prior to initiation of the next 
cycle of therapy. 
 


 
 
Trial Period: 
Screening Phase 
Treatment Cycles a 
End of 
Treatment (last 
dose) or 
Discontinuatio
n 
Post-Treatment 
Azacitidine (4 weeks per cycle) 
Pembrolizumab (3 weeks per 
cycle) 
Treatment Week: 
1 
2 
3 
5 
6 
8 
9 
12 
15 
18 
Safety 
Follow- Up 
(30 days from 
last dose)q 
Follow Up 
Visitsb (Q8W) 
Survival 
Follow-
Up 
(Phone) 
Scheduling Window (Days): 
-28 to -1 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 7 
Administrative Procedures 
Informed Consent c 
X 
Inclusion/Exclusion Criteria 
X 
Demographics and Medical History 
X 
Prior and Concomitant Medication 
Review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Clinical Procedures/Assessments 
Review Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
12-Lead ECG 
X 
Physical Examination 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Ht (V1 only), Wt, & Vital Signs 
(T/P/RR/BP) 
X 
X 
ECOG Performance Status 
Xp 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Azacitidine Treatment 
Administrationo 
X 
X 
X then Q4W 
Pembrolizumab Treatment 
Administrationo 
X 
X 
X then Q3W 
Post-study Anticancer Therapy 
Status 
X 
Q12W 
Survival Status 
Q12W 
Laboratory Procedures/Assessments: analysis performed by LOCAL laboratory 
Pregnancy Test – Urine or Serum 
- HCGd 
X 
PT/INR and aPTTe 
X 
CBC with Differentiale,g 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Chemistry Panele,f 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urinalysise 
X 
Amylase and Lipase 
X 
X 
X 
X 
 
 


 
51 
Trial Period: Screening Phase 
Treatment Cycles a 
End of 
Treatment (last 
dose) or 
Discontinuatio
n 
Post-Treatment 
Azacitidine (4 weeks per cycle) 
Pembrolizumab (3 weeks per 
cycle) 
Treatment Week: 
1 
2 
3 
5 
6 
8 
9 
12 
15 
18 
Safety 
Follow- Up 
(30 days from 
last dose) 
Follow Up 
Visitsb (Q8W) 
Survival 
Follow-
Up 
(Phone) 
Scheduling Window (Days): 
-28 to -1 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 7 
T3, FT4 and TSHe 
X 
X 
X 
X then Q6W 
X 
X 
Serum CA 19-9e,h 
X 
X 
X 
X 
X 
then 
Q6W 
X 
HBV, HCV, HIVe,i 
X 
Efficacy Measurements 
Tumor Imaging 
Xj 
Xk then 
Q8W 
Xl 
Tumor Biopsies/Archival Tissue Collection/Correlative Studies Blood 
Archival or Newly Obtained Tissue 
Collectionm 
X 
X 
Xoptional 
Correlative Studies Blood 
Collection 
Xn 
X 
X 
X 
X 
a. Unless otherwise specified, assessment/procedures are to be performed prior to dose administration on Day 1 of each cycle. 
b. Subjects who discontinue study treatment without documented disease progression should continue to be monitored for disease by radiologic imaging every 8 weeks (7 days) until (1) the start of new anti-cancer 
treatment, (2) disease progression, (3) death, or (4) the end of the study, whichever occurs first. 
c. Informed consent will include consent for correlative studies including biopsies and serum collections. 
d. For women of reproductive potential, a negative pregnancy test should be performed within 72 hours prior to first dose of trial treatment. Pregnancy tests (serum and/or urine tests) should be repeated if required by local 
guidelines. 
e. Laboratory Screening Tests should be performed within 7 days prior to first dose of treatment. For all subjects, unresolved abnormal labs resulting in drug-related AEs should be followed until resolution. Post dose lab may 
be collected up to 72 hours prior to the scheduled timepoint. 
f. Chemistry will be collected on Day 1 of each cycle of azacitidine and pembrolizumab. 
g. CBC with differentials will be collected on Day 1 of each cycle of azacitidine and pembrolizumab. 
h. On treatment CA 19-9 – starting at Cycle 1 of Pembrolizumab, CA 19-9 will be collected Q3W until week 15 then every 2 pembrolizumab cycles (Q6W +/- 2 weeks) through the end of treatment 
i. All subjects will be tested for HIV, HBV, and HCV prior to enrollment. Those who are positive for HIV, untreated active Hepatitis B, and dual infection with HBV/HCV will be excluded. 
j. Tumor imaging at screening: Imaging will be performed within 28 days prior to the first dose of induction. Imaging should include CT chest, abdomen, and pelvis or MRI if CT is clinically contraindicated. 
k. The first-on study tumor imaging will be performed after 8 weeks (7 days) of treatment, and will continue every 8 weeks (
7 days) thereafter (or more frequently if clinically indicated). Timing of imaging follows 
calendar days and should not be adjusted due to dose interruptions. The same imaging technique, acquisition, and processing parameters for a subject should be used throughout the trial if possible. 
l. Subjects without confirmed PD who discontinue treatment will have imaging performed at the time study treatment is discontinued (i.e. date of discontinuation 
4 week window). If a scan was obtained within 4 weeks 
prior to discontinuation of treatment, then imaging at treatment discontinuation is not required. Continue to monitor disease status as indicated in Section 6.6. Subjects who discontinue treatment after confirmed PD will not 
need further imaging performed during the follow-upperiod. 
m. If archival tissue is not available then fresh biopsy is considered any tumor tissue collection within 42 days prior to first dose of study treatment and after previous therapy. All 31 subjects will have a newly-obtained 
biopsy during week 8 (
7 days) of the study. An optional biopsy is also requested at the time of discontinuation for PD. 
 


 
Trial Period: 
Screening Phase 
Treatment Cycles a 
End of 
Treatment (last 
dose) or 
Discontinuation 
Post-Treatment 
Azacitidine (4 weeks per cycle) 
Pembrolizumab (3 weeks per 
cycle) 
Treatment Week: 
1 
2 
3 
5 
6 
8 
9 
12 
15 
18 
Safety 
Follow- Up 
(30 days 
from last 
dose)q 
Follow Up 
Visitsb (Q8W) 
Survival 
Follow-Up 
(Phone) 
Scheduling Window (Days): 
-28 to -1 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
± 7 
n. Collect  at baseline, and then on weeks 3, 5, and 6 prior to study treatment administration. Whole blood for Genetics/RNA and DNA analyses. Serum and plasma for Proteomics. 
o. The first dose of azacitidine is Week 1 Day 1, other doses have a +/-3 day window for dose administrations (for azacitidine as well as pembrolizumab). Azacitidine will be dosed on 5 consecutive business days.  On the days 
when azacitidine is given with pembrolizumab, the pembrolizumab will be administered first followed by azacitidine.  
p. Screening ECOG should be performed within 3 days prior to first dose of study therapy. 
q. Safety follow-up visit should be conducted approximately 30 days after the last dose of trial treatment or before the initiation of a new anti-cancer treatment, whichever comes first. 
 


72 
 
12.2. Trial Procedures 
 
The Trial Flow Chart - Section 12.1 summarizes the trial procedures to be performed at each 
visit. Individual trial procedures are described in detail below. It may be necessary to perform 
these procedures at unscheduled time points if deemed clinically necessary by the investigator. 
Furthermore, additional evaluations/testing may be deemed necessary by the Sponsor and/or 
Merck for reasons related to subject safety. In some cases, such evaluation/testing may be 
potentially sensitive in nature (e.g., HIV, Hepatitis C, etc.), and thus local regulations may 
require that additional informed consent be obtained from the subject. In these cases, such 
evaluations/testing will be performed in accordance with those regulations. 
 
12.3. Administrative Procedures 
12.1.1 
Informed Consent 
The Investigator must obtain documented consent from each potential subject or each subject’s 
legally acceptable representative prior to participating in a clinical trial. 
 
Consent must be documented by the subject’s dated signature or by the subject’s legally 
acceptable representative’s dated signature on a consent form along with the dated signature 
of the person conducting the consent discussion. A copy of the signed and dated consent form 
should be given to the subject before participation in the trial. 
 
The initial informed consent form, any subsequent revised written informed consent form and 
any written information provided to the subject must receive the IRB/ERC’s approval/ favorable 
opinion in advance of use. The subject or his/her legally acceptable representative should be 
informed in a timely manner if new information becomes available that may be relevant to the 
subject’s willingness to continue participation in the trial. The communication of this 
information will be provided and documented via a revised consent form or addendum to the 
original consent form that captures the subject’s dated signature or by the subject’s legally 
acceptable representative’s dated signature. 
 
The informed consent will adhere to IRB/ERC requirements, applicable state laws and federal 
regulations. 
 
12.1.2 Inclusion/Exclusion Criteria 
All inclusion and exclusion criteria will be reviewed by the investigator or qualified designee to 
ensure that the subject qualifies for the trial. 
 
12.1.3 
Medical History 
A medical history will be obtained by the investigator or qualified designee. Medical history will 
include all active conditions, and any condition diagnosed within the prior 10 years that are 
considered to be clinically significant by the Investigator. Details regarding the disease for which 
the subject has enrolled in this study will be recorded separately and not listed as medical history. 
 
12.1.4 Prior and Concomitant Medications 
12.1.4.1 
Prior Medications 
The investigator or qualified designee will review prior medication use, including any protocol- 
 


73 
 
specified washout requirement, and record prior medication taken by the subject within 28 days 
before starting the trial. Treatment for the disease for which the subject has enrolled in this 
study will be recorded separately and not listed as a prior medication. 
 
12.1.4.2 
Concomitant Medications 
The investigator or qualified designee will record medication, if any, taken by the subject during 
the trial.  All medications related to reportable SAEs and ECIs should be recorded. 
 
12.1.5 
Disease Details and Treatments 
12.1.5.1 
Disease Details 
The investigator or qualified designee will obtain prior and current details regarding disease 
status. 
 
12.1.5.2 
Prior Treatment Details 
The investigator or qualified designee will review all prior cancer treatments including systemic 
treatments, radiation and surgeries. 
 
12.1.5.3 
Subsequent Anti-Cancer Therapy Status 
The investigator or qualified designee will review all new anti-neoplastic therapy initiated after 
the last dose of trial treatment. If a subject initiates a new anti-cancer therapy within 30 days after 
the last dose of trial treatment, the 30 day Safety Follow-up visit must occur before the first dose 
of the new therapy. Once new anti-cancer therapy has been initiated the subject will move into 
survival follow-up. 
 
12.1.6 
Clinical Procedures/Assessments 
12.1.6.1 
Adverse Event (AE) Monitoring 
The investigator or qualified designee will assess each subject to evaluate for potential new or 
worsening AEs as specified in the Trial Flow Chart and more frequently if clinically indicated. 
Adverse experiences will be graded and recorded throughout the study and during the follow-up 
period according to NCI CTCAE Version 4.0. Toxicities will be characterized in terms 
regarding seriousness, causality, toxicity grading, and action taken with regard to trial treatment. 
 
Refer to Section 10 for detailed information regarding the assessment and recording of adverse 
events. 
 
12.1.6.2 
Physical Exam 
The investigator or qualified designee will perform a complete physical exam during the 
screening period. Clinically significant abnormal findings should be recorded as medical 
history. A physical exam should be performed as specified in the Trial Flow Chart (Section 
12.1). For subsequent cycles the investigator or qualified designee will perform a directed 
physical exam as clinically indicated prior to dosing on Day 1 of each treatment cycle. After the 
first dose of trial treatment new clinically significant abnormal findings should be recorded as 
AEs. 
 
12.1.6.3 
Vital Signs 
The investigator or qualified designee will take vital signs at screening, prior to the 


74 
 
administration of each dose of trial treatment and at treatment discontinuation as specified in 
the 
 
Trial Flow Chart (Section 12.1). Vital signs should include temperature, pulse, respiratory rate, 
weight and blood pressure. Height will be measured at screening only. 
 
12.1.6.4 
Eastern Cooperative Oncology Group (ECOG) Performance Status 
The investigator or qualified designee will assess ECOG status (see Appendix 1) at 
screening, prior to the administration of each dose of trial treatment and discontinuation of trial 
treatment as specified in the Trial Flow Chart. 
 
12.1.6.5 
Tumor Imaging and Assessment of Disease 
CT chest, abdomen, and pelvis with contrast will be performed at baseline screening, prior to 
the administration of study drugs, and every 8 weeks thereafter. 
 
12.1.6.6 
Tumor Tissue Collection and Correlative Studies Blood 
Sampling 
All patients will have tumor biopsy specimens obtained at baseline prior to study drug 
administration and then during week 8 to assess methylation status and immune response. 
Peripheral blood will be evaluated for methylation status at baseline and then prior to treatment 
administration on weeks 3, 5, and 6.  
 
12.1.6.7 
Laboratory Procedures/Assessments 
Details regarding specific laboratory procedures/assessments to be performed in this trial are 
provided below. Laboratory tests for hematology, chemistry, urinalysis, and others are specified 
in the Trial Flow Chart (Section 12.1). 
 
Laboratory tests for screening should be performed within 7 days prior to the first dose of 
treatment. After Cycle 1, pre-dose laboratory procedures can be conducted up to 72 hours prior 
to dosing. Results must be reviewed by the investigator or qualified designee and found to be 
acceptable prior to each dose of trial treatment. 
 
 
13. 
MEASUREMENT OF EFFECT 
 
13.1. Antitumor Effect – Solid Tumors 
For the purposes of this study, patients should be re-evaluated for response every 8 weeks. In 
addition to a baseline scan, confirmatory scans should also be obtained 8 (not less than 4) weeks 
following initial documentation of objective response. 
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1)74. 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. 
 


75 
 
13.1.1 
Definitions of evaluable subjects 
Evaluable for toxicity: All patients will be evaluable for toxicity from the time of their first 
treatment with azacitidine. 
 
Evaluable for DLT assessment: The initial 6 subjects treated with at least 1 cycles (5 doses) of 
 
azacitidine and 1 dose of pembrolizumab will be evaluated for DLT. Subjects who do not 
complete these doses will be replaced. 
 
Evaluable for PFS- primary outcome: All subjects who receive a single dose of pembrolizumab 
will be included in the primary outcome analysis of PFS. If subjects are removed from study 
prior to completing a single dose of pembrolizumab, they will be replaced. 
 
Evaluable for objective response: Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated 
will be considered evaluable for response.  These patients will have their response classified 
according to the definitions stated below. (Note: Patients who exhibit objective disease 
progression prior to the end of cycle 1 will also be considered evaluable.) 
 
13.2. 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 for non-nodal lesions and short axis for 
nodal lesions) as >20 mm by chest x-ray, as >10 mm with CT scan, or >10 mm with calipers by 
clinical exam. All tumor measurements must be recorded in millimeters (or decimal fractions of 
centimeters). Tumor lesions that are situated in a previously irradiated area are not 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, and abdominal masses 
(not followed by CT or MRI), are considered as non-measurable. 
 
Note: Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. Cystic lesions thought to represent cystic metastases can be considered 
as measurable lesions, if they meet the definition of measurability described above. However, if 
non-cystic lesions are present in the same patient, these are preferred for selection as target 
lesions. 
 
Target lesions: All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 


76 
 
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. 
 
13.3. Methods for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler or calipers. All 
baseline evaluations should be performed as closely as possible to the beginning of treatment 
and never more than 4 weeks before the beginning of the treatment. 
 
The same method of assessment, i.e. CT or MRI, and the same technique should be used to 
characterize each identified and reported lesion at baseline and during follow-up. 
 
Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm or less.  If CT scans have slice 
thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice 
thickness. MRI is also acceptable in certain situations (e.g., for body scans). 
 
Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which greatly 
impact image quality, lesion conspicuity, and measurement.  Furthermore, the availability of 
MRI is variable globally. As with CT, if an MRI is performed, the technical specifications of the 
scanning sequences used should be optimized for the evaluation of the type and site of disease. 
Furthermore, as with CT, the modality used at follow-up should be the same as was used at 
baseline and the lesions should be measured/assessed on the same pulse sequence. It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all 
scanners, body parts, and diseases. Ideally, the same type of scanner should be used and the 
image acquisition protocol should be followed as closely as possible to prior scans. Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
Tumor markers: Tumor markers alone cannot be used to assess response. If markers are initially 
above the upper normal limit, they must normalize for a patient to be considered in complete 
clinical response. 


77 
 
 
13.4. Response Criteria- RECIST Criteria 
13.4.1 
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 study. 
 
13.4.2 
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). 
 
13.4.3 
Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria. 
 
 


78 
 
Table 9 
Disease Assessment For Patients with Measurable Disease 
Target Lesions 
Non-Target Lesions 
New 
Lesions 
Overall 
Response 
Best Overall 
Response when 
Confirmation is 
Required* 
CR 
CR 
No 
CR 
>4 wks. 
Confirmation** 
CR 
Non-CR/Non-PD 
No 
PR 
>4 wks. 
Confirmation** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non- 
PD/not evaluated 
No 
PR 
SD 
Non-CR/Non- 
PD/not evaluated 
No 
SD 
documented at least 
once >4 wks. from 
baseline** 
PD 
Any 
Yes or 
No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes or 
No 
PD 
Any 
Any 
Yes 
PD 
* 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
** 
Only for non-randomized trials with response as primary endpoint. 
*** 
In exceptional circumstances, unequivocal progression in non-target lesions may be 
accepted as disease progression. 
Note: Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be reported 
as “symptomatic deterioration.” Every effort should be made to document the objective 
progression even after discontinuation of treatment. 
 
 
13.5. Assessment of Disease According to Immune Related RECIST for Solid Tumors 
Although this will not be the primary endpoint we will allow subjects to remain on study if they 
meet the criteria for immune related RECIST as described. The immune related RECIST 
(irRECIST), is adapted to account for the unique tumor response seen with immunotherapies.75 
 
The irRECIST criteria considers index lesions identified at baseline together with new lesions 
that may occur after the start of treatment and are incorporated into the calculated tumor burden. 
The appearance of new lesions alone does not constitute PD. 
 
If imaging shows PD, tumor assessment should be repeated 4 weeks later to confirm PD with 
the option of continuing treatment for clinically stable subjects. Clinically stable will be defined 
by the following criteria: 
• Absence of signs and symptoms indicating disease progression 
• No decline in ECOG performance status 


79 
 
• Absence of rapid progression of disease 
• Absence of progressive tumor at critical anatomical sites (eg, cord compression) 
requiring urgent alternative medical intervention 
• Absence of disease progression in close proximity to a vital organ. 
 
Subjects must meet the above bulleted criteria for clinically stable disease in order to continue 
on study treatment beyond initial imaging showing PD. Clinically stable subjects who continue 
on study treatment will first be reconsented. 
In determining whether the tumor burden has increased or decreased, investigators should 
consider all target lesions as well as non-target lesions. Subjects who are deemed clinically 
unstable are not required to have repeat imaging for confirmation. If radiologic progression is 
confirmed, then the subject will be discontinued from study treatment as specified in the 
Protocol, and the first radiographic evidence of PD should be the date of progression. If 
radiologic progression is not confirmed, then the subject should resume/ continue study 
treatment and have their next scan according to the Protocol-specified schedule (ie 4 weeks later 
and then every 8 weeks). If progression is not confirmed and the subject continues on treatment, 
the next scan that documents disease progression (and is confirmed by a second scan at least 4 
weeks later) will be considered the date 
of disease progression. 
 
NOTE: If a subject with confirmed radiographic progression (ie, 2 scans at least 28 days apart 
demonstrating PD) is clinically stable or clinically improved, and there is no further increase in 
the tumor dimensions at the confirmatory scan, an exception may be considered to continue 
treatment upon consultation with the sponsor. In order for a patient to be considered clinically 
stable, all bulleted criteria listed above in section 13.5 must be fulfilled. Clinically stable 
subjects should also have at the confirmatory scan no further increase in the target lesions, no 
unequivocal increase in non-target lesions, and no additional new lesions develop (non-
worsening PD) to continue study treatment. Such exceptions will need to be made in 
consultation with the study Sponsor and the trial’s DSMC. However, study treatment continued 
beyond PD will be discontinued if radiologic progression worsens. 
 
13.5.1 
Evaluation of Target Lesions by irRECIST 
Tumor burden = Sum of diameter (target) + Sum of diameter (new) 
 
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 tumor burden compared with baseline. 
 
Progressive Disease (PD): At least a 20% increase in the tumor burden compared, taking as 
reference the smallest sum on study (this includes the baseline sum if that is the smallest on 
study), with confirmation of progression by a scan at least 4 weeks later (Note: With 
irRECIST, the appearance of new lesions alone is not considered progression). 
 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to 


80 
 
qualify for PD, taking as reference the smallest sum diameters while on study. 
 
13.5.2 
Evaluation of Best Overall Response with irRECIST 
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. 
 
Measurable 
Response 
Nonmeasurable Response 
Overall Response 
Total Measurable 
Tumor Burden 
Non-Index Lesions 
New Nonmeasurable 
Lesions 
Using irRECIST 
100% Decrease 
Absent 
Absent 
irCR 
≥ 30% Decrease 
Any 
Any 
irPR 
<30% Decrease to 
<20% Increase 
Any 
Any 
irSD 
≤ 20% Increase 
Any 
Any 
irPD 
 
 
13.6. Analysis of Endpoints 
Efficacy and safety endpoints that will be evaluated are listed below. 
 
13.6.1 
Efficacy Endpoints 
13.6.1.1 
Primary Efficacy Endpoint 
▪ Progression-Free Survival 
o PFS is defined as the time from the first day of trial treatment to the first 
documented disease progression per RECIST 1.1 or death due to any cause, 
whichever occurs first. 
 
13.6.1.2 
Secondary Efficacy Endpoints 
▪ Objective Response Rate 
o ORR is defined as the proportion of the subjects in the analysis population who 
have a CR or PR. Responses are based on assessments per RECIST 1.1. 
▪ Duration of Response 
o For subjects who demonstrate CR or PR, based on assessments per RECIST 1.1, 
DOR is defined as the time from first documented evidence of CR or PR until 
disease progression or death due to any cause, whichever occurs first. 
▪ Disease Control Rate 
o DCR is defined as the percentage of subjects who have achieved CR, PR, or SD 
based on assessments per RECIST 1.1. 
• Overall Survival (OS) 
o OS is defined as the time from first dose of study medication to death due to any 
cause. 
 
13.6.2 
Safety Endpoints 


81 
 
The primary safety objective of this trial is to characterize the safety and tolerability of 
pembrolizumab in combination with azacitidine in subjects with advanced pancreatic ductal 
adenocarcinoma. The primary safety analysis will be based on subjects who experienced 
toxicities as defined by CTCAE criteria. Safety will be assessed by quantifying the toxicities 
and grades experienced by subjects who have received pembrolizumab, including serious 
adverse events (SAEs) and events of clinical interest (ECIs). 
 
Safety will be assessed by reported adverse experiences using CTCAE, Version 4.0. The 
attribution to study treatment, time-of-onset, duration of the event, its resolution, and any 
concomitant medications administered will be recorded. AEs will be analyzed including but not 
limited to all AEs, SAEs, fatal AEs, and laboratory changes. Furthermore, specific immune- 
related adverse events (irAEs) will be collected and designated as immune-related events of 
clinical interest (ECIs) as described in Section 10.4. 
 
13.6.3 
Correlative Endpoints 
13.6.3.1 
Global DNA Methylation 
DNA methylation, using LINE-1 assay, will be determined and expressed as continuous 
variables with mean, median, and standard deviation calculations reported. Average changes in 
global DNA methylation will be assessed at baseline and every two weeks for the first eight 
weeks of the study. Disease control rates (DCR) and time to event endpoints (PFS and OS) will 
 
be estimated for patients who have methylation below the median compared to above the 
median at baseline. We will also estimate these outcomes for those who achieve low 
methylation (<10% methylation) compared to normal methylation (≥10% methylation) after 
eight weeks of therapy. We will also estimate these outcomes for those who achieve a change in 
methylation greater than the median compared to lower than the median at eight weeks 
compared to baseline. 
 
 
13.6.3.2 
Epigenetic effect in tumor tissue 
The premise of our proposal is that hypomethylation of tumor cells and/or stromal cells results 
in a significant polarization of the immune response seen in pancreatic cancer and this leads to 
an increase in response to tumor checkpoint inhibition.  Our preliminary data provides strong 
support for this, however this study provides a unique opportunity to understand the dynamic 
changes that occur in the tumor. Therefore we will first assess the impact of the systemically 
administered demethylating agent on tumor tissue. This assessment is performed in all 31 
patients 8 weeks after completion of TCI therapy. Core biopsies are obtained and tumor tissue is 
microdissected for methylation profiling using the Illumina 800K platform. Comparison is made 
to the pre-treatment tumor biopsy.  The Herbert Irving Comprehensive Cancer Center 
Epigenetics Core Laboratory (led by co-investigator Benjamin Tycko, MD, PhD) routinely 
performs this procedure and the subsequent statistical analysis and mapping of the resulting data 
to ENCODE tracks. Validation of up to 48 amplicons in up to 48 samples is done using the 
Fluidigm Access Array – Illumina MiSEQ platform. Here, bisulfite treatment and sequencing is 
performed to validate “hits” from the methylation array. 
 
A subsequent validation step at the transcriptional and translational level will be performed 


82 
 
based on the classes of genes identified but include one of three strategies (1) RNASeq; (2) Q- 
PCR; (3) immunohistochemistry or immunofluorescence on concurrent biopsy specimens. In 
cases where sufficient quantity of tumor material is obtained to perform RNASeq analysis this 
will be pursued. The parallel use of methylation and expression profiling allows for the 
selection of functionally most relevant genes. Although there is support for the feasibility of 
sufficient amount of high quality RNA obtained from endoscopic biopsies to perform RNASeq 
as we are uncertain whether in each case this will be feasible the alternative strategies may also 
be pursued. 
 
13.6.3.3 
Immune phenotyping 
It is our hypothesis that azacitidine will have significant impact on immune polarization in the 
tumor and potentially the number of PD1 or PDL1 positive cells. We have recently shown and 
validated the ability to score expression of epithelial markers and inflammatory cell markers in 
pancreatic cancer endoscopic core biopsies. We therefore will evaluate the expression of the 
ratio of CD8/CD3 T cells, CD86/CD68 macrophages and PD1 and PD1L expression using 
immunohistochemistry. 
 
The ratio of CD8/CD3 TILs and CD86/CD68 macrophages will be calculated and expressed as 
a continuous variable with mean, median, and standard deviation calculations reported. We will 
compare pre- and post-treatment CD8/CD3 and CD86/CD68 ratios using a paired t-test or a 
nonparametric test based on the data distribution. 
 
PD-L1 expression at baseline will be quantified as a dichotomous variable (>1% expression 
 
considered positive, <1% considered negative). PD-L1 expression is reported to be higher in 
81% of pancreatic tumors in historical controls than in paired non-malignant samples26. 
Correlation between baseline PD-L1 expression (positive vs. negative) and response to therapy 
(patients with clinical benefit, as defined by radiographic response and disease control, and 
those without clinical benefit) will be analyzed using frequency tables and Fisher’s exact test. 
 
 
13.7. Unblinding Procedures 
N/A- this is not a blinded study. 
 
13.8. Stopping Rules 
Early trial termination will be the result of the criteria specified below: 
 
• Unacceptable aggregate toxicity as determined by the trial’s Sponsor in consultation 
with the trial’s DSMC 
• Quality or quantity of data recording is inaccurate or incomplete 
• Poor adherence to protocol and regulatory requirements 
• Incidence or severity of adverse drug reaction in this or other studies indicates a 
potential health hazard to subjects 
• Plans to modify or discontinue the development of the study drug 
 


83 
 
In the event of Merck decision to no longer supply study drug, ample notification will be 
provided so that appropriate adjustments to subject treatment can be made. 
 
 
14. 
DATA REPORTING / REGULATORY REQUIREMENTS 
 
14.1. Data Collection 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 10.0 
(Adverse Events: List and Reporting Requirements). The Data Safety Monitoring Plan is 
described in Section 14.3. 
 
The Herbert Irving Comprehensive Cancer Center has an electronic clinical trials and data 
management system (CTMS) that will be used for data collection. CRFs for the study will be 
built into the CTMS for data entry. The system has full auditing capabilities which is web-based 
and housed on a server in a fully HIPAA compliant server room with restricted access and video 
camera monitoring.  All users must login with their own application username and password. 
Users off campus must first access the Virtual Private Network with their assigned campus 
username and password and then use their application credentials. Users are only able to see 
study information if they are indicated as study personnel in our electronic IRB system. Users 
are limited to access based on the role assigned in their corresponding protocol. Subject data is 
entered directly into the system, which (in the case of Columbia subjects) confirms the correct 
identity of patients via an interface with the electronic medical patient index. Staff with the 
appropriate IRB defined roles can run reports within the system for reporting purposes. 
 
14.2. Data Reporting 
Case Report Forms will be completed for each subject enrolled into the clinical study through 
the CTMS. It is the investigator’s responsibility for ensuring that all clinical and laboratory data 
 
entered on the corresponding CRFs are complete, accurate and authentic. 
 
14.3. Data and Safety Monitoring Committee 
The NCI-approved Data Safety and Monitoring Committee (DSMC) of the Herbert Irving 
Comprehensive Cancer Center (HICCC) will monitor every subject who receives treatment on 
this protocol for toxicity. This protocol will adhere to the policies of the currently approved 
HICCC Data and Safety Monitoring Plan (DSMP), which is in accordance with NCI and 
CUMC-IRB policy and guidelines. The committee is chair is appointed by the HICCC Director. 
The committee consists of HICCC faculty and staff with expertise in oncology, research 
pharmacy, research nursing, and data management. The DSMC convenes twice a month to 
review patient safety and the conduct of the trial. The PI will submit data and safety monitoring 
reports to the DSMC at a frequency to be determined by the DSMC based on risk to the 
subjects. 
 
At the time of renewal, the study team will submit the most recent DSMC approval letter for 
safety review to the CUMC IRB. Any modifications that are required by the DSMC to ensure 
patient safety will be submitted to the IRB. All protocol deviations, violations, and eligibility 


84 
 
waivers will be submitted to and approved by the DSMC prior to being reported to the IRB. All 
study data reviewed and discussed during these meetings will be kept confidential. 
 
For multicenter research, the principal investigator will assure that there is a mechanism in place 
to distribute the report to all participating investigators for submission to their local IRB. The 
report will document that a review of data and outcomes across all centers took place on a given 
date. It will summarize the DSMC’s review of the cumulative toxicities reported from all 
participating sites without specific disclosure by treatment arm. It will also inform site 
investigators of the study the DSMC’s conclusion with respect to progress or need for 
modification of the protocol. 
 
14.4. Quality Control and Quality Assurance 
Independent monitoring of the clinical study for protocol and GCP compliance will be 
conducted periodically by the CPDM Compliance Core on behalf of the HICCC DSMC. 
Additionally, the Compliance Oversight Committee of the IRB at Columbia University Medical 
Center may audit the study at any time per institutional policies and procedures. The 
investigator-sponsor and Columbia University Medical Center will permit direct access of the 
study monitors and appropriate regulatory authorities to the study data and to the corresponding 
source data and documents to verify the accuracy of this data. 
 
A risk-based approach will be used by the Compliance Core to determine the frequency, number 
of subject charts, and data elements to be monitored. The Compliance Coordinator will review the 
study status and summarize enrollment, toxicities, SAEs/UPs, dose escalation, statistical endpoints 
(e.g., stopping rules), etc. for the full DSMC membership at the regularly scheduled meetings. 
 
Internal On-site Monitoring: 
 
• Initial, recurrent, and close-out on-site monitoring visits will also be conducted at 
remote clinical sites, as appropriate/feasible. Other sites will have monitoring 
performed remotely (see below for further details). 
• The study Monitoring Visit Log will be completed and signed by the monitor and the 
PI/CRNP/CRN and/or CRC and will be filed in the regulatory binder. 
• The Compliance Coordinator will communicate with the site coordinator/Site Principle 
Investigator to schedule the monitoring visit and arrange for access to study materials 
and documentation. 
• The assigned Compliance Coordinator will monitor IIT trials within 1 month after the 
first subject is enrolled and throughout the life of the study to ensure that the study is 
being conducted in accordance with the protocol, GCP, applicable federal and local 
regulations, and per all applicable SOPs. The Compliance Coordinator is responsible to 
notify the PI and CRNP/CRN/CRC of upcoming monitor visits and convey what 
information and documentation will be required for the visit(s). The Compliance 
Coordinator is responsible for verifying that informed consent is properly obtained, 
eligibility is met (via the central registration process), and all study procedures are 
conducted according to the study protocol. The Compliance Coordinator will also verify 


85 
 
that the data reported in the CRF’s accurately reflect source documents, that all toxicities 
have been reported to date, and that all SAE’s/UPs/deviations/violations have been 
reported according to local IRB and HICCC DSMC requirements. The Compliance 
Coordinator will issue queries and ensure resolution in a timely and efficient manner. 
The Compliance Coordinator will also monitor for applicable regulatory compliance and 
research pharmacy compliance (if applicable) and communicate any deficiencies as 
appropriate. 
 
14.5. Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act (HIPAA). Those 
regulations require a signed subject authorization informing the subject of the following: 
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI. 
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization. For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (e.g., that the subject is alive) 
at the end of their scheduled study period. 
The subject binders will be maintained with in the CPDM offices, a secured floor within the 
 
Herbert Irving Pavilion and only the investigator and study staff will have access to the file. 
 
14.6. Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities 
in a clinical trial necessary for the reconstruction and evaluation of the trial. Source data are 
contained in source documents Examples of these original documents, and data records include: 
hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries or 
evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, 
copies or transcriptions certified after verification as being accurate and complete, microfiches, 
photographic negatives, microfilm or magnetic media, x-rays, subject files, and records kept at the 
pharmacy, at the laboratories, and at medico-technical departments involved  in the clinical trial. 
 
14.7. Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study. All data 
requested on the CRF must be recorded. All missing data must be explained. If a space on the CRF 
is left blank because the procedure was not done or the question was not asked, write “N/D”. If 
the item is not applicable to the individual case, write “N/A”. 
 
14.8. Records Retention 


86 
 
Records relating to a specific research activity, including research records collected by 
investigators, must be maintained for at least three years after completion of the research (45 
CFR 46.115(b); 21 CFR 56.115(b); 21 CFR 312.62). This minimum retention period applies 
whether or not any subjects were enrolled in the study. 
 
If the research is FDA regulated, records should be retained for at least two years after approval 
of the investigational agent by FDA; if it is not approved, records should be retained at least two 
years after the study is terminated and FDA is notified (note the additional requirement below 
for clinical research studies). 
 
Clinical records, including consent forms that document clinical intervention or clinical 
diagnostic procedure research-related procedures, must be retained in medical records by the 
institution for at least seven years, per CUMC and NYP policy which is based on state law. 
 
 
15. 
STATISTICAL CONSIDERATIONS 
 
15.1. Statistical Analysis Plan Summary 
 
This statistical analysis plan was developed in collaboration with the study statistician, Shing 
Lee, Ph.D. 
 
15.2. Populations for Statistical Analysis and Reporting 
15.2.1 
DLT Evaluable Population 
The DLT Evaluable Population consists of subjects in the initial 6 patient DLT cohort who 
complete at least 5 doses of azacitidine and 1 dose of pembrolizumab and completed the DLT 
observation period (6 weeks), and those who did not complete the DLT observation period and 
discontinued from study treatment due to a DLT event. The DLT Evaluable Population will be 
used for DLT assessments. 
 
 
15.2.2 
Safety Population 
The Safety Population consists of all subjects treated with at least one dose of any study drug. 
The Safety Population for azacitidine consists of all subjects treated with at least one dose of 
azacitidine, and will be used for the analysis of the safety data. The Safety Population for 
pembrolizumab consists of all subjects treated with at least one dose of pembrolizumab, and 
will be used for the analysis of the safety data. 
 
15.2.3 
Efficacy Population 
Evaluable for PFS- primary outcome: All subjects who receive a single dose of protocol therapy 
will be included in the primary outcome analysis of PFS. If subjects are removed from study 
prior to completing a single dose of pembrolizumab, they will be replaced but will be included 
in the primary analysis. 
 
Evaluable for objective response: Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated 


87 
 
will be considered evaluable for response.  These patients will have their response classified 
according to the definitions stated below. (Note: Patients who exhibit objective disease 
progression prior to the end of cycle 1 will also be considered evaluable.) 
 
15.2.4 
Reporting of Outcomes 
All conclusions should be based on all eligible patients. Sub analyses may then be performed on 
the basis of a subset of patients, excluding those for whom major protocol deviations have been 
identified (e.g., early death due to other reasons, early discontinuation of treatment, major 
protocol violations, etc.). However, these sub analyses may not serve as the basis for drawing 
conclusions concerning treatment efficacy, and the reasons for excluding patients from the 
analysis should be clearly reported.  The 95% confidence intervals should also be provided. 
 
15.3. Study Design/Endpoints 
15.2.5 
Primary Endpoint 
The primary hypothesis of this study is that combination hypomethylation induction followed 
by PD-1 blockade maintenance will result in increased efficacy compared to standard of care 
chemotherapy. This will be evaluated by comparing time to disease recurrence or death in this 
study with historical controls. This is based on recent studies evaluating therapy options after 
failure of first-line therapy in metastatic pancreatic cancer. The recently completed cooperative 
group study (SWOG S11156) was designed to evaluate an experimental therapy compared to 
standard chemotherapy with a null hypothesis of median PFS of 2 months. The study was a 
negative study and as reported in December 2016 both arms resulted in PFS of around 2 months 
in this setting. 
 
The primary endpoint is progression-free survival defined as the time from first treatment with 
the study drug to the earliest of either disease progression or death from any cause. Patients who 
are alive and progression free at the time of analysis will be censored at the time of their last 
follow-up. With 31 eligible subjects enrolling over 18 months with an additional 6 months of 
follow-up, we will have 80% power to detect a median PFS of 2 months in historical controls 
versus 4 months with one-sided alpha of 0.05. 
 
 
The Kaplan-Meir method will be used to evaluate all time to event endpoints. Median 
progression-free survival will be reported with 95% confidence intervals. 
 
15.2.6 
Secondary Endpoints 
The secondary hypothesis of this study is that combination therapy will lead to improvements in 
overall response rate (ORR), duration of response (DOR), disease control rate (DCR), and 
overall survival (OS). These will all be reported with percentages and 95% confidence intervals. 
The Kaplan-Meir method will be used to evaluate all time to event endpoints. 
 
15.2.6.1 
Definition of secondary endpoints: 
▪ Objective Response Rate 
o ORR is defined as the proportion of the subjects in the analysis population who 
have a CR or PR. Responses are based on assessments per RECIST 1.1 as 
described in Section 13.4. 


88 
 
▪ Duration of Response 
o For subjects who demonstrate CR or PR, based on assessments per RECIST 1.1, 
DOR is defined as the time from first documented evidence of CR or PR until 
disease progression or death due to any cause, whichever occurs first. 
▪ Disease Control Rate 
o DCR is defined as the percentage of subjects who have achieved CR, PR, or SD 
based on assessments per RECIST 1.1. 
▪ Overall Survival (OS) 
o OS is defined as the time from first dose of study medication to death due to any 
cause. 
 
15.2.7 
Exploratory and Ancillary Studies 
See Section 13.6.3 for description of correlative studies. All subjects will be required to agree to 
an on treatment biopsy after 8 weeks of therapy. Given the patient population and the likelihood 
that some subjects will have disease or clinical progression precluding biopsies we estimate that 
we will obtain on-treatment biopsy samples from a minimum of 20 subjects. 
15.2.7.1 
Global DNA Methylation will be assessed in all subjects at baseline and every 2 
weeks for the first 8 weeks of study. We will estimate the disease control rates 
(DCR) and time to event endpoints (median PFS and median OS) for subjects 
who have methylation below the median compared to above the median at 
baseline. We will also estimates these outcomes for those who achieve low 
methylation (<10% methylation) compared to normal methylation (≥10% 
methylation) after 8 weeks of therapy. We will also estimates these outcomes for 
those who achieve a change in methylation greater than the median compared to 
higher than the median at 8 weeks (compared to baseline). 
 
15.2.7.2 
Fisher’s exact test will be performed to compare the disease control rate for the 
two groups. Kaplan-Meier estimates of the survival distribution for the two 
groups will be calculated, and the two groups will be compared using a log-rank 
test. Change in methylation in tumor tissue will be evaluated in 20 patients who 
undergo baseline and week eight biopsies and will be compared using the paired 
t-test or the Wilcoxon signed-rank test depending on the data distribution. With 
20 patients, we will have 80% power to detect a change of 0.66 standard 
deviations given an alpha of 0.05. 
 
15.2.7.3 
Change in methylation in tumor tissue will be evaluated in subjects who undergo 
baseline and week 8 biopsies. We will describe changes in specific gene 
methylation patterns as described in Section 13.6.3. 
 
15.2.7.4 
Immune phenotyping will be measured on the subjects who undergo an on- 
treatment tumor biopsy. We will provide descriptive tables of IHC expression of 
CD8/CD3 T cell ratio, CD86/CD68 macrophage ratio, PD1 expression. Samples 
will be compared between pre and post combination specimens in treated 
subjects using the paired t-test. 
15.4. Size/Accrual Rate 
A total of 31 subjects will be enrolled over 18 months with plan to screen 4-5 subjects in our 


89 
 
multi-disciplinary pancreas clinic each month with enrollment of 2-3 patients per month. If the 
original 6 patient DLT cohort requires a dose reduction then up to a maximum of 37 subjects 
will be enrolled with 31 additional enrolled at the final dose level. 
 
15.5. Stratification Factors 
No stratification is planned. 
 
15.6. Statistical Methods for Safety Analysis 
Safety and tolerability will be assessed by clinical review of all relevant parameters including 
adverse experiences (AEs), laboratory tests, and vital signs. Count and percentage AE will be 
provided. Confidence interval rate of AE of clinical interest will be estimated using Exact 
method based on binomial distribution. 
 
15.7. Analysis Populations 
All subjects who received at least one dose of study treatment will be included in the primary 
and secondary efficacy and safety analysis as detailed in Section 15.2. 
 
 
16. 
PROTECTION OF HUMAN SUBJECTS 
This study is to be conducted in accordance with applicable government regulations and 
Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted Institutional 
Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the 
study conduct. The decision of the IRB concerning the conduct of the study will be made in 
writing to the investigator and a copy of this decision will be obtained before commencement of 
this study. 
 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in 
this study. This consent form will be submitted with the protocol for review and approval by 
the IRB for the study. The formal consent of a subject, using the IRB-approved consent form, 
must be obtained before that subject is submitted to any study procedure. This consent form 
must be signed by the subject or legally acceptable surrogate, as outlined in the IRB approved 
protocol, and the investigator-designated research professional obtaining the consent. 
 
 
17. 
STUDY FINANCES 
 
17.1. Conflict of Interest 
 
 
N/A 
 
17.2 
Subject Stipends or Payments 


90 
 
 
 
N/A 
 
18. 
PUBLICATION PLAN 
 
Neither the complete nor any part of the results of the study carried out under this 
protocol, nor any of the information provided by the sponsor for the purposes of 
performing the study, will be published or passed on to any third party without the 
consent of the study sponsor. Any investigator involved with this study is obligated to 
provide the sponsor with complete test results and all data derived from the study. 
 
19. 
REFERENCES 
 
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Miller KD, Siegel RL, Lin CC, et al. Cancer treatment and survivorship statistics, 2016. 
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Von Hoff DD, Ervin T, Arena FP, et al. Increased survival in pancreatic cancer with 
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Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs 
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2016. 
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Burt BM, Rodig SJ, Tilleman TR, Elbardissi AW, Bueno R, Sugarbaker DJ. Circulating 
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Mu CY, Huang JA, Chen Y, Chen C, Zhang XG. High expression of PD-L1 in lung 
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20. 
APPENDICES 
 
20.1. 
Appendix 1- ECOG Performance Status 
 
Grade 
Description 
0 
Normal activity. Fully active, able to carry on all pre-disease performance without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous activity, but ambulatory and 
able to carry out work of a light or sedentary nature (e.g., light housework, office work). 
2 
In bed <50% of the time. Ambulatory and capable of all self-care, but unable to carry out any 
work activities. Up and about more than 50% of waking hours. 
3 
In bed >50% of the time. Capable of only limited self-care, confined to bed or chair more 
than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-care. Totally confined to bed 
or chair. 
5 
Dead. 
 
 
 
 
20.2. 
Appendix 2- Common Terminology Criteria for Adverse Events V4.0 (CTCAE) 
The descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized 
for adverse event reporting. 
 
http://www.oncology.tv/SymptomManagement/NationalCancerInstituteUpdatesC
TCAEtov403.a spx 
 
20.3. 
Appendix 3- Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 *
 As
 published
 in
 Am.
 J.
 Clin.
 Oncol.:
 Oken,
 M.M.,
 Creech,
 R.H.,
 Tormey,
 D.C.,
 Horton,
 J.,
 Davis,
 T.E.,
 McFadden, E.T.,
 Carbone,
 P.P.:
 Toxicity
 And
 Response
 Criteria
 Of
 The
 Eastern
 Cooperative
 Oncology
 Group.
 Am
 J  Clin
 Oncol 5:649-655,
 1982.
 The
 Eastern
 Cooperative
 Oncology
 Group,
 Robert
 Comis
 M.D.,
 Group
 Chair.
 


96 
 
 
Criteria for Evaluating Response in Solid Tumors RECIST version 1.174  will be used in this 
study for assessment of tumor response. While either CT or MRI may be utilized, as per 
RECIST 1.1, CT is the preferred imaging technique in this study. 
 
In addition, volumetric analysis will be explored for response assessment.