Conditions: Sarcoma Liposarcoma Leiomyosarcoma Undifferentiated Pleomorphic Sarcoma
Keywords: Sarcoma
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 57
Healthy volunteers: no

Brief summary:
This research study is studying a combination of drugs (chemotherapy + Immunotherapy) as a possible treatment for liposarcoma, leiomyosarcoma, or undifferentiated pleomorphic sarcoma that has spread and has not responded to standard treatment.

Detailed description:
This research study is a Phase II clinical trial. Phase II clinical trials test the safety and effectiveness of an investigational drug, or in the case of this study, combination of drugs, to learn whether the combination of drugs works in treating a specific disease. "Investigational" means that the combination of drugs is being studied.

The primary purpose of this research study is to test the safety and effectiveness of eribulin and pembrolizumab in combination for controlling this cancer

The FDA (the U.S. Food and Drug Administration) has approved eribulin for the treatment of liposarcoma, based on a phase III study that compared eribulin and dacarbazine in the treatment of liposarcoma and leiomyosarcoma. The FDA has not approved pembrolizumab for this specific disease but it has been approved for other uses. A phase II study showed rare responses of liposarcoma and undifferentiated pleomorphic sarcoma to treatment with pembrolizumab. While eribulin in combination with pembrolizumab has not previously been tested in the treatment of liposarcoma, leiomyosarcoma, or undifferentiated pleomorphic sarcoma, other research studies and laboratory experiments and information from those studies suggest that the combination of these drugs may help to stop cancer cells from growing. Chemotherapy treatment with eribulin may increase the response to immunotherapy with pembrolizumab

Arms:
arm 1: * Participants will receive eribulin intravenously on Day 1 and Day 8
* Pembrolizumab is administered intravenously Day 1, on a 21-day cycle arm 2: * Participants will receive eribulin intravenously on Day 1 and Day 8
* Pembrolizumab is administered intravenously Day 1, on a 21-day cycle arm 3: * Participants will receive eribulin intravenously on Day 1 and Day 8
* Pembrolizumab is administered intravenously Day 1, on a 21-day cycle

Interventions: intervention 1: Eribulin intervention 2: Pembrolizumab
Intervention descriptions: intervention 1: The ability of chemotherapy to kill cancer cells depends on its ability to halt cell division. Usually, the drugs work by damaging the RNA or DNA that tells the cell how to copy itself in division. If the cells are unable to divide, they die. The faster the cells are dividing, the more likely it is that chemotherapy will kill the cells, causing the tumor to shrink. They also induce cell suicide (self-death or apoptosis). intervention 2: The drug blocks the PD-1 receptor, preventing binding and activation of PD-L1 and PD-L2. This mechanism causes the activation of T-cell mediated immune responses against tumor cells.

Protocol document:
Prot_SAP_000.pdf: 
 
Title:  A Phase II Study of Eribulin and Pembrolizumab in Soft Tissue Sarcomas   
 
NCT Number:  NCT03899805 
 
IRB Approval Date:  05JUN2024 
 


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DF/HCC Protocol #:  19-082 
 
 
TITLE:  A Phase II Study of Eribulin and Pembrolizumab in Soft Tissue Sarcomas 
 
Coordinating Center: 
 
 
Dana-Farber / Harvard Cancer Center 
 
Principal Investigator (PI): 
Suzanne George, MD 
 
Dana-Farber Cancer Institute 
 
 
 
Study Agent(s): Eribulin supplied by Eisai and Pembrolizumab supplied by Merck 
 
IND #:  NA 
 
IND Sponsor:  NA  
 
Sponsor-Investigator: Suzanne George, MD 
 
Protocol Type / Version # / Version Date: 
Version #10 / 15MAY2024 
 
 
 


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SCHEMA 
 
 
 
 


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TABLE OF CONTENTS 
 
SCHEMA .........................................................................................................................................3 
List of abbreviations and definition of terms ...................................................................................7 
 
OBJECTIVES ......................................................................................................................9 
1.1 
Study Design ............................................................................................................9 
1.2 
Primary Objective ....................................................................................................9 
1.3 
Secondary Objectives.............................................................................................10 
 
BACKGROUND ...............................................................................................................10 
2.1 
Study Diseases: Liposarcoma, Leiomyosarcoma, Undifferentiated 
Pleomorphic Sarcoma/Other Sarcomas .................................................................10 
2.2 
Immunotherapy in Sarcomas .................................................................................11 
2.3 
Rationale for eribulin .............................................................................................11 
2.4 
Rationale for combination of eribulin and pembrolizumab ...................................12 
2.5 
IND Agents ............................................................................................................13 
2.6 
Summary of Pembrolizumab and Eribulin combination Data. ..............................21 
2.7 
Rationale ................................................................................................................22 
2.8 
Correlative Studies Background ............................................................................22 
 
PARTICIPANT SELECTION ...........................................................................................23 
3.1 
Eligibility Criteria ..................................................................................................23 
3.2 
Exclusion Criteria ..................................................................................................26 
3.3 
Inclusion of Women and Minorities ......................................................................28 
 
REGISTRATION PROCEDURES ...................................................................................28 
4.1 
General Guidelines for DF/HCC Institutions ........................................................28 
4.2 
Registration Process for DF/HCC Institutions .......................................................28 
 
TREATMENT PLAN ........................................................................................................29 
5.1 
Treatment Regimen ................................................................................................29 
5.2 
Pre-Treatment Criteria ...........................................................................................30 
5.3 
Agent Administration.............................................................................................31 
5.4 
General Concomitant Medication and Supportive Care Guidelines ......................32 
5.5 
Duration of Therapy ...............................................................................................34 
5.6 
Duration of Follow-Up ..........................................................................................36 
5.7 
Criteria for Taking a Participant Off-Study ...........................................................36 
5.8 
Criteria to Resume Treatment after a pembrolizumab related iAE .......................36 
5.9 
Treatment of Pembrolizumab Related Infusion Reactions ....................................38 
5.10 
Treatment Beyond Progression ..............................................................................40 
5.11 
Lifestyle Restrictions .............................................................................................40 
 
DOSING DELAYS/DOSE MODIFICATIONS ...............................................................41 
6.1 
Eribulin dosing delays/dose modifications ............................................................42 
6.2 
Pembrolizumab dosing delays ...............................................................................44 


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ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................57 
7.1 
Expected Toxicities ................................................................................................57 
7.2 
Adverse Event Characteristics ...............................................................................59 
7.3 
Expedited Adverse Event Reporting ......................................................................60 
7.4 
Expedited Reporting to the Food and Drug Administration (FDA) ......................60 
7.5 
Expedited Reporting to Hospital Risk Management .............................................60 
7.6 
Expedited Reporting to MERCK ...........................................................................61 
7.7 
Expedited Reporting to Eisai .................................................................................63 
7.8 
Routine Adverse Event Reporting .........................................................................64 
 
PHARMACEUTICAL INFORMATION ..........................................................................64 
8.1 
Pembrolizumab ......................................................................................................64 
8.2 
Eribulin ..................................................................................................................67 
 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................71 
9.1 
Summary table: Research tissue and blood specimen collection...........................72 
9.2 
Biomarker Studies ..................................................................................................72 
9.3 
Tumor Tissue Exploratory/Ancillary Correlative Studies .....................................74 
9.4 
Microbiome Exploratory Correlative Studies ........................................................75 
9.5 
Laboratory Exploratory Correlative Studies ..........................................................75 
 
STUDY CALENDAR .......................................................................................................78 
 
MEASUREMENT OF EFFECT........................................................................................81 
11.1 
Antitumor Effect – Solid Tumors ..........................................................................81 
11.2 
Other Response Parameters: irRECIST .................................................................87 
 
DATA REPORTING / REGULATORY REQUIREMENTS ...........................................90 
12.1 
Data Reporting .......................................................................................................90 
12.2 
Data Safety Monitoring..........................................................................................90 
 
STATISTICAL CONSIDERATIONS...............................................................................91 
13.1 
Study Design/Endpoints.........................................................................................91 
13.2 
Sample Size, Accrual Rate and Study Duration ....................................................91 
13.3 
Stratification Factors ..............................................................................................92 
13.4 
Interim Monitoring Plan ........................................................................................92 
13.5 
Analysis Plan .........................................................................................................93 
13.6 
Analysis of Primary Endpoints ..............................................................................93 
13.7 
Analysis of Secondary Endpoints ..........................................................................93 
13.8 
Analysis of Correlative Biomarkers.......................................................................93 
13.9 
Reporting and Exclusions ......................................................................................94 
 
PUBLICATION PLAN .....................................................................................................95 
 
REFERENCES ..................................................................................................................96 
 
APPENDIX A:  PERFORMANCE STATUS CRITERIA ..............................................101 


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Appendix B:  MANAGEMENT ALGORITHMS FOR ENDOCRINOPATHY, 
GASTROINTESTINAL, HEPATIC, NEUROLOGICAL, PULMONARY, RENAL, 
AND SKIN ADVERSE EVENTS ...................................................................................102 
 
APPENDIX C:  INFORMATION ON POSSIBLE DRUG INTERACTIONS ..............106 
 
appendix d:  Information on Possible Interactions with Other Agents for Patients and 
Their Caregivers and Non-Study Healthcare Team .........................................................107 
 
appendix E:  participant information card .......................................................................109 
 
APPENDIX F:  Guidelines for collecting research biopsy tissue....................................110 
 
Appendix G:  Contraceptive Guidance and Pregnancy Testing ......................................114 
 
LIST of TABLES 
 
Table 1 
 
Treatment Regimen  
 
 
 
29 
Table 2 
 
Eribulin dosing levels  
 
 
 
41 
Table 3.1  
Eribulin Diarrhea Toxicity Dose Modification 
 
42 
Table 3.2  
Eribulin Peripheral Neuropathy Dose Modification 
 
42 
Table 3.3  
Eribulin Neutropenia Dose Modification 
 
 
42 
Table 3.4  
Eribulin Thrombocytopenia Dose Modification 
 
43 
Table 3.5  
Eribulin Anemia Dose Modification 
 
 
43 
Table 4.1-4.9 
Pembrolizumab dose delays 
 
 
 
50-56 
Table 5 
 
DF/HCC Adverse Events 
 
 
 
60 
Table 6 
 
Research tissue and blood specimen collection 
 
72 
Table 7 
 
Study Calendar 
 
 
 
 
79 
Table 8.1-8.2 
RECIST 
 
 
 
 
 
85-86 
Table 9 
 
Immune-related Response Evaluation Criteria in Solid Tumors 
90 
Table 10  
Accrual Targets 
 
 
 
 
92 
Table 11  
Performance Status 
 
 
 
 
101 
Table 12  
Highly Effective Contraceptive Methods 
 
 
115
 
 
 
LIST of FIGURES 
 
Figure 1 
Study Schema………………………………………………………………………….3
 
 
 
 


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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
The following abbreviations and special terms are used in this study Clinical Study Protocol. 
Abbreviation and 
special term 
Explanation 
AE 
Adverse event 
CRF 
Case Report Form (electronic/paper) 
CSA 
Clinical Study Agreement 
CSR 
Clinical Study Report 
CTCAE 
Common Terminology Criteria for Adverse Event 
DAE 
Discontinuation of Investigational Product due to Adverse Event 
DNA 
Deoxyribonucleic acid  
RNA 
Ribonucleic acid 
EC 
Ethics Committee, synonymous to Institutional Review Board (IRB) 
and Independent Ethics Committee (IEC) 
GCP 
Good Clinical Practice 
ICH 
International Conference on Harmonization 
IP 
Investigational Product  
IVRS 
Interactive Voice Response System 
IWRS 
Interactive Web Response System 
LSLV 
Last Participant Last Visit 
OAE 
Other Significant Adverse Event 
PGx 
Pharmacogenetic research 
PI 
Principal Investigator  
SAE 
Serious adverse event  
WBDC 
Web Based Data Capture 
STS 
Soft Tissue Sarcoma 
LPS 
Liposarcoma 
LMS 
Leiomyosarcoma 
UPS 
Undifferentiated Pleomorphic Sarcoma 
PD-1 
Programmed Death 1 
PD-L1 
Programmed Death Ligand 1 


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Abbreviation and 
special term 
Explanation 
PD-L2 
Programmed Death Ligand 2 
TILs 
Tumor Infiltrating Lymphocytes 
NKs 
Natural Killer cells 
ECIs 
Events of Clinical Interest 
MTD 
Maximum tolerated dose 
PK 
Pharmacokinetics 
DLT 
Dose limiting toxicity 
RP2D 
Recommend phase 2 dose 
MSI-high/MMR 
Microsatellite instability/Mismatch Repair Deficient 
mTNBC 
Metastatic triple negative breast cancer 
PFR 
Progression-free rate 
PFS 
Progression-free survival 
OS 
Overall Survival 
IDO 
Indoleamine 2,3-dioxygenase 
MDSC’s 
myeloid derived suppressors cells  
Treg 
T regulatory cells 
 
 
Trial Summary 
 
Abbreviated Title 
Eribulin and Pembrolizumab in Soft Tissue Sarcomas 
Trial Phase 
A Phase II Study of Eribulin and Pembrolizumab in Soft Tissue 
Sarcomas 
Clinical Indication 
Locally advanced or metastatic Soft Tissue Sarcomas 
Trial Type 
Phase II 
Type of control 
Single Arm 
Route of administration 
Intravenous 
Trial Blinding 
None 
Treatment Groups  
Arm A: Leiomyosarcoma, Arm B: Liposarcoma, and Arm C: 
Undifferentiated Pleomorphic Sarcoma/Other Sarcomas 
Number of trial participants 
57 
Estimated enrollment period 
24 months 
Estimated duration of trial 
36 months 
Duration of Participation 
3 months 
Estimated average length of 
treatment per participant 
4 Cycles 
 
 
 
 


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 OBJECTIVES 
 
Hypotheses:  
Eribulin in combination with PD-1 blockade with pembrolizumab will result in objective 
responses and durable disease control in participants with metastatic/recurrent or locally 
advanced liposarcomas, leiomyosarcomas, and undifferentiated pleomorphic sarcomas/other 
sarcomas. 
  
1.1 
Study Design 
 
This is a phase II, parallel cohort, non-randomized, three-arm, open-label trial of eribulin in 
combination with pembrolizumab (EP) in participants with liposarcomas, leiomyosarcomas, and 
undifferentiated pleomorphic sarcomas/other sarcomas. The purpose of this study is to assess the 
efficacy and safety of this combination in this population, as well as to explore the baseline 
immunologic tumor characteristics in the enrolled cohorts. 
 
Each sarcoma subtype cohort will be analyzed separately. 
 
Participants will receive eribulin 1.4 mg/m2 intravenously on Day 1 and Day 8 with 
pembrolizumab 200mg intravenously Day 1, on a 21-day cycle until disease progression, study 
discontinuation, unacceptable toxicity, or two years of treatment. 
 
All participants will undergo a history and physical examination and laboratory evaluation (CBC 
with Diff, Lytes, BUN, Cr, LFT’s, and TSH) during screening for trial enrollment. All 
participants will have baseline imaging for disease assessment. Archival tissue will be submitted. 
If archival tissue is not available, a new tumor biopsy will be performed if feasible. Tumor 
assessment per RECIST 1.1 will be performed after each 2 cycles.1 Participants will remain on 
treatment unless there is progressive disease per RECIST 1.1, or unacceptable toxicity, or 
completion of two years of therapy.  
 
All participants will undergo a history and physical examination and laboratory evaluation (CBC 
with Diff, Lytes, BUN, Cr, LFT’s) prior to each drug(s) administration, to assess for the 
development of adverse events, including immune related adverse events (irAEs). TSH will be 
monitored every 6 weeks. Monitoring for irAEs will continue in participants who come off study 
for progression or other reasons at a follow-up period of 90 days. Participants who experience 
grade 3 or higher irAEs will receive treatment with systemic corticosteroids as per protocol and 
standard guidelines 2, 3. Discontinuation of drug, duration of corticosteroid treatment, and further 
participation in the trial will be at the discretion of the Principal Investigator (PI).   
 
1.2 
Primary Objective 
 
1.2.1 To assess the 12-week progression-free survival for eribulin in combination with 
pembrolizumab in participants with metastatic or locally advanced liposarcomas, 
leiomyosarcoma, and undifferentiated pleomorphic sarcoma/other sarcomas. 
 
 


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1.3 
Secondary Objectives 
 
1.3.1 To assess the objective response rate (ORR) based on RECIST 1.1, clinical benefit rate 
(complete response (CR) + partial response (PR) + stable disease (SD) at 12 weeks), for 
eribulin in combination with pembrolizumab in participants with metastatic or locally 
advanced liposarcomas, leiomyosarcoma, and undifferentiated pleomorphic 
sarcoma/other sarcomas. 
1.3.2 To assess tolerability and toxicities of eribulin in combination with pembrolizumab in 
this participant population. 
1.3.3 To assess overall survival of participants with metastatic/locally advanced liposarcomas, 
leiomyosarcoma, and undifferentiated pleomorphic sarcomas/other sarcomas receiving 
eribulin in combination with pembrolizumab. 
 
Correlative objectives 
1.3.4 Determine the expression of biomarkers (including but not limited to PD-1, PD-L1, MHC 
class I expression, IDO), and quantification of tumor infiltrating lymphocytes (TILs) 
(CD8+, CD4+, Tregs), tumor infiltrating macrophages, and myeloid derived suppressors 
cells (MDSC’s)  in archival tissue or pre-treatment biopsies, and optional post-treatment 
biopsies via immunohistochemistry and immunofluorescence.  
1.3.5 Targeted genomic analysis (Oncopanel) of archival tissue or pre-treatment biopsies, and 
RNA sequencing of fresh frozen tumor biopsies to evaluate for markers of response to 
immunotherapy, such as MMR def or high mutation load.  
1.3.6 Evaluation of the microbiome in participants with soft tissue sarcoma (Liposarcoma, 
Leiomyosarcoma, Undifferentiated pleomorphic sarcoma, utilizing a pre-treatment stool 
sample 
1.3.7 Identification/quantification of immunologic changes (including but not limited to 
cytokines, CD4+, CD8+, Teff and Treg cells, tumor infiltrating macrophages 
(particularly in the leiomyosarcoma cohort)) in peripheral blood.  
1.3.8 Quantification of circulating Tumor DNA (ctDNA) in peripheral blood.  
 
 BACKGROUND 
 
2.1 
Study Diseases: Liposarcoma, Leiomyosarcoma, Undifferentiated Pleomorphic 
Sarcoma/Other Sarcomas 
 
Sarcomas are rare cancers in adults, representing about 1% of all adult malignancies.4 In adults, 
there are approximately 13,000 cases of soft tissue sarcomas5. Sarcomas are not one disease, but 
rather a group of multiple genetically distinct diseases, with the current WHO classification 
listing over 50 different histologic subtypes6. The primary management of these tumors is wide 
local surgical excision with adjuvant or neoadjuvant radiation therapy7 and +/- adjuvant or 
neoadjuvant chemotherapy with an anthracycline and ifosfamide based regimen.8-13 Prognosis 
and outcomes vary by histologic subtype, anatomic location, size, grade, depth of invasion, and 
patient age14-16. The five-year survival of patients with Stage III soft tissue sarcomas is still only 
approximately fifty percent.17 Palliative chemotherapy in the metastatic setting can provide a 
modest increase in survival, but does not result in a cure, and the median overall survival for 
patients with metastatic soft tissue sarcoma remains less than 2 years. New therapeutic strategies 


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are therefore needed in this patient population. Additionally, due to the differences in prognosis, 
outcomes, and disease natural history by histologic subtype, histology-specific clinical trials are 
required to evaluate novel therapies in soft tissue sarcomas.  
 
2.2 
Immunotherapy in Sarcomas 
 
A rapidly evolving treatment strategy in oncology is immunotherapy — manipulating a patient’s 
immune system to create a successful anti-tumor response. This treatment actually revives an old 
strategy that was first described by Dr. Coley in a sarcoma patient18, 19.Recent dramatic responses 
in checkpoint inhibition with PD1 and PDL1 inhibitors have revolutionized the management of 
melanoma, lung cancer, urothelial cancers, and MSI high solid tumors and Hodgkin lymphoma 
and led to multiple new drug approvals and changes in standards of care. 
  
Efficacy of this approach in sarcomas is quite limited however. SARC028 evaluated 
pembrolizumab in multiple subtypes of bone and soft tissue sarcomas. Of the multiple subtypes 
evaluated, only modest activity was seen in liposarcoma and unclassified pleomorphic sarcoma 
(UPS). Although an exceptional response to pembrolizumab in uterine LMS has been reported, a 
single center trial evaluating single agent nivolumab in uterine LMS, demonstrated no responses 
and a median PFS of less than 2 months. Similarly, a multicenter randomized phase II trial 
evaluating the combination of nivolumab/ipilumumab and single agent nivolumab demonstrated 
minimal activity in soft tissue sarcomas, with isolated responses in LMS, LPS, alveolar soft parts 
sarcoma and UPS. 
 
Check point inhibition alone has limited activity in soft tissue sarcomas, therefore, we now 
propose to combine check point inhibition with chemotherapy. 
 
2.3 
Rationale for eribulin 
 
A Phase II study of eribulin in soft tissue sarcomas suggested a benefit in leiomyosarcomas and 
liposarcomas with a three-month progression-free survival of 31.6% for leiomyosarcomas and 
46.9% for liposarcomas, and a 21.1% for synovial sarcomas, and a 19.2% for other soft tissue 
sarcomas, including UPS65. A Japanese phase II trial showed similar results with a 12-week 
progression-free survival of 60% for liposarcomas and leiomyosarcomas66. More recently, 
eribulin was approved for the treatment of metastatic or recurrent liposarcomas67 based on the 
results of a randomized phase III trial comparing eribulin to dacarbazine in leiomyosarcomas and 
liposarcomas68. This trial showed an improvement in the median overall survival of  13.5 months 
for participants treated with eribulin vs 11.5 months for participants treated with dacarbazine68. 
There was no difference in median progression-free survival, 2.6 months in each arm; 12-week 
progression-free survival was 33% in the eribulin group and 29% in the dacarbazine group68. A 
subgroup analysis in the liposarcoma cohort showed an improvement in progression-free 
survival of 2.9 vs 1.7 months, p=0.0015, and overall survival of 15.6 vs 8.4 months, p=0.000669. 
Thus, the FDA approved eribulin for liposarcomas, including dedifferentiated, myxoid/round 
cell, and pleomorphic liposarcomas. Eribulin is currently NCCN compendium listed for 
leiomyosarcoma and is a standard of care in the US for this indication. 
 
 


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2.4 
Rationale for combination of eribulin and pembrolizumab 
 
The combination of cytotoxic chemotherapy with immunotherapy is a rational approach to 
increase the response to immunotherapy. Cytotoxic chemotherapy may lead to cell death and the 
release of neoantigens that can be utilized in an immune response. Additionally, eribulin has 
non-mitotic effects which increase vascular perfusion and may impact the tumor stromal 
microenvironment. This may allow an increase in tumor infiltration by immune cells and 
potentiate the effects of immune checkpoint inhibitors71. Recently, the combination of eribulin 
and pembrolizumab has been shown to be safe and effective in patients with triple negative 
breast cancer. Because of the activity of eribulin in LPS and LMS; together with the reported 
activity of pembrolizumab, nivolumab, or nivolumab + ipilimumab in a subset of patients with 
LPS, LMS and UPS/Other sarcomas; and the potential for synergy; we now propose a parallel-
cohort three-arm -uncontrolled phase II study evaluating the combination of eribulin and 
pembrolizumab. The dosing of eribulin will be 1.4mg/m2 on Day 1 and Day 8, and the dosing for 
pembrolizumab will be 200mg every 3 weeks. This is the standard dosing for each drug and has 
been shown to be active and safe in the eribulin and pembrolizumab metastatic triple negative 
breast cancer trial.  
 
The standard end-point for phase II soft tissue sarcoma trials is the progression-free rate (PFR) at 
12 weeks,72 with an active regimen defined as having a PFR of  > 40% at 12 weeks and an 
inactive regimen defined as having a PFR of < 20% at 12 weeks. The activity of eribulin in the 
phase II soft tissue sarcoma trial was a PFS of 32% for leiomyosarcomas, and 47% for 
liposarcomas at 3 months. Also, a 3-month PFS seen in the SARC028 trial was 55%, and a 3-
month PFS seen in the nivolumab alone arm of the Alliance A091401 was ~ 40%. Thus, for this 
trial, it was determined that a 40% PFS is inadequate to determine if the eribulin/pembrolizumab 
combination is effective, as 40% PFS at 3 months may be due to the single agents alone. For the 
purposes of this trial, we will define an active regimen as having a PFS of >60% at 12 weeks, 
indicating activity of the combination, and an inactive regimen as having a PFS of <30% at 12 
weeks. 
 
 
Recent advances in immunotherapy has shown significant benefit for patients with advanced 
lung cancer, metastatic renal cell carcinomas,23-25 metastatic melanoma,26-29 colon cancer or other 
tumors with microsatellite instability30, 31, or Hodgkin’s lymphoma32, 33.   
One potential predictor for the response to immunotherapy in solid tumors is tumor-infiltrating 
lymphocytes (TILs).34 TILs have been noted in a many solid tumors35 including colon cancer36, 
non-small cell lung cancer,37 melanoma,38 and most importantly in many soft tissue sarcomas 
and gastrointestinal stromal tumors.39, 40 In fact TILs have been reported as a possible prognostic 
factor in soft tissue sarcomas41 and bone sarcomas.42, 43 Additionally PD-1 and PD-L1 expression 
have been noted in soft tissue sarcomas and potentially correlate with prognosis.39, 44, 45 This 
evidence suggests a potential therapeutic responsiveness of sarcomas to newer immunotherapy 
agents, such as immune checkpoint inhibitors. Though whether the presence of TILs, PD-1, PD-
L1, and PD-L2 expression are predicative markers has yet to be determined. The PD-1/PD-L1 
pathway leads to inhibition of T-cell activation and immune escape by tumor cells. Blocking this 
pathway can lead to immune system activation and tumor suppression. Targeting the PD-1 
pathway can be accomplished by targeting PD-1, or its ligands PD-L1, PD-L2. 
 


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This rational has already lead to several phase II trials of immune checkpoint inhibitors in 
patients with advanced sarcomas:  Single agent pembrolizumab in patients with advanced 
sarcoma, SARC028; Nivolumab in Uterine Leiomyosarcomas; and the Alliance trial of 
Nivolumab +/- Ipilimumab in soft tissue sarcomas, A091401. Chemotherapy may potentiate the 
immune response in soft tissue sarcomas46. In fact, immunotherapy (immune checkpoint 
inhibitor) trials in combination with chemotherapy (doxorubicin, gemcitabine, or trabectedin) are 
already planned or enrolling in soft tissue sarcomas.  
The SARC028 trial suggested immunotherapy responses in dedifferentiated and 
pleomorphic liposarcoma and in undifferentiated pleomorphic sarcomas. The Alliance trial 
confirmed rare responses in these histologic subtypes but, also, response in leiomyosarcoma, 
angiosarcoma, and Alveolar soft part sarcoma, and myxofibrosarcoma74. The responses of 
alveolar soft part sarcoma have now been confirmed in two other reports, a trial of axitinib and 
pembrolizumab75, and retrospective review of phase I trials of immunotherapy in soft tissue 
sarcomas76. Additionally, 7/9 cutaneous angiosarcomas were shown to benefit from 
immunotherapy in a retrospective series77. Furthermore, mismatch repair deficiency is a known 
prognostic factor and this has been identified to rarely occur in soft tissue sarcomas78. Thus there 
is a rational for expanding the undifferentiated pleomorphic sarcoma cohort into a 
undifferentiated pleomorphic sarcoma/other sarcoma cohort to include a wider spectrum of 
sarcomas patients that may respond to immunotherapy.  
 
 
2.5 
IND Agents  
 
2.5.1 Pembrolizumab Background 
 
Pembrolizumab, MK-3475, Keytruda, is potent an anti-PD-1 IgG4 humanized 
monoclonal anti-body with high specificity of binding to the programmed cell death 1 
(PD-1) receptor, thus inhibiting its interaction with programmed cell death ligand 1 (PD-
L1) and programmed cell death ligand 2 (PD-L2).  Based on preclinical in vitro data, 
pembrolizumab has high affinity and potent receptor blocking activity for PD-1.  
Pembrolizumab has an acceptable preclinical safety profile and is in clinical development 
as an intravenous (IV) immunotherapy for advanced malignancies.  Keytruda® 
(pembrolizumab) is indicated for the treatment of patients across a number of indications 
because of its mechanism of action to bind the PD-1 receptor on the T cell.   
 
The amino acid sequence of pembrolizumab includes 4 polypeptide chains, which include 
2 identical heavy chains and 2 identical light chains. The molecular weight of 
Pembrolizumab is 148.9-149.5 KDa. Pembrolizumab targets the programmed death–1 
(PD-1, cluster of differentiation 279 [CD279]) cell surface membrane receptor. PD-1 is a 
negative regulatory receptor expressed by activated T and B lymphocytes. Binding of 
PD-1 to its ligands, programmed death–ligand 1 (PD-L1) and 2 (PD-L2), results in the 
down-regulation of lymphocyte activation. Pembrolizumab inhibits the binding of PD-1 
to PD-L1 and PD-L2. Inhibition of the interaction between PD-1 and its ligands promotes 
immune responses and antigen-specific T-cell responses to both foreign antigens as well 
as self-antigens.48 
 


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2.5.1.1 
Clinical Development of Pembrolizumab 
 
The safety of Pembrolizumab was studied in a phase I trial, NCT01295827. This was a 
standard 3+3 dose escalation study in participants with solid tumors to examine 
tolerability, pharmacokinetics, pharmacodynamics, and safety, and to determine the 
maximum tolerated dose (MTD) as well as the preliminary recommended phase 2 dose 
(RP2D). The dosing studied was 1, 3, and 10 mg/kg every 2 weeks, or 2, 10 mg/kg every 
3 weeks. All dose levels were well tolerated and no dose-limiting toxicity (DLT) were 
observed. No MTD was determined. The RP2D determined by the sponsor (MERCK) 
based on the safety, pharmacokinetic and pharmacodynamic data, as well as the strength 
of the anti-tumor activity observed was 2mg/kg Q3 weeks.48 
 
Pembrolizumab has shown efficacy in the treatment of metastatic melanoma, metastatic 
non-small cell lung cancer, metastatic head and neck cancer, renal cell cancer, colon 
cancer, classical Hodgkin lymphoma, and most recently microsatellite instable tumors. 
Pembrolizumab has now received FDA approval for the treatment of metastatic 
melanoma, metastatic non-small cell lung cancer, metastatic head and neck cancer, renal 
cell cancer, classical Hodgkin lymphoma, and most recently microsatellite instable 
tumors (MSI-high) particularly colon and endometrial carcinomas.  
 
2.5.1.2 
Pharmacokinetics 
 
The pharmacokinetics (PK) of pembrolizumab were 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 every 2 weeks or 2 to 10 mg/kg every 3 
weeks. The half-life (t1/2) of pembrolizumab is approximately 4 weeks. There was no 
indication of dose dependency or changes in half-life between the three dose groups (1, 3, 
and 10 mg/kg) on the phase I study. The long t1/2 pembrolizumab supports using a dosing 
interval of every 2 or 3 weeks.48 Pembrolizumab clearance (CV%) is approximately 21% 
lower [geometric mean, 196 mL/day (41%)] at steady state than after the first dose [249 
mL/day (38%)]; this decrease in clearance with time is not considered clinically 
important. The geometric mean value (CV%) for volume of distribution at steady state is 
6.0 L (21%) and for terminal half-life (t1/2) is 22 days (32%).48 
 
Steady-state concentrations of pembrolizumab were reached by 16 weeks of repeated 
dosing with an every 3-week regimen and the systemic accumulation was 2.2-fold. The 
peak concentration (Cmax), trough concentration (Cmin), and area under the plasma 
concentration versus time curve at steady state (AUCs) of pembrolizumab increased dose 
proportionally in the dose range of 2 to 10 mg/kg every 3 weeks.48 
 
Pembrolizumab has been found to have a wide therapeutic range based on the melanoma 
studies. The population PK data revealed that there was no significant impact of tumor 
burden on exposure to pembrolizumab. Additionally, the exposure was similar between 
the NSCLC and melanoma studies. Therefore, there are no anticipated changes in 
exposure between different tumors.48  
 


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The choice of the 200 mg Q3 week dosing was an appropriate dose for the switch to fixed 
dosing. It is based on simulations performed using the population PK model of 
pembrolizumab showing that the fixed dose of 200 mg every 3 weeks will provide 
exposures that are consistent with those obtained with the 2 mg/kg dose every 3 weeks. 
This dose will maintain individual patient exposures in the exposure range established in 
melanoma studies, which were associated with maximal efficacy response and were well 
tolerated and safe.48 
 
Furthermore, a fixed dose regimen will simplify the dosing regimen, which can reduce 
potential for dosing errors, reduce wastage, and reduce the complexity in the logistics 
chain.48 
 
 
 
Anti-Drug Antibodies (ADA) Data 
 
The occurrence of ADA has been observed in less than 1% of the patients screened, 
indicating a low potential of pembrolizumab to elicit the formation of ADA. No impact 
of ADA on pembrolizumab exposure has been observed48. 
 
2.5.1.3 
Justification for Pembrolizumab Dose 
 
The planned dose of pembrolizumab for this study is 200 mg every 3 weeks (Q3W), 
standard dosing based on the Investigational drug brochure.  Based on the totality of data 
generated in the Keytruda development program, 200 mg Q3W is the appropriate dose of 
pembrolizumab for adults across all indications and regardless of tumor type.  As 
outlined below, this dose is justified by: 
 
 Clinical data from 8 randomized studies demonstrating flat dose- and exposure-
efficacy relationships from 2 mg/kg Q3W to 10 mg/kg every 2 weeks (Q2W),  
 Clinical data showing meaningful improvement in benefit-risk including overall 
survival at 200 mg Q3W across multiple indications, and 
 Pharmacology data showing full target saturation in both systemic circulation 
(inferred from pharmacokinetic [PK] data) and tumor (inferred from 
physiologically-based PK [PBPK] analysis) at 200 mg Q3W 
 


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2.5.1.4 
Safety 
 
A maximum tolerated dose (MTD) of pembrolizumab has not been defined. Per the 
MERCK pembrolizumab label, serious adverse events (SAEs) include: pneumonitis, 
vitiligo, colitis, hepatitis, hypophysitis, and thyroiditis.  Renal failure, pancreatitis and 
diabetes, neurologic events, and vasculitis have also been reported. The most frequent 
treatment-related adverse events (AEs) were fatigue, nausea, cough, pruritus, 
diarrhea, and rash. Most AEs were not considered serious. The most commonly-
reported immune-related AEs were rash, pruritus, vitiligo, hypothyroidism, arthralgia, 
diarrhea, and pneumonitis. Important identified risks include: pneumonitis, thyroid 
disorders (hypothyroidism and hyperthyroidism), colitis, diarrhea, hepatitis, nephritis, 
uveitis, rash/pruritus, and neuropathy.48 
 
2.5.1.5 
Pharmacodynamics/Biomarkers 
 
PD-1, PD-L1 expression may correlate with response in metastatic malignant 
melanoma. Tumor-cell expression (melanoma) of PD-L1 was characterized in 
combination with ipilimumab with the use of IHC staining and pharmacodynamic 
changes in the peripheral-blood absolute lymphocyte count.52 With PD-L1 positivity 
defined as expression in at least 5% of tumor cells, biopsy specimens from 21 of 56 
patients (38%) were PD-L1–positive. Among patients treated with the concurrent 
regimen of nivolumab and ipilimumab, ORs were observed in patients with either 
PDL1–positive tumor samples (6 of 13 patients) or PD-L1–negative tumor samples (9 
of  22). In the sequenced regimen cohorts, a higher number of overall responses was 
seen among patients with PD-L1–positive tumor samples (4 of 8 patients) than among 
patients with PD-L1–negative tumor samples (1 of 13) suggesting the possibility that 
these tumors have higher response rates to the combination. The relationship between 
PDL-1 expression and responses may not be present in patients treated with the 
combination.  
 
Additionally, PD-L1 is being investigated as a predictive biomarker for nivolumab 
and pembrolizumab treatment in lung cancer. In fact, the FDA approved nivolumab 
for patients with adenocarcinoma of the lung and squamous cell carcinoma of the 
lung after progression on platinum-based therapy. In contrast, pembrolizumab was 
approved by the FDA for metastatic non-small cell lung cancer, which has progressed 
on prior treatment, but only with PD-L1 positivity by IHC. This was based on the 
KEYNOTE-001 study53. Positive PD-L1 staining was defined as ≥ 50%. Patients with 
positive PD-L1 staining had an ORR of 45% compared to 17% in patients with 1% to 
49% staining by IHC for PD-L1, and 11% in patients with <1% IHC staining for PD-
L1. 53 
 
In the SARC028 trial, PD-L1 expression correlated with response in UPS, though this 
analysis included a total of 10 participants.49 In the metastatic triple negative breast 
cancer eribulin and pembrolizumab trial, PD-L1 expression status did not correlate 
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Additionally, tissue expression of PDL-2, interferon-γ (IFN- γ), indoleamine 2,3-
dioxygenase (IDO), T cell infiltrates with CD8+ cells, CD4+ cells, T-suppressor 
Foxp3, or tumor infiltrating macrophages are of investigational interest as potential 
biomarkers. Tumor mutational load and microsatellite instability are also of interest.  
 
Until more reliable data based on standardized procedures for tissue collection and 
assays are available, PD-L1 status cannot be used to select patients for treatment at 
this time in soft tissue sarcomas, but it is a biomarker worth investigating. 
 
2.5.2 Eribulin 
 
2.5.2.1 
Nonclinical development of Eribulin: Mechanism of action  
 
Eribulin mesylate (eribulin) is a microtubule inhibitor, derived from the marine 
sponge, Halichondria okadai54, 55. The natural compound Halichondrin B (Hal B), of 
which Eribulin  is an analog, is a large polyether macrolide, naturally occurring in 
Halichondria okadai54. This compound has anti-cancer activity based a on a 
microtubule destabilizing anti-mitotic mechanism of action56. Other anti-cancer 
drugs, such as vinca alkaloids or taxanes, also inhibit microtubule activity57. 
However, the interaction between Hal B and tubulin is unique58. Eribulin  sequesters 
tubulin into nonproductive aggregates, leading to tubulin polymerization inhibition, 
and resulting in a mitotic block.59  
 
Summary of mechanism of action  
In vitro studies have shown that analogues of Hal B inhibit cell growth at sub-Nano 
molar concentrations60. This occurs in a wide variety of cancer cell types, such as 
breast, ovary, colon, melanoma, and sarcomas60. Eribulin  exerts its effects by binding 
to the positive end of microtubules, this leads to suppression of microtubule growth61. 
Eribulin sequesters tubulin into nonproductive tubulin aggregates. This leads to 
inhibition of tubulin polymerization and microtubule dynamics. The result is an 
interference with normal mitotic spindle formation and the blockage of the pro-
metaphase portion of mitosis61. The end effect is the induction of irreversible cell 
cycle block at G2/M and cell death via apoptosis after this prolonged mitotic block.62 
Eribulin is a substrate for the P-glycoprotein drug efflux pump. Eribulin has reduced 
potency against cells expressing high levels of this pump. Additionally, upregulation 
of this pump is a possible resistant mechanism to eribulin. Taxane-resistant cell lines 
have β-tubulin mutations. However, in vitro, these cell lines are sensitive to eribulin. 
In vivo, eribulin  has led to tumor regression and even eradication against several 
human cancer xenograft models, including sarcomas.54, 63 
2.5.2.2 
Pharmacokinetics pre-clinical development of Eribulin 
 
In animal models (mice, rat and dogs), the pharmacokinetics of eribulin after 
intravenous administration is characterized by a rapid distribution phase, a large 
volume of distribution and a prolonged elimination phase (t1Ú2: 3.6 -6.9 hours in 


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mice, 15.9- 27.9 hours in rats, 21.9-28.2 hours in dogs). Eribulin also has low 
penetration in brain, likely related to its role as a substrate of the P-glycoprotein drug 
efflux pump. It also has high penetration in tissues such as the lung, bladder, renal 
cortex and medulla, liver, spleen, thyroid, stomach, and salivary gland. 
Unchanged eribulin is the major circulating compound in plasma following its 
administration. Metabolism is a minor component of eribulin clearance, with minor 
metabolic changes occurring through cytochrome P450 3A4 (CYP3A4). Eribulin is 
eliminated primarily unchanged in feces.64  
 
2.5.2.3 
Pharmacokinetics clinical development of Eribulin 
 
In clinical studies, eribulin ’s PK is characterized by a rapid distribution phase, with a 
prolonged elimination phase after intravenous infusion. The disposition of eribulin 
follows linear kinetics over the dose range studied (0.25mg/m2- 4.0mg/m2). It has low 
plasma clearance, with a mean clearance=1.16-2.42 L/hr/m2, a large mean volume of 
distribution at steady state (43-114 L/m2) and a half-life of elimination of 40 hours. 
The human plasma protein binding of eribulin occurs at concentrations of 100ng/mL 
to 1.000ng/mL and ranges from 49% to 65%. Eribulin exposure after multiple doses 
is comparable to a single dose, with no accumulation of eribulin with weekly 
administration. As expected based on work in pre-clinical models, metabolism is a 
minor component of eribulin clearance. Metabolites represent less than 0.6% of 
parent compound in plasma. Renal elimination is also a minor route of eribulin 
excretion, with less than 10% of drug excreted unchanged in urine. Most of excretion 
of eribulin is fecal and unchanged. It is unknown if eribulin  is excreted into human 
milk.64 
 
Eribulin does not induce or inhibit hepatic CYP3A4 activity at clinically relevant 
concentrations. Concomitant administration of ketoconazole, a CYP3A4 inhibitor, or 
rifampicin, a CYP3A4 inducer, had no effect on exposure to eribulin. Eribulin  does 
not induce or inhibit CYP1A, CYP2C9, CYP2C19, CYP2D6 activity at clinically 
relevant concentrations.64 
Hepatic impairment may decrease the clearance of eribulin and prolong the 
elimination half-life, resulting in increased exposure to eribulin. As such, it is 
proposed that the eribulin dose in patients with moderate hepatic impairment should 
be adjusted. No studies for patients with severe hepatic impairment have been 
performed.64 
Moderate renal impairment (CrCL 30-50 mL/min) may also impact the clearance of 
eribulin, resulting in increased exposure. As such, it is proposed that eribulin dose in 
patients with moderate renal impairment should be adjusted. No studies for patients 
with severe renal impairment have been performed.64 
Population PK analyses based on Phase 1 and 2 studies showed that eribulin 
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and bilirubin. The effects of age, gender, race and concomitant medications (CYP3A4 
inhibitors and inducers) on clearance were not found to be significant.64 
2.5.2.4 
Efficacy 
 
A Phase II study of eribulin in soft tissue sarcomas suggested a benefit in 
leiomyosarcomas and liposarcomas with a three-month progression-free survival of 
31.6% for leiomyosarcomas and 46.9% for liposarcomas, and a 21.1% for synovial 
sarcomas, and a 19.2% for other soft tissue sarcomas65. A Japanese phase II trial 
showed similar results with a 12-week progression-free survival of 60% for 
liposarcomas and leiomyosarcomas66. More recently, eribulin was approved for the 
treatment of metastatic or recurrent liposarcomas67 based on the results of a 
randomized phase III trial comparing eribulin to dacarbazine in leiomyosarcomas and 
liposarcomas68. This trial showed an improvement in the median overall survival of  
13.5 months for participants treated with eribulin vs 11.5 months for participants 
treated with dacarbazine68. There was no difference in median progression-free 
survival, 2.6 months in each arm; 12-week progression-free survival was 33% in the 
eribulin group and 29% in the dacarbazine group68. A subgroup analysis in the 
liposarcoma cohort showed an improvement in progression-free survival of 2.9 vs 1.7 
months, p=0.0015, and overall survival of 15.6 vs 8.4 months, p=0.000669. Thus, the 
FDA approved eribulin for liposarcomas, including dedifferentiated, myxoid/round 
cell, and pleomorphic liposarcomas. 
 
2.5.2.5 
Toxicology and Safety 
 
A variety of nonclinical toxicology studies have been conducted to support the use of 
eribulin in humans. The findings from these studies are summarized below. No 
significant serious adverse events (AE) were observed in any preclinical safety 
studies with regard to central nervous, respiratory, or cardiovascular systems. Eribulin 
induced no significant reduction in nerve conduction velocity or peak nerve 
amplitude in caudal and digital nerves, in contrast to paclitaxel. The morphological 
changes in sciatic nerve and dorsal root ganglia were less severe in eribulin than those 
observed with paclitaxel. In animal models, eribulin  induced markedly less 
neuropathy than paclitaxel.64 
Bone marrow toxicity appeared to be dose-limiting in both rats and dogs. Intestinal 
toxicity was also present in dogs. Other toxicities that were considered to be drug-
related occurred in the lymphoid tissue, testes, and skeletal muscle. All observed 
toxicities (except testicular toxicity) were reversible in both dogs and rats. In 
repeated-dose toxicity studies in rats, testicular toxicity, thymic atrophy, bone marrow 
toxicity, and fiber degeneration of sciatic nerve were found.64 
Although the changes in testes and sciatic nerve were still present after a 14-day 
recovery period, other toxicities were reversible. Repeated-dose toxicity in dogs 
produced leukopenia, which was fully reversible in 14 days with compensatory 
extramedullary hematopoiesis. The chronic toxicity studies in rats and dogs were 
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important effects observed. Hypocellularity of bone marrow and a reduction in the 
weight of testes (correlating with hypocellularity of seminiferous epithelium with 
associated hypospermia/aspermia of the epididymides) were found. Increases in 
alanine aminotransaminase (ALT), aspartate aminotransaminase (AST), and 
cholesterol were also observed. In dogs, bone marrow toxicity mainly represented by 
leukopenia was observed. Regarding findings in the testes, this finding was limited to 
high doses of drugs and included decrease of testes weights and microscopic changes 
with mild to moderate hypocellularity of testis with hypospermia/aspermia of the 
epididymides. In addition, hyper-cellularity of bone marrow, lymphoid depletion in 
mesenteric lymph nodes and Peyer’s patches, and thymic atrophy were noted. These 
studies suggest that male fertility may be compromised by eribulin treatment. 
Carcinogenicity studies have not been conducted with eribulin. Genotoxicity was 
evaluated both in vitro and in vivo. In vitro, results indicated that the effect was due 
primarily to chromosome segregation interference rather than chromosome breakage 
because eribulin was negative in the Ames test with or without S9 and was weakly 
positive in the L5178Y tk+/- mouse lymphoma mutagenesis assay. In vivo, in rats, 
dose-related increases of micro-nucleated- polychromatic erythrocytes (MN-PCEs) at 
either sampling time and dose- related decreases in the proportion of PCEs were 
observed, which may indicate some degree of bone marrow suppression. In the 
intravenous embryo and fetal developmental studies in rats, eribulin  was given to rats 
at doses of 0.01, 0.03, 0.10, and 0.15 mg/kg/day on gestational days 8, 10, and 12. 
External and/or soft tissue anomalies were noted at 0.15 mg/kg/day, indicating that 
eribulin  has teratogenic potential.64  
Summary of safety data for eribulin   
In the phase III EMBRACE trial, AEs occurred in 99% of participants receiving 
eribulin, however serious AEs occurred in 25% and AEs leading to therapy 
discontinuation occurred in 13% of participants on study. The primary toxicities with 
eribulin were asthenia or fatigue (54%) and neutropenia (52%). Grade 4 neutropenia 
lasting more than 1 week occurred in 12% of participants and F+N occurred at low 
incidence (5%). Participants with elevated ALT/AST or bilirubin experienced a 
higher frequency of grade 4 neutropenia or F+N. Peripheral neuropathy was the most 
common AE leading to discontinuation of therapy, occurring in 5% of participants. 
Neuropathy lasting more than one year occurred in 5% of the participants. Alopecia 
occurred in 45% of participants. Nausea occurred in 35% of participants, but it was 
grade 3 just in 1% of participants. Diarrhea occurred in 18% of cases; in all cases was 
grade 1 or 2. Dose interruptions, delays and reductions were undertaken in 6%, 49% 
and 29% in the eribulin group, respectively.70 
Overall Adverse events and serious adverse events  
In clinical studies, the most common treatment-related toxicities were hematological 
toxicity, including neutropenia; asthenia or fatigue; alopecia; nausea and peripheral 
neuropathy. Most adverse events were grade 1 or grade 2 in severity.  
Peripheral neuropathy was an important adverse event leading to discontinuation of 


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therapy. The most frequently reported eribulin-related adverse events were 
asthenia/fatigue (65%), alopecia (60%), neutropenia (60%), nausea (44%), anemia 
(28%), pyrexia (23%), leucopenia (22%), anorexia (21%), constipation (19%), 
vomiting (18%), and peripheral neuropathy (5.5%; only grade 3). Grade 4 
neutropenia occurred in 32% of participants, and fever plus neutropenia occurred in 
5.5% of participants. The frequency of all other grade 3/4 AEs was less than 3%.64  
2.5.2.6 
Pharmacodynamics / Biomarkers 
 
No known biomarker exists for predicting response to Eribulin.  
 
2.6 
Summary of Pembrolizumab and Eribulin combination Data. 
 
The safety and efficacy of eribulin and pembrolizumab was studied in a Phase I/II study of 
patients with metastatic triple-negative breast cancer (mTNBC), NCT02513472. In the 
combination arm, the dosing of pembrolizumab was 200mg IV Q 3 weeks and the dosing of 
eribulin was 1.4mg/m2 IV day 1 and day 8 of a 21-day cycle. The overall response rate (ORR) 
was 26.4% (95% CI 18.3-35.9) in 106 evaluable participants. The CR rate was 2.8%, and PR was 
23.6%. The clinical benefit rate (CR+PR+SD for ≥ 24 weeks) was 36.8%. Median duration of 
response was 8.3 months (95% CI 6.5-12.9) for the 28 responders in the participant population. 
Response lasted >6 months in 53.6% of responders. Median PFS was 4.2 months and median OS 
was 17.7 months, suggesting activity in mTNBC. PD-L1 staining by IHC was not predictive of 
response in this cohort on interim analysis. The ORR was 29.4% (95% CI 11.1-51.1) in the PD-
L1 positive participants and 33.3% (95% CI 14.1-54.6) in the PD-L1 negative participants. Most 
importantly, this combination was well tolerated. There were no dose-limiting toxicities 
observed in the phase Ib portion of this study. The recommend phase II dose (RP2D) was 
1.4mg/m2 of Eribulin, day 1, day 8, and 200mg IV of Pembrolizumab day 1 on a Q21 day 
schedule.  The most common treatment-related adverse events (all grades) were fatigue (73.8%), 
peripheral neuropathy (62.6%), nausea (61.7%), alopecia (42.1%), neutropenia (41.1%), anemia 
(29.9%) and constipation (39.3%). Grade 3 or 4 treatment-related adverse events were seen in 
47.7% and 18.7% of participants, respectively, the most common grade 3 or 4 adverse events 
being neutropenia (30.8%), peripheral neuropathy (9.3%), anemia (5.6%), fatigue (5.6%), and 
hypokalemia (5.6%). On this study, 24 participants (22.4%) had treatment emergent adverse 
events (TEAEs) leading to study drug withdrawal (2 participants in phase 1b, 22 participants in 
phase 2). On this study 34 Participants (31.8%) had TEAEs leading to eribulin dose reduction 
(all in phase 2). Seven participants on this study had grade 5 events, all of which were related to 
disease progression:  Respiratory failure, n = 1; respiratory failure/sepsis, n = 1; pleural effusion, 
n = 1; unknown, n = 1; multiple organ dysfunction syndrome, n = 1; cardiac arrest, n = 1; and 
malignant neoplasm progression, n = 1. Other adverse events (all grades) that occurred in >15% 
of participants were decreased appetite (36.4%), pyrexia (35.5%), cough (30.8%), diarrhea 
(29.9%), arthralgia (29.9%), vomiting (25.2%), headache (24.3%), weight decrease, (24.3%), 
rash (20.6%), dyspnea (19.6%), stomatitis (19.6%), dehydration (18.7%), hypothyroidism 
(18.7%), dry mouth (16.8%), AST increase (16.8%), ALT increase (16.8%), UTI (15.9%), 
dysgeusia (15.0%), and musculoskeletal pain (15.0%). Possible immune-related events (all 
grades) occurred in 82.2% of participants. These included in > 4% of participants:  Anemia 
(29.9%), diarrhea (29.9%), rash (20.6%), hypothyroidism (18.7%), pruritus (14.0%), 
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(8.4%). Possible immune related events (all grades) that occurred in <4% of participants were 
infusion-related reaction, colitis, generalized rash, pruritic rash, adrenal insufficiency, 
pancreatitis, renal failure, photosensitivity reaction, type I DM, cheilitis, dermatitis, contact 
dermatitis, exfoliative rash, hypophysitis, miliaria, and uveitis. Grade 3 or 4 immune-related 
adverse events occurred in only 18.7% of participants. The most common grade 3 or 4 immune-
related side effects included anemia (5.6%), diarrhea (4.7%), rash (1.9%), pneumonitis (0.9%), 
hyperglycemia (1.9%), adrenal insufficiency (0.9%), pancreatitis (1.9%), renal failure (0.9%), 
and type I DM (1.9%). These data indicate that the combination of eribulin and pembrolizumab 
is well tolerated with non-overlapping side effect profiles.  
 
2.7 
Rationale 
 
The combination of cytotoxic chemotherapy with immunotherapy is a rational approach to 
increase the response to immunotherapy. Cytotoxic chemotherapy may lead to cell death and the 
release of neoantigens that can be utilized in an immune response. Additionally, eribulin has 
non-mitotic effects which increase vascular perfusion and may impact the tumor stromal 
microenvironment. This may allow an increase in tumor infiltration by immune cells and 
potentiate the effects of immune checkpoint inhibitors71. Recently, the combination of eribulin 
and pembrolizumab has been shown to be safe and effective in patients with triple negative 
breast cancer. Because of the activity of eribulin in LPS and LMS; together with the reported 
activity of pembrolizumab, nivolumab, or nivolumab + ipilimumab in a subset of patients with 
LPS, LMS and UPS/Other sarcomas; and the potential for synergy; we now propose a parallel-
cohort three-arm -uncontrolled phase II study evaluating the combination of eribulin and 
pembrolizumab. The dosing of eribulin will be 1.4mg/m2 on Day 1 and Day 8, and the dosing for 
pembrolizumab will be 200mg every 3 weeks. This is the standard dosing for each drug and has 
been shown to be active and safe in the eribulin and pembrolizumab metastatic triple negative 
breast cancer trial.  
 
The standard end-point for phase II soft tissue sarcoma trials is the progression-free rate (PFR) at 
12 weeks,72 with an active regimen defined as having a PFR of  > 40% at 12 weeks and an 
inactive regimen defined as having a PFR of < 20% at 12 weeks. The activity of eribulin in the 
phase II soft tissue sarcoma trial was a PFS of 32% for leiomyosarcomas, and 47% for 
liposarcomas at 3 months. Also, a 3-month PFS seen in the SARC028 trial was 55%, and a 3-
month PFS seen in the nivolumab alone arm of Alliance A091401was ~ 40%. Thus, for this trial, 
it was determined that a 40% PFS is inadequate to determine if the eribulin/pembrolizumab 
combination is effective, as 40% PFS at 3 months may be due to the single agents alone. For the 
purposes of this trial, we will define an active regimen as having a PFS of >60% at 12 weeks, 
indicating activity of the combination, and an inactive regimen as having a PFS of <30% at 12 
weeks. 
 
 
2.8 
Correlative Studies Background 
 
There is currently no biomarker for predicting response to eribulin. There are multiple possible 
biomarkers for predicting response to immunotherapy. These include multiple factors 
influencing the tumor microenvironment, such as PD-1, PD-L1, and PD-L2 expression. The 
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and composition of TILs or tumor infiltrating macrophages may be important for predicting 
response to immunotherapy. Both TILs and tumor infiltrating macrophages have been noted in 
soft tissue sarcomas. Tumors with genomic instability, such as microsatellite unstable tumors, or 
tumors with a high mutational load may be more sensitive to immunotherapy as well. It will be 
critically important to investigate potential biomarkers for response to eribulin in combination 
with pembrolizumab in soft tissue sarcomas. Current results from the SARC 028 trial with 
pembrolizumab suggest PD-L1 expression as a potential predictor of response. Though in the 
eribulin and pembrolizumab metastatic triple negative breast cancer trial, PD-L1 expression was 
not predictive of response. As a correlative study to this trial, we will characterize the immune 
profile of available pre-treatment tissue biopsies, with particular regard to PD-1, PD-L1, and PD-
L2 expression and influence on response to therapy and progression-free survival. Tumor 
infiltrating lymphocytes (CD3, CD4, CD8, FOX-P3), tumor infiltrating macrophages (CD68, 
CD63), and tumor genomics will be investigated as well. We hypothesize that the expression of 
these markers, either alone or in combination, may lead to the identification of a subset of 
patients with liposarcoma, leiomyosarcoma, or undifferentiated pleomorphic sarcoma/other 
sarcomas patients who are more likely to respond to the combination of eribulin and 
pembrolizumab. Examination of peripheral blood (pre-treatment, on-treatment, and post-
treatment blood draws) for immunologic markers and cytokines will be performed as well. 
This evaluation will be performed on fresh tumor pre-treatment biopsy samples, or on archival 
tumor material. Any archival tissue is acceptable, however, if there are multiple archival 
samples, it is preferable to use the archival tissue that was obtained within 6 months and was 
obtained prior to any new systemic therapy. When possible, pre-treatment tumor samples will be 
compared to optional post-treatment tumor biopsies.  
This work will be performed under the direction of Scott Rodig, MD, PhD at the Center for 
Immuno-oncology Pathology Core at Dana-Farber/Harvard Cancer Center (DF/HCC). The 
immuno-oncology core at DF/HCC has optimized IHC for these markers.73 Additionally, the 
immuno-oncology core lab at DF/HCC has experience evaluating the gene expression profiling 
of tumor samples and peripheral blood with the aim of identifying an immune gene signature.  
This effort may result in identifying patients more likely to respond to therapy with immune 
checkpoint inhibitors. Further details can be found in Section 9. 
 
 PARTICIPANT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Histologically confirmed liposarcoma, leiomyosarcoma, or undifferentiated/unclassified 
pleomorphic sarcoma, or other sarcomas (that have been reported to respond to 
immunotherapy such as, but not limited to, alveolar soft part sarcoma, cutaneous 
angiosarcoma, mismatch repair deficiency sarcomas, after review by the principal 
investigator and treating physician) by a Dana-Farber Cancer Institute, Brigham and 
Women’s Hospital or Massachusetts General Hospital pathologist.  
Alternative terms for undifferentiated/unclassified pleomorphic sarcomas meeting 
inclusion criteria include but are not limited to the following: 


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pleomorphic undifferentiated sarcoma  
unclassified spindle cell sarcoma  
spindle cell sarcoma not otherwise specified  
pleomorphic spindle cell sarcoma  
pleomorphic fibroblastic sarcoma  
undifferentiated high-grade pleomorphic sarcoma  
pleomorphic sarcoma with prominent inflammation  
pleomorphic sarcoma with giant cells  
malignant fibrous histiocytoma (including storiform-pleomorphic and 
inflammatory subtypes)  
fibrosarcoma  
myxofibrosarcoma 
extraskeletal osteosasrcoma (soft tisse sarcoma with osteoid 
differentiation)  
 
 
3.1.2 Participants must have measurable disease, defined as at least one lesion 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 with conventional techniques 
or as ≥10 mm with spiral CT scan, MRI, or calipers by clinical exam.  See Section 11 for 
the evaluation of measurable disease. 
 
3.1.3 Participants must have received at least one prior line of chemotherapy. No limit on prior 
lines of therapy. 
 
3.1.4 Age ≥ 18 years.  
 
3.1.5 ECOG performance status of 0 or 1 (see Appendix A). 
 
3.1.6 Participants must have normal organ and marrow function as defined below: 
 
 
leukocytes 
≥3,000/mcL 
 
absolute neutrophil count 
≥1,500/mcL 
 
platelets 
≥100,000/mcL 
 
Hemoglobin ≥ 8 g/dL within the first 2 weeks prior to the first dose of study drugs, 
transfusion is allowed. 
 
total bilirubin 
≤1.5× institutional upper limit of normal (ULN) 
(except participants with Gilbert Syndrome, who can have total bilirubin <3.0 mg/dL) 
 
AST(SGOT)/ALT(SGPT)<2.5 x ULN in a participant with no documented liver 
metastases; ALT and AST <5.0 x ULN in a participant with documented liver 
metastases 
 
 
 
creatinine 
≤1.5× ULN 
OR 


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 
creatinine clearance 
≥50 mL/min/1.73 m2 for participants with creatinine 
levels above institutional normal (using the Cockcroft-
Gault Formula below): 
 
Female CrCl = (140 - age in years) x weight in kg x 0.85 
72 x serum creatinine in mg/dL 
 
Male CrCl = (140 - age in years) x weight in kg  
72 x serum creatinine in mg/dL 
 
 
 
3.1.7 The effects of eribulin and pembrolizumab on the developing human fetus are unknown.  
For this reason, women of child-bearing potential (WOCBP) and men must agree to use 
adequate contraception (hormonal or barrier method of birth control; abstinence) prior to 
study entry and for the duration of study participation.  A male participant must agree to 
use a contraception as detailed in Appendix G of this protocol during the treatment period 
and for at least 20 weeks, corresponding to the time needed to eliminate any study 
treatments, plus an additional 120 days (a spermatogenesis cycle) after the last dose of 
study treatment. A female participant is eligible to participate if she is not pregnant (see 
Appendix G), not breastfeeding, and at least one of the following conditions applies:  
 
a.) Not a woman of childbearing potential (WOCBP) as defined in Appendix G  
OR  
b.) A WOCBP who agrees to follow the contraceptive guidance in Appendix G during 
the treatment period and for at least 20 weeks plus an additional 30 days (a menstruation 
cycle) after the last dose of study treatment. 
 
WOCBP should use an adequate method to avoid pregnancy for at least 20 weeks plus an 
additional 30 days after the last dose of investigational drug. Women of childbearing 
potential must have a negative serum pregnancy test within 72 hours prior to the start of 
Eribulin and Pembrolizumab. Women must not be breastfeeding. Women who are not of 
childbearing potential (i.e., who are postmenopausal or surgically sterile) do not require 
contraception. Women of childbearing potential (WOCBP) is defined as any female who 
has experienced menarche and who has not undergone surgical sterilization 
(hysterectomy or bilateral oophorectomy) or who is not postmenopausal. Menopause is 
defined clinically as 12 months of amenorrhea in a woman over 45 in the absence of 
other biological or physiological causes. In addition, women under the age of 55 must 
have a documented serum follicle stimulating hormone (FSH) level less than 40 mIU/mL. 
 
3.1.8 Ability to understand and the willingness to sign a written informed consent document. 
 
 
 
 


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3.2 
Exclusion Criteria 
 
3.2.1 Participants who have had standard chemotherapy or radiotherapy within 3 weeks prior to 
entering the study. 
 
3.2.2 Participants who have not recovered from adverse events (grade 2 or higher toxicities) 
due to agents administered, radiotherapy, or surgery, with the exception of alopecia and 
anemia.  
 
3.2.3 Previous treatment with eribulin  or any anti-PD-1, PD-L1, or PD-L2 agent, or with an 
agent directed to another stimulatory or co-inhibitory T-cell receptor (eg, CTLA-4, 
OX-40, CD137). 
 
3.2.4 Participants who are currently participating in or have participated in a study of an 
investigational agent or have used an investigational device within 3 weeks prior to the 
first dose of study treatment. 
Note:  Participants who have entered the follow-up phase of an investigational study may 
participate as long as it has been 3 weeks after the last dose of the previous 
investigational agent. 
 
3.2.5 Known brain metastases that are untreated, symptomatic or require therapy to control 
symptoms. Participants with previously diagnosed brain metastases are eligible if they 
have completed treatment at least 4 weeks prior to registration, are neurologically stable 
and have not experienced any new neurologic symptoms for the last 4 weeks prior to 
study entry, and have recovered from the effects of radiotherapy or surgery.  There must 
also be no requirement for immunosuppressive doses of systemic corticosteroids (>10 
mg/day prednisone equivalents) for at least 2 weeks prior to study drug administration. 
Treatment for brain metastases may have included whole brain radiotherapy, 
radiosurgery, surgery, or a combination as deemed appropriate by the treating physician.  
 
3.2.6 Have received a live vaccine within 30 days prior to the first dose of study drug.  
Examples of live vaccines include, but are not limited to, the following:  measles, 
mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus Calmette–
Guérin (BCG), and typhoid vaccine.  Seasonal influenza vaccines for injection are 
generally killed virus vaccines and are allowed; however, intranasal influenza vaccines 
(eg, FluMist®) are live attenuated vaccines and are not allowed. 
 
3.2.7 Inability to comply with study and/or follow-up procedures. 
 
3.2.8 History of severe hypersensitivity reaction (≥Grade 3) to any monoclonal antibody. 
 
3.2.9 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to Eribulin or Pembrolizumab. 
 


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3.2.10 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or 
psychiatric illness/social situations which in the PI’s opinion makes it undesirable for the 
participant to participate in the trial or which would jeopardize compliance with the trial 
and study requirements. 
 
3.2.11 Pregnant women (WOCBP who had a positive serum pregnancy test on screening or 72 
hours prior to initiation of study protocol) are excluded from this study because the 
effects of Eribulin and Pembrolizumab on the developing fetus are unknown. There is the 
potential for teratogenic or abortifacient effects.  Because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the mother 
with Eribulin and Pembrolizumab, breastfeeding should be discontinued if the mother is 
treated with Eribulin and Pembrolizumab.   
 
3.2.12 Because the effects of pembrolizumab on chronic viral infection are not well known, 
participants should be excluded if they have known history of testing positive for human 
immunodeficiency virus (HIV) (true positive) or known acquired immunodeficiency 
syndrome (AIDS) or if they have a positive test for hepatitis B virus surface antigen 
(HBV sAg) or hepatitis C virus ribonucleic acid (HCV antibody) indicating acute or 
chronic infection. 
 
3.2.13 Participants with active autoimmune disease or history of autoimmune disease that might 
recur, which may affect vital organ function or require immune suppressive treatment 
including systemic corticosteroids, are excluded. These include but are not limited to 
participants with a history of immune related neurologic disease such as multiple 
sclerosis, autoimmune (demyelinating) neuropathy, Guillain-Barre syndrome, or 
myasthenia gravis; participants with a history of systemic autoimmune disease such as 
SLE, connective tissue diseases, scleroderma, inflammatory bowel disease (IBD), 
Crohn’s, ulcerative colitis, or hepatitis; and participants with a history of toxic epidermal 
necrolysis (TEN), Stevens-Johnson syndrome, or phospholipid syndrome.  These 
participants should be excluded because of the risk of recurrence or exacerbation of 
disease. Participants with vitiligo or endocrine deficiencies, including thyroiditis 
managed with replacement hormones such as physiologic corticosteroids, are eligible. 
Participants with rheumatoid arthritis or other arthropathies; Sjögren’s syndrome; 
psoriasis controlled with topical medication; or participants with positive serology, such 
as antinuclear antibodies (ANA) or anti-thyroid antibodies, should be evaluated for the 
presence of target organ involvement and potential need for systemic treatment but 
should otherwise be eligible. 
 
3.2.14 Participants are permitted to enroll if they have vitiligo, type I diabetes mellitus, residual 
hypothyroidism due to autoimmune condition only requiring hormone replacement, 
psoriasis not requiring systemic treatment, or conditions not expected to recur in the 
absence of an external trigger (precipitating event). 
 


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3.2.15 Participants should be excluded if they have a condition requiring systemic treatment 
with either corticosteroids (>10 mg daily prednisone equivalents) or other 
immunosuppressive medications within 14 days of study drug administration. Inhaled or 
topical steroids and adrenal replacement doses <10 mg daily prednisone equivalents are 
permitted in the absence of active autoimmune disease. Participants are permitted to use 
topical, ocular, intraarticular, intranasal, and inhalational corticosteroids (with minimal 
systemic absorption). Physiologic replacement doses of systemic corticosteroids are 
permitted, even if <10 mg/day prednisone equivalents. A brief course of corticosteroids 
for prophylaxis (e.g., contrast dye allergy) or for treatment of non-autoimmune conditions 
(e.g., delayed-type hypersensitivity reaction caused by contact allergen) is permitted. 
 
3.2.16 Participants with a history of pneumonitis or interstitial lung disease. 
 
3.2.17 History of primary immunodeficiency or solid organ transplantation. 
 
3.2.18 Participants who have had evidence of active or acute diverticulitis, intra-abdominal 
abscess, GI obstruction, or fistula or abdominal carcinomatosis (which are known risk 
factors for bowel perforation) should be evaluated for the potential need for additional 
treatment before coming on study. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial. Every attempt will 
be made to enter all eligible participants into this protocol in this rare set of diseases.  
 
 REGISTRATION PROCEDURES 
 
4.1 
General Guidelines for DF/HCC Institutions 
 
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 
registration will be denied. 
 
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 
 
Following registration, participants may begin protocol therapy. Issues that would cause 
treatment delays should be discussed with the Overall PI. If a participant does not receive 
protocol therapy following registration, the participant’s registration on the study must be 
canceled. Registration cancellations must be made in OnCore as soon as possible.  
 
4.2 
Registration Process for DF/HCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.   


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 TREATMENT PLAN 
 
5.1 
Treatment Regimen 
This is a non-randomized phase 2 study of eribulin in combination with pembrolizumab for the 
treatment of liposarcomas, leiomyosarcoma, and undifferentiated pleomorphic sarcomas. 
Eligible participants with liposarcoma, leiomyosarcoma, or undifferentiated pleomorphic 
sarcoma/other sarcomas will be divided into three separate cohorts by histologic subtype. Arm 
A: Leiomyosarcoma, Arm B: Liposarcoma, and Arm C: Undifferentiated Pleomorphic 
Sarcoma/other sarcomas. A treatment cycle will be defined as 21 consecutive days. Treatment 
will be eribulin 1.4 mg/m2 administered on Day 1 and on Day 8 of each 21-day cycle, plus 
pembrolizumab 200mg administered on Day 1, of each 21-day cycle. If treatment is delayed, 
protocol required restaging assessments will remain on-schedule. Eribulin and pembrolizumab 
will be administered on an outpatient basis. Reportable adverse events and potential risks are 
described in Section 7.  Appropriate dose modifications are described in Section 6.  No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the participant's malignancy. 
 
Treatment regimen is described in Table l. 
 
 
 
Table 1 Treatment Regimen. 
Regimen Description 
Agent 
Premedication; 
Precautions 
Dose 
Route* 
Schedule 
Cycle 
Length 
Eribulin 
No routine 
premedication 
required, addition 
of 4 to 8mg of 
dexamethasone 
and/or 8 to 16mg 
of Zofran allowed 
for nausea as per 
institutional 
standard+ 
1.4mg/m2 
IV, infuse over 2 
to 5 min, may 
be administered 
per institutional 
standard 
Day 1 and 
Day 8 
21 days 
(3 weeks)
 
 
 
Pembrolizumab 
Not routinely 
necessary unless 
prior infusion 
reaction.+ 
200mg 
IV infuse over ~ 
30 minas per 
institutional 
standard, infuse 
prior to starting 
eribulin 
infusion, per 
institutional 
standard
Day 1 
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be found in Section 6. 
+Pre-medications can be administered prior to pembrolizumab. Pre-medications for 
pembrolizumab and eribulin may be administered per institutional standards.
 
5.2 
Pre-Treatment Criteria 
 
5.2.1 Cycle 1, Day 1 
 
Criteria to treat on Cycle 1 Day 1 (Patient does not need to re-meet full eligibility 
criteria): 
-Absolute neutrophil count >1500/ mcL 
-Platelets >100,000/ mcL 
-ALT and AST <2.5 x ULN in a participant with no documented liver metastases; ALT 
and AST <5.0 x ULN in a participant with documented liver metastases 
-Total bilirubin <1.5 x ULN (2.0 x ULN in a participant with well documented Gilbert’s 
syndrome)  
 
 
5.2.2 Cycle 1, Day 8 and Day 8 of subsequent cycles 
 
Criteria to treat on Cycle 1 Day 8 and Day 8 of subsequent cycles: 
-Absolute neutrophil count >1000/ mcL 
-Platelets >100,000/ mcL 
-ALT and AST <2.5 x ULN in a participant with no documented liver metastases; ALT 
and AST <5.0 x ULN in a participant with documented liver metastases 
-Total bilirubin <1.5 x ULN (2.0 x ULN in a participant with well documented Gilbert’s 
syndrome) 
5.2.3 Day 1 of subsequent cycles 
 
Criteria to treat on Day 1 of subsequent cycles: 
-Absolute neutrophil count >1000/ mcL 
-Platelets >100,000/ mcL 
-ALT and AST <2.5 x ULN in a participant with no documented liver metastases; ALT 
and AST <5.0 x ULN in a participant with documented liver metastases 
-Total bilirubin <1.5 x ULN (2.0 x ULN in a participant with well documented Gilbert’s 
syndrome) 
 
Any non-hematologic toxicities must return to baseline or to < Grade 2 beginning with 
Day 1of each cycle.  
 
If dose is held or missed on Day 1 of a cycle, that cycle will not be considered to start 
until the day the dose is actually administered to the patient (ie, D1-D8-rest, X-D1-D8-
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5.3 
Agent Administration 
 
5.3.1 Eribulin 
 
Eribulin will be administered by trained medical personnel at the investigational site. 
Treatment compliance will be monitored through documentation of study treatment 
administration in the participant’s medical record. 
 
Please refer to the FDA-approved package insert for eribulin for product information 
and a comprehensive list of adverse events. 
 
Eribulin will be administered on Days 1 and 8 of each 21-day cycle. Eribulin should be prepared 
and administered per institutional standard. Institutional standard procedures include BSA 
calculations, body weight assessments and dose calculations/recalculations. 
 
 
5.3.2 Pembrolizumab 
 
Pembrolizumab will be administered by trained medical personnel at the investigational site. 
Treatment compliance will be monitored through documentation of study treatment 
administration in the participant’s medical record. 
 
Pembrolizumab will be administered in the outpatient clinic on Day 1 of each cycle. 
Pembrolizumab should be prepared and administered as an approximately 30-minute IV infusion 
per institutional standard, infuse prior to Eribulin  
 
Please refer to the FDA-approved package insert for pembrolizumab for product information and 
a comprehensive list of adverse events. Pembrolizumab should be prepared and administered per 
institutional standard. Institutional standard procedures include BSA calculations, body weight 
assessments and dose calculations/recalculations. Infusion times may be prolonged in 
participants who experience an infusion reaction as per section 5.9.  
 
Pembrolizumab should be administered prior to eribulin administration. There should be no 
overlap in timing of the two administrations. 
 
The standard dose of pembrolizumab is 200mg IV.  
 
5.3.3 Discontinuation of eribulin  
 
If eribulin is stopped for toxicity, participants are permitted to continue protocol therapy with 
pembrolizumab alone. 
 
5.3.4 Discontinuation of pembrolizumab 
 
If pembrolizumab is stopped for toxicity, participants are permitted to continue protocol therapy 
with eribulin alone. 


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5.4 
General Concomitant Medication and Supportive Care Guidelines 
 
5.4.1 General Concomitant Medication Guidelines 
 
Pembrolizumab is a human monoclonal antibody and as such is not expected to be 
metabolized by the cytochrome P450 (CYP) enzymes or other typical drug metabolizing 
enzymes. Thus, it is not expected to have any effect on the CYP or other drug 
metabolizing enzymes in terms of inhibition or induction, and is, therefore, not expected 
to induce this type of PK-based drug interaction. However, with eribulin there is a 
potential for interaction with other concomitantly administered drugs through the 
cytochrome P450 system.  Concurrent use of all other drugs, over-the-counter 
medications, or alternative therapies will be reviewed at each visit.  The Overall PI 
should be alerted if the participant is taking any agent known to affect or with the 
potential to affect selected CYP450 isoenzymes.  Appendix C presents guidelines for 
identifying medications/substances that could potentially interact with the study agent(s). 
 
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 may be required. The investigator should discuss any questions regarding 
this with the overall PI who will communicate with the Merck Clinical team and Eisai 
Clinical Team. The final decision on any supportive therapy or vaccination rests with 
the PI and/or the participant's primary physician. 
 
Acceptable Concomitant Medications 
 
All treatments that the investigator considers necessary for a participant’s welfare may be 
administered at the discretion of the investigator in keeping with the community 
standards of medical care with the exception of those prohibited medications noted 
below.  Concomitant medications will be reviewed as noted in table 7. 
 
Prohibited Concomitant Medications 
 
Participants are prohibited from receiving the following therapies during the Screening 
and Treatment Phase of this trial: 
 
 Antineoplastic systemic chemotherapy or biological therapy 
 Immunotherapy not specified in this protocol 
 Chemotherapy not specified in this protocol 
 Biologic or targeted agents not specified in this protocol 
 Investigational agents other than pembrolizumab and eribulin 
 Live vaccines within 28 days prior to the first dose of trial treatment and while 
participating in the trial. Examples of live vaccines include, but are not limited to, the 


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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 (10 mg prednisone by mouth daily or equivalent) is allowed. 
 Care should be taken with concomitant use of strong CYP3A4 inhibitors/inducers 
(e.g. ketoconazole and itraconazole; see Appendix C) and eribulin. An alternate 
medication with no or minimal potential to inhibit CYP3A4 should be considered. If a 
strong CYP3A4 inhibitor is co-administered with eribulin, participants should be 
closely monitored for adverse reactions. 
 Participants 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. 
Participants may receive other medications that the investigator deems to be 
medically necessary. 
 There are no prohibited therapies during the Post-Treatment Follow-up Phase. 
 
5.4.2 Supportive Care Guidelines – General Medications 
 
The following treatments are permitted throughout the duration of the study treatment 
phase and during follow-up: 
 
 Standard therapies for pre-existing medical conditions unless listed as prohibited 
therapy below. Any medication intended solely for supportive care (e.g., analgesics, 
antidiarrheal, anti-depressants) may be used at the investigator’s discretion.  
 Anti-diarrheal medications should not be administered prophylactically before initial 
treatment with study drugs. At the discretion of the investigator, prophylactic 
antiemetic and anti-diarrheal medication(s) may be used as per standard clinical 
practice before doses of study drugs. 
 Hematopoietic growth factors (e.g., G-CSF, granulocyte macrophage colony 
stimulating factor) may be used at investigator’s discretion for the primary 
prophylaxis and/or management of treatment-emergent neutropenia and/or for 
secondary prophylaxis as per NCCN/European Society for Medical Oncology 
guidelines 47, 48 or local standard practice.  
 Bisphosphonate or denosumab therapy to be used in accordance with the approved 
labeled indication and/or nationally recognized treatment guidelines. Participants 
already receiving bisphosphonate/denosumab at the time of study entry can continue 
the treatment. 
 Anticoagulants - Anticoagulation with heparin, heparin derivatives, and/or warfarin, 
and/or NOAC’s may be given at the discretion of the treating physician.  
 Pain medications administered per standard clinical practice are acceptable while the 
participant is enrolled in the study. 
 Participants who experience toxicities should be treated symptomatically as clinically 
indicated. Medications that are considered necessary for the participant’s welfare and 
that are not expected to interfere with the evaluation of study treatment or be 
restricted may be given at the discretion of the investigator. Ancillary treatments will 
be given as medically indicated. 


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5.5 
Duration of Therapy 
 
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue for 
2 years or 35 cycles of therapy or until one of the following criteria applies: 
 
 Disease progression in any participant who showed first radiologic evidence of 
progressive disease (PD) by RECIST 1.1 (see Section 11.1.4) and is deemed clinically 
stable, it is at the discretion of the investigator to continue treating the participant until 
progression is confirmed at least 4 weeks from the date of the first radiologic evidence of 
PD. Further details are described below.  
 Intercurrent illness that prevents further administration of treatment 
 Unacceptable adverse event(s) which include the following (see also section):  
 
o Any Grade 2 drug-related uveitis or eye pain or blurred vision that does not 
respond to topical therapy and does not improve to Grade 1 severity within the re-
treatment period OR requires systemic treatment   
o Participants requiring > two dose delays for the same type of event should be 
removed from protocol   
o Any adverse event, laboratory abnormality, or intercurrent illness which, in the 
judgment of the investigator, presents a substantial clinical risk to the participant 
with continued study drug dosing   
o Any dosing interruption lasting >5 weeks, with the following exceptions:   
 Participants being tapered after high dose corticosteroids over one month 
followed by a two-week observation period will be allowed an additional 
two weeks to restart treatment (a maximum eight-week interruption).   
 Dosing interruptions >5 weeks that occur for non-drug-related reasons 
may be allowed if approved by the Investigator. Prior to re-initiating 
treatment in a participant with a dosing interruption lasting >5 weeks, the 
PI must be consulted.   
o Grade 2 pneumonitis requiring steroids.  
o Grade 3 or Grade 4 drug-related autoimmune or inflammatory events including 
uveitis, pneumonitis, diarrhea, colitis, neurologic adverse events, hypersensitivity 
reaction, or infusion reaction of any duration requires discontinuation except as 
noted below:   
 Any other grade 3 non-skin, drug-related AE lasting >7 days including 
fatigue.   
 Any grade 3 or 4 drug-related laboratory abnormality or electrolyte 
abnormality, not associated with underlying organ pathology, that does not 
require treatment except for electrolyte replacements does not require 
treatment discontinuation.   
 Grade 3 amylase or lipase abnormalities that are not associated with 
diabetes mellitus (DM), associated liver or gall bladder inflammation 
clinical manifestations of pancreatitis and which decrease to < Grade 2 


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within 1 week of onset may resume study treatment when resolved.   
o Any grade 4 events except as noted above.   
 
 Any participants who require additional immune suppressive treatment beyond steroids 
should go off study treatment   
 Participant demonstrates an inability or unwillingness to comply with the medication 
regimen and/or documentation requirements 
 Participant decides to withdraw from the protocol therapy 
 General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator 
Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF). Alternative care options will be discussed with the 
participant. 
 
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify the Overall PI, Dr. Suzanne George, MD. 
 
Confirmation of Progressive Disease 
 
Pembrolizumab, like other immunotherapeutic agents, may produce antitumor effects by 
potentiating endogenous cancer-specific immune responses. The response patterns seen with 
such an approach may extend beyond the typical time course of image responses seen with 
cytotoxic agents, and can manifest as a clinical response after an initial increase in tumor burden 
or even the appearance of new lesions. 
 
For any participant who shows first radiologic evidence of progressive disease (PD) by 
RECIST1.1 (see Section 11.1.4) and is deemed clinically stable, it is at the discretion of the 
investigator to continue treating the participant until progression is confirmed at least 4 weeks 
from the date of the first radiologic evidence of PD. If progression is confirmed, the participant 
will be discontinued from study treatment. If progression is not confirmed on the subsequent 
scan, the participant should continue to receive study treatment and have radiographic scans 
performed every 6 weeks if the participant has been on study for less than 24 weeks, or every 9 
weeks for participants who have been on study greater than 24 weeks to monitor disease status. 
Any participant who had initial radiologic progression and is deemed clinically unstable should 
be discontinued from both study drugs and no subsequent scan for confirmation is required.  
Exceptions may be considered to continue treatment in the presence of clinically stable or 
improved condition only after consultation with the PI. 
 
For purposes of PFS assessment on this trial, in addition to radiographic assessment of tumor 
response or progression, the investigator should take into account the clinical condition/stability 
of participants.  Clinically stable is defined by the following criteria: 
 
 Absence of signs and symptoms (including worsening of laboratory values) indicating 
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 No decline in ECOG performance status 
 Absence of rapid progression of disease 
 Absence of progressive tumor(s) at critical anatomical sites (eg, cord compression) 
requiring urgent alternative medical intervention 
 
5.6 
 Duration of Follow-Up 
 
Participants will follow-up at approximately 4 weeks for an end of study clinic visit after the last 
dose of study drug whenever possible. If an in-person visit is not possible, the participant will be 
contacted by phone. Immune mediated event surveillance will be conducted approximately 100 
days after the last dose of study treatment via telephone. Otherwise, ongoing long-term follow-
up will be accomplished by phone for all participants. Participants will be followed 
approximately every three months until death. 
 
In addition to the follow-up schedule above, participants removed from protocol therapy for 
unacceptable adverse event(s) will be followed until resolution or stabilization of the adverse 
event. 
 
In participants who come off trial for a reason other than progressive disease, if possible during 
the follow-up period, scans should be performed every 8 weeks or 2 months to evaluate for 
disease progression, until the participant has disease progression or dies or starts a new systemic 
therapy. 
 
NOTE:  With Protocol Version 15MAY2024, further long-term follow-up is being 
terminated. 
 
5.7 
Criteria for Taking a Participant Off-Study 
 
Participants will be removed from study when any of the following criteria apply: 
 Lost to follow-up 
 Withdrawal of consent for data submission 
 Death 
 Inability to follow study protocol as listed in section 5.6. 
 
The reason for taking a participant off study and the date the participant was removed must be 
documented in the CRF. 
 
For Decentralized Participant Registrations, the research team updates the relevant Off 
Treatment/Off Study information in OnCore.  
 
5.8 
Criteria to Resume Treatment after a pembrolizumab related iAE 
 
Management of adverse events is summarized in section 6 and may include holding of 
pembrolizumab, and/or the use of steroids for the management of immune related AEs. If 
pembrolizumab is held for toxicity, participants are permitted to continue protocol therapy with 
eribulin. Eribulin can be continued during corticosteroid treatment. 


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If drug administration is held until the next scheduled time point, please continue to count 
weeks/doses. If participants must be delayed due to toxicity, all assessments can be obtained with 
the modified treatment dose schedule as noted in this section.  
Pembrolizumab may be interrupted for situations other than treatment-related AEs such as 
medical / surgical events or logistical reasons not related to study therapy. Participants should be 
placed back on study therapy within 8 weeks of the scheduled interruption, unless otherwise 
discussed with the Sponsor. The reason for interruption should be documented in the 
participant's study record. 
 
Restarting pembrolizumab may be considered in participants who experience grade 2 events and 
some grade 3 events (skin rash and thyroiditis). Because of this, stopping treatment and starting 
steroids earlier, as per section 6, to obtain resolution with the possibility for restarting rather than 
waiting for higher grade events is encouraged.  
For non-autoimmune or non-inflammatory events, participants may resume treatment with study 
drug when the drug-related AE(s) resolves to Grade ≤1 or the baseline value, with the following 
exceptions:  
 Evaluation to exclude any additional immune mediated events (endocrine, GI, and liver / 
pancreas function) as clinically indicated must be made prior to restarting.   
 Non-drug-related toxicity including hepatic, pulmonary toxicity, diarrhea, or colitis, must 
have resolved to baseline before treatment is resumed.  If the criteria to resume 
treatment are met, the participant should restart treatment no sooner than the next 
scheduled time point per protocol. However, if the treatment is delayed past the next 
scheduled time point per protocol, the treatment should resume at the earliest convenient 
point that is within the five-week delay period.  
 
For participants treated with corticosteroids:  
For participants treated with high dose steroids with pembrolizumab, toxicity must resolve to 
baseline within 8 weeks of treatment.  
Participants should be off steroids for at least 2 weeks with no recurrence or new events. New 
immune related events or exacerbation of existing events during steroid treatment or taper 
suggest the presence of ongoing immune activation and should require permanent 
discontinuation of pembrolizumab.  
Grade 2 events must resolve to grade < 1 or baseline before considering retreatment.  
All participants treated with steroids for grade ≥2 events should have pembrolizumab held until 
resolution to grade < 1 for at least 2 weeks following complete removal from steroid treatment 
except for maintenance replacement doses for adrenal insufficiency (preferably no greater than 
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All participants treated with steroids for grade ≥3 events should have pembrolizumab 
discontinued. Participants with grade 3 thyroiditis and skin rash may continue therapy as for 
grade 2 events with resolution and stable replacement treatment.  
Participants with hepatitis, pancreatitis, pneumonitis, and colitis are at risk for exacerbation with 
retreatment if there is residual inflammation and should resolve to Grade 0 or baseline before 
retreatment. Baseline can mean the initial grade i.e. grade ≤1 where permitted on study.  
Participants with thyroiditis or hypopituitarism who are stable as above may be restarted with 
replacement hormones including thyroid hormone and physiologic doses only of corticosteroids. 
Please note that hypophysitis with symptoms of headache, visual or neurologic changes or 
radiologic evidence of pituitary enlargement and other CNS events such as aseptic meningitis or 
encephalitis should be considered grade 3 events.  
Prior to starting corticosteroids or hormone replacement for any reason, appropriate endocrine 
testing including cortisol, ACTH, TSH and T4 must be drawn if clinically feasible to document 
baseline function and distinguish the pituitary from peripheral organ dysfunction and later from 
steroid (or thyroid) treatment associated ACTH (or TSH) suppression. Steroids should be started 
prior to obtaining results based on clinical indications.  
 
5.9 
Treatment of Pembrolizumab Related Infusion Reactions 
 
Since pembrolizumab contains only human immunoglobulin protein sequences, it is unlikely to 
be immunogenic and induce infusion or hypersensitivity reactions. However, in rare cases, 
Pembrolizumab may cause severe or life-threatening infusion-reactions including severe 
hypersensitivity or anaphylaxis. Signs and symptoms usually develop during or shortly after drug 
infusion and generally resolve completely within 24 hours of completion of infusion. However, 
if such a reaction were to occur, it might manifest with fever, chills, rigors, headache, rash, 
urticaria, angioedema, pruritus, arthralgias, hypo- or hypertension, bronchospasm, or other 
symptoms.  
All Grade 3 or 4 infusion reactions should be reported as an SAE if criteria are met. Infusion 
reactions should be graded according to NCI CTCAE version 5.0 guidelines.  
Treatment recommendations are provided below and may be modified based on local treatment 
standards and guidelines as medically appropriate:  
For Grade 1 symptoms: (Mild reaction; infusion interruption not indicated; intervention not 
indicated)  
Remain at bedside and monitor participant until recovery from symptoms. Infusion rate may be 
slowed. If the infusion is interrupted, then restart the infusion at 50% of the original infusion rate 
when symptoms resolve; if no further complications ensue after 30 minutes, the rate may be 
increased to 100% of the original infusion rate. Monitor participant closely.  
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diphenhydramine 50 mg (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen) at 
least 30 minutes before additional pembrolizumab administrations, slowing infusion rate as 
above.  
For Grade 2 symptoms: (Moderate reaction requires therapy or infusion interruption but 
responds promptly to symptomatic treatment [e.g., antihistamines, non-steroidal anti- 
inflammatory drugs, narcotics, corticosteroids, bronchodilators, IV fluids]; close observation for 
recurrence and treatment medications may need to be continued for 24-48 hours).  
Stop the pembrolizumab infusion, begin an IV infusion of normal saline, and treat the participant 
with diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 to 1000 mg 
(acetaminophen); remain at bedside and monitor participant until resolution of symptoms. 
Corticosteroid or bronchodilator therapy may also be administered as appropriate. If symptoms 
resolve within 1 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 participant should be premedicated for the next scheduled dose. If the 
infusion was interrupted, then restart the infusion at 50% of the original infusion rate when 
symptoms resolve; if no further complications ensue after 30 minutes, the rate may be increased 
to 100% of the original infusion rate. Monitor participant closely. If symptoms recur, then no 
further pembrolizumab will be administered at that visit. Administer diphenhydramine 50 mg IV, 
and remain at bedside and monitor the participant until resolution of symptoms. The amount of 
study drug infused must be recorded on the electronic case report form (eCRF). The following 
prophylactic pre-medications are recommended for future infusions: diphenhydramine 50 mg (or 
equivalent) and (acetaminophen) (or paracetamol) 325 to 1000 mg should be administered at 
least 30 minutes before additional pembrolizumab administrations. If necessary, corticosteroids 
(recommended dose: up to 25 mg of IV hydrocortisone or equivalent) may be used.  
 
For Grade 3 or Grade 4 symptoms:  
Grade 3 symptoms: (Severe reaction; 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 symptoms: (life threatening; pressor or ventilatory support indicated).  
Immediately discontinue infusion of pembrolizumab. Begin an IV infusion of normal saline, and 
treat the participant as follows: Recommend bronchodilators, epinephrine 0.2 to 1 mg of a 
1:1,000 solution for subcutaneous administration or 0.1 to 0.25 mg of a 1:10,000 solution 
injected slowly for IV administration, and/or diphenhydramine 50 mg IV with 
methylprednisolone 100 mg IV (or equivalent), as needed. Participant should be monitored until 
the investigator is comfortable that the symptoms will not recur. Pembrolizumab will be 
permanently discontinued. Investigators should follow their institutional guidelines for the 
treatment of anaphylaxis. Remain at bedside and monitor participant until recovery from 
symptoms. In the case of late-occurring hypersensitivity symptoms (e.g., appearance of a 
localized or generalized pruritus within 1 week after treatment), symptomatic treatment may be 
given (e.g., oral antihistamine, or corticosteroids).  


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Please note that late occurring events including isolated fever and fatigue may represent the 
presentation of systemic inflammation. Please evaluate accordingly.  
5.10 
Treatment Beyond Progression 
 
A minority of participants treated with immunotherapy may derive clinical benefit as either 
delayed responses, stable disease, or increased overall survival despite initial evidence of 
progressive disease (PD) with pembrolizumab and eribulin.  
Participants may be permitted to continue treatment beyond initial RECIST 1.1-defined PD that 
occurs during the initial (24 weeks) of treatment as long as they meet the following criteria:  
 No more than 4 new lesions, total sum of the longest diameter (SHORT diameter for LN) 
cannot exceed 40% of the initial sum including new lesions 
 Participants must be clinically stable with no change in performance status due to disease 
progression 
 No indication for immediate alternative treatment, however, palliative radiation to 
isolated symptomatic lesions is allowed 
 Participant [assessed by the investigator] is showing clinical benefit and tolerates study 
drug. The assessment of clinical benefit should take into account whether the participant 
is clinically stable or deteriorating and likely or unlikely to receive further benefit from 
continued treatment. 
 The time of progression is noted from the first assessment that exceeds standard criteria  
 
New lesions are considered measurable at the time of initial progression if the longest diameter is 
at least 10 mm (except for pathological lymph nodes, which must have a short axis of at least 15 
mm). Any new lesion considered non-measurable at the time of initial progression may become 
measurable and therefore be included in the tumor burden measurement if the longest diameter 
increases to at least 10 mm (except for pathological lymph nodes, which must have an increase 
in short axis to at least 15 mm).  
5.11 
Lifestyle Restrictions 
 
5.11.1 Meals and Dietary Restrictions 
 
Participants should maintain a normal diet unless modifications are required to manage 
an AE such as diarrhea, nausea or vomiting. 
 
5.11.2 Contraception 
 
Pembrolizumab or Eribulin may have adverse effects on a fetus in utero.  Refer to 
Appendix G for approved methods of contraception. 
 
For this study, male participants 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).   


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5.11.3 Pregnancy 
 
If a participant inadvertently becomes pregnant while on treatment with pembrolizumab 
or Eribulin, the participant will be immediately discontinued from study treatment.  The 
site will contact the participant at least monthly and document the participant’s status 
until the pregnancy has been completed or terminated.  The outcome of the pregnancy 
will be reported to Merck within 2 working days if the outcome is a serious adverse 
experience (eg, death, abortion, congenital anomaly, or other disabling or life-threatening 
complication to the mother or newborn).  The study Investigator will make every effort to 
obtain permission to follow the outcome of the pregnancy and report the condition of the 
fetus or newborn to Merck and Eisai.  If a male participant impregnates his female 
partner, the study personnel at the site must be informed immediately and the pregnancy 
must be reported to Merck and followed as described in Section 7.6. 
 
5.11.4 Use in Nursing Women 
 
It is unknown whether pembrolizumab is excreted in human milk.  Eribulin may be 
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, participants who are breast-
feeding are not eligible for enrollment. 
 DOSING DELAYS/DOSE MODIFICATIONS 
 
Dose delays and modifications will be made as indicated in the following table(s). The 
descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 5.0 will be utilized for dose delays and dose modifications. A 
copy of the CTCAE version 5.0 can be downloaded from the CTEP website 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
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, participant vacation, 
and/or holidays). Participants should be placed back on study therapy within 5 weeks of the 
scheduled interruption, unless otherwise discussed with the Sponsor. The reason for interruption 
should be documented in the participant's study record.  
Dose modifications and delays for eribulin will be allowed and are described below. No re-
escalation will be allowed for eribulin. Dose delays for pembrolizumab for adverse events are 
described below. There are no dose reductions of pembrolizumab allowed. See Section 5.9 for 
guidelines regarding resumption of pembrolizumab following dose delays.  
 
For toxicities in this Section which are attributable to pembrolizumab alone, only 
pembrolizumab should be held as directed. It is permissible to continue eribulin despite 
discontinuation of pembrolizumab in these select cases. This will be left to the treating 
physician’s discretion after discussion and approval of the study PI.  
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as directed. It is permissible to continue pembrolizumab despite discontinuation of eribulin in 
these select cases. This will be left to the treating physician’s discretion after discussion and 
approval by the study PI.  
6.1 
Eribulin dosing delays/dose modifications 
 
Participants should be carefully monitored for toxicity. If a treatment delay is required for 
eribulin toxicity or if treatment with eribulin is withheld permanently, treatment with 
pembrolizumab is allowed. Dosing levels for eribulin are shown in Table 2.  Eribulin toxicities 
should be managed according to the guidelines in Tables 3.1 through 3.5. Once reduced, the dose 
of eribulin will not be re-escalated.  
Clinical judgement should be used to determine appropriate management of the patient during 
any adverse event. Temporary interruption, dose reduction or permanent discontinuation of 
Eribulin should be considered if clinically indicated.  
Table 2. Eribulin dosing levels 
Dose Level
Eribulin Dose
Starting dose
1.4mg/m2 (1 cycle = 21 days)
1st dose reduction
1.1 mg/m2
2nd dose reduction
0.7 mg/m2
 
 Toxicities graded in accordance with National Cancer Institute Common Toxicity Criteria 
for AEs, version 5.0   
 Discontinuation of eribulin is required if a dose reduction to less than 0.7 mg/m
2 is 
required.   
 A minimum of 6 days between Day 1 and Day 8 of eribulin administration will be 
required. Day 8 administration of Eribulin must not be given prior to Day 8.  A minimum 
of 13 days between Day 8 and Day 1 of next cycle will be required.  
 If a participant does not meet criteria to receive Day 8 of eribulin, the Day 8 dose should 
be skipped (i.e., it will not be made up on Day 15) for that cycle.   
 Once a dose is reduced, it should not be re-escalated.   
 Treatment with eribulin will be discontinued if participants require a delay greater than 5 
weeks.    
 QTc prolongation has been observed in patients receiving eribulin.  Cardiac monitoring, 
including EKG, will be performed per institutional standard of care.  
 
 
 
 
 
Table 3.1 Eribulin Diarrhea Toxicity Dose Modification 
Diarrhea 
Management/Next Dose for Eribulin 
≤ Grade 2
No dose modification


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Diarrhea 
Management/Next Dose for Eribulin 
Grade 3, first 
occurrence 
Hold eribulin until recovery to grade < 2. Maximize supportive care 
measures. If symptom recovery occurs within 1 week, then eribulin 
may be resumed at the same dose if deemed appropriate by the 
investigator, otherwise, reduce by 1 dose level.
Grade 3, despite 
maximal supportive 
measures
Hold eribulin until recovery to grade < 2 then reduce by 1 dose level.  
Grade 4
Hold eribulin until recovery to grade < 2 then reduce by 1 dose level. 
 
Table 3.2 Eribulin Peripheral Neuropathy Dose Modification 
Peripheral 
Neuropathy 
Management/Next Dose for Eribulin 
≤ Grade 1
No dose modification
Grade 2 
For intolerable (as determined by physician and participant) grade 2, 
decrease eribulin by one dose level. 
Grade 3
Hold eribulin until recovery to grade < 2 then reduce by 1 dose level. 
Grade 4
Permanently discontinue eribulin.
 
Table 3.3 Eribulin Neutropenia Dose Modification 
Neutropenia 
Management/Next Dose for Eribulin 
ANC < 500 cells/mm3 lasting 
> 7 days with or without use 
of growth factors
Hold eribulin until recovery to grade < 2 and reduce by 1 
dose level. Prophylactic growth factor support should be 
instituted for subsequent cycles. 
ANC < 500 cells/mm3 lasting 
≤7 days without use of 
growth factors
Hold eribulin until recovery to grade < 2. Resume eribulin at 
the same dose. Growth factor support should be provided.  
ANC < 500 cells/mm3 lasting 
≤ 7 days in despite use of 
growth factors
Hold eribulin until recovery to grade < 2, and reduce by 1 
dose level. Continue ongoing prophylactic growth factor 
support for subsequent cycles. 
ANC <1000 /mm3 with fever 
or infection without use of 
growth factors
Hold eribulin until recovery to grade < 2. Resume eribulin at 
the same dose. Growth factor support should be provided.  
ANC <1000 /mm3 with fever 
or infection despite use of 
growth factors
Hold eribulin until recovery to grade < 2, and reduce by 1 
dose level. Growth factor support should be provided.  
ANC <1000 /mm3 without 
fever or infection 
 
First occurrence: Hold eribulin until recovery to grade < 2 
then resume at the same dose. Growth factor support should 
be provided.  
If uncomplicated neutropenia (<1000 /mm3 without fever or 
infection) occurs/recurs despite growth factor support, then 
hold eribulin until recovery to grade < 2. Eribulin may be 
then be resumed at the same dose with growth factor support, 
or it may be reduced by one dose level.  
If a participant misses two consecutive Day 8 eribulin doses 
due to uncomplicated neutropenia, then hold eribulin  until 


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Neutropenia 
Management/Next Dose for Eribulin 
recovery to grade < 2, reduce by 1 dose level, and consider 
prophylactic growth factor support for subsequent cycles. 
ANC = absolute neutrophil count 
 
Table 3.4 Eribulin Thrombocytopenia Dose Modification 
Thrombocytopenia 
Management/Next Dose for Eribulin 
≤ Grade 1
No dose modification
Grade 2
Hold eribulin until recovery to grade < 2.
Grade 3
Hold eribulin until recovery to grade < 2 then reduce by 1 dose level. 
Grade 4
Hold eribulin until recovery to grade < 2 then reduce by 1 dose level. 
 
Table 3.5 Eribulin Anemia Dose Modification 
Anemia 
Management/Next Dose for Eribulin 
≤ Grade 1
No dose modification
Grade 2
No dose modification
Grade 3
No dose modification
Grade 4 
Hold eribulin until recovery to grade < 2 then reduce by 1 dose level. 
PRBC transfusions are permitted to treat anemia on protocol. 
 
6.2 
Pembrolizumab dosing delays 
 
Participants should be carefully monitored for toxicity. If a treatment delay is required for 
pembrolizumab, treatment with Eribulin is allowed. Guidelines for dose interruption 
recommendations for pembrolizumab are shown in Table 4. If treatment with pembrolizumab is 
withheld permanently, participants are allowed to continue to receive eribulin therapy.Evaluation 
of possible AEs should occur early, with early withholding of drug, and appropriate treatment as 
indicated in the management tables and following event specific guidelines. In some cases, 
pembrolizumab may be resumed as per section 5.9 
AEs associated with pembrolizumab exposure may represent an immunologic etiology. These 
immune-related AEs (irAEs) may occur shortly after the first dose or several months after the 
last dose of pembrolizumab treatment and may affect more than one body system 
simultaneously. Therefore, early recognition and initiation of treatment is critical to reduce 
complications.  Based on existing clinical study data, most irAEs were reversible and could be 
managed with interruptions of pembrolizumab, administration of corticosteroids, and/or other 
supportive care. For suspected irAEs, ensure adequate evaluation to confirm etiology or exclude 
other causes. Additional procedures or tests such as bronchoscopy, endoscopy, skin biopsy may 
be included as part of the evaluation. Based on the severity of irAEs, withhold or permanently 
discontinue pembrolizumab and administer corticosteroids. Dose interruption and toxicity 
management guidelines for irAEs associated with pembrolizumab are provided in Table 4.1 to 
Table 4.9. 


 
 
 
 
 
 
 
 
50 
 
 
 
Table 4.1 Guidelines for dose interruption and toxicity management guidelines for 
immune-related AEs associated with pembrolizumab  
General instructions: 
1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 
weeks. 
2. For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to 
Grade 1 or 0 and corticosteroid has been tapered. Pembrolizumab should be permanently discontinued if AE does not 
resolve within 12 weeks of last dose or corticosteroids cannot be reduced to ≤10 mg prednisone or equivalent per day 
within 12 weeks.  
3. For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other 
immunosuppressive treatment should be initiated if irAEs cannot be controlled by corticosteroids. 
 
Immune-related 
AEs 
Toxicity grade or 
conditions 
(CTCAEv5.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies  
Monitor and follow-up  
Pneumonitis  
Grade 2 
Withhold  
 Administer 
corticosteroids (initial 
dose of 1-2 mg/kg 
prednisone or equivalent) 
followed by taper 
 
 
Monitor participants for signs 
and symptoms of 
pneumonitis 
 
Evaluate participants with 
suspected pneumonitis with 
radiographic imaging and 
initiate corticosteroid 
treatment 
 
Add prophylactic antibiotics 
for opportunistic infections
Grade 3 or 4, or 
recurrent Grade 2 
Permanently 
discontinue 
Diarrhea / Colitis 
Grade 2 or 3 
Withhold 
 Administer 
corticosteroids (initial 
dose of 1-2 mg/kg 
prednisone or equivalent) 
followed by taper 
 
 
Monitor participants for signs 
and symptoms of 
enterocolitis (ie, diarrhea, 
abdominal pain, blood or 
mucus in stool with or 
without fever) and of bowel 
perforation (ie, peritoneal 
signs and ileus). 
 
Participants with ≥ Grade 2 
diarrhea suspecting colitis 
should consider GI 
consultation and performing 
endoscopy to rule out colitis.  
 
Participants with 
diarrhea/colitis should be 
advised to drink liberal 
quantities of clear fluids.  If 
sufficient oral fluid intake is 
not feasible, fluid and 
electrolytes should be 
substituted via IV infusion.
Grade 4 
Permanently 
discontinue 
AST and ALT 
elevation or 
Increased 
bilirubin 
Grade 2 
Withhold 
 Administer 
corticosteroids (initial 
dose of 0.5- 1 mg/kg 
prednisone or equivalent) 
followed by taper
 
Monitor with liver function 
tests (consider weekly or 
more frequently until liver 
enzyme value returned to 
baseline or is stable


51 
 
 
Grade 3 or 4  
Permanently 
discontinue 
 Administer 
corticosteroids (initial 
dose of 1-2 mg/kg 
prednisone or equivalent) 
followed by taper
Type 1 diabetes 
mellitus (T1DM) 
or 
Hyperglycemia 
 
Newly onset 
T1DM or  
Grade 3 or 4 
hyperglycemia 
associated with 
evidence of -cell 
failure 
Withhold 
 Initiate insulin 
replacement therapy for 
participants with T1DM  
 Administer anti-
hyperglycemic in 
participants with 
hyperglycemia  
 
Monitor participants for 
hyperglycemia or other signs 
and symptoms of diabetes. 
Hypophysitis 
Grade 2 
Withhold 
 Administer 
corticosteroids and 
initiate hormonal 
replacements as 
clinically indicated.   
 
Monitor for signs and 
symptoms of hypophysitis 
(including hypopituitarism 
and adrenal insufficiency)  
Grade 3 or 4  
Withhold or 
permanently 
discontinue1  
Hyperthyroidism  
Grade 2 
Continue  
 Treat with non-selective 
beta-blockers (eg, 
propranolol) or 
thionamides as 
appropriate  
 
Monitor for signs and 
symptoms of thyroid 
disorders.  
 
Grade 3 or 4  
Withhold or  
permanently 
discontinue1 
Hypothyroidism 
Grade 2-4 
Continue  
 Initiate thyroid 
replacement hormones 
(eg, levothyroxine or 
liothyroinine) per 
standard of care
 
Monitor for signs and 
symptoms of thyroid 
disorders.  
 
Nephritis and 
Renal 
dysfunction 
Grade 2 
Withhold  
 Administer 
corticosteroids 
(prednisone 1-2 mg/kg 
or equivalent) followed 
by taper.
 
Monitor changes of renal 
function 
 
Grade 3 or 4  
Permanently 
discontinue 
Myocarditis 
Grade 1 or 2 
Withhold 
 Based on severity of AE 
administer 
corticosteroids 
 
Ensure adequate evaluation 
to confirm etiology and/or 
exclude other causes 
 
Grade 3 or 4 
Permanently 
discontinue 
All other 
immune-related 
AEs 
Intolerable/ 
persistent Grade 2 
Withhold 
 Based on type and 
severity of AE 
administer 
corticosteroids  
 
Ensure adequate evaluation 
to confirm etiology and/or 
exclude other causes 
 
Grade 3 
Withhold or 
discontinue 
based on the 
type of event.  
Events that 
require 
discontinuation 
include and not 
limited to:  
Gullain-Barre 
Syndrome, 
encephalitis


52 
 
 
Grade 4 or 
recurrent Grade 3  
Permanently 
discontinue 
1. Withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating physician.   
NOTE:  
For participants with Grade 3 or 4 immune-related endocrinopathy where withhold of pembrolizumab is required, 
pembrolizumab may be resumed when AE resolves to ≤ Grade 2 and is controlled with hormonal replacement therapy or 
achieved metabolic control (in case of T1DM).  
 
Table 4.2 Pembrolizumab dose delay for non-immunologically mediated adverse events 
ALL OTHER 
EVENTS* 
Management/Next Dose for Pembrolizumab 
≤ Grade 1
No change in dose
Grade 2 
Hold until ≤ Grade 1 OR baseline (exceptions as noted below); Evaluate 
and continue at investigator discretion
Grade 3
Stop pembrolizumab (exceptions as noted below)
Grade 4
Stop pembrolizumab
*Not Pembrolizumab related, or pembrolizumab related non-immunologically mediated 
Recommended management:  As clinically indicated 
 
 Any grade 2 drug-related uveitis or eye pain or blurred vision that does not respond to 
topical therapy and does not improve to Grade 1 severity within the re-treatment period 
OR requires systemic treatment should result in protocol treatment discontinuation.   
 Any adverse event, laboratory abnormality, or intercurrent illness which, in the judgment 
of the investigator, presents a substantial clinical risk to the participant with continued 
study drug dosing should result in protocol treatment discontinuation.  
 Tumor pain or associated tumor flare does not require permanent discontinuation.  
 Participants with any grade < 2 laboratory abnormality may continue study treatment at 
the discretion of the investigator. Any grade 3 or 4 drug-related laboratory abnormality 
or electrolyte abnormality, that can be managed independently from underlying organ 
pathology with electrolyte replacement, hormone replacement, insulin, or that does not 
require treatment does not require discontinuation.  
 Expected hematologic AEs which are related to eribulin will be managed per eribulin 
dose modification tables and do not require delay of pembrolizumab, see section 6.1 
Table 4.3 Pembrolizumab dose delay for skin rash and oral lesions 
Skin Rash and Oral 
Lesions 
Management/Next Dose for Pembrolizumab 
≤ Grade 1 
No change in dose; * evaluate and continue at investigator discretion 
Grade 2 
Hold* until ≤ Grade 1 or resolved. Evaluate and continue at investigator 
discretion


53 
 
 
Grade 3 
Hold* until ≤ Grade 1; Evaluate and resume at investigator discretion at 
same dose level
Grade 4 
 Stop pembrolizumab. 
*Participants with purpuric or bullous lesions must be evaluated for vasculitis, Steven-Johnson 
syndrome, TEN, and autoimmune bullous disease including oral lesions of bullous 
pemphigus/pemphigoid. Pruritus may occur with or without skin rash and should be treated 
symptomatically if there is no associated liver or GI toxicity. Note skin rash typically occurs 
early and may be followed by additional events particularly during steroids tapering.
 
Table 4.4 Pembrolizumab dose delay for pancreatitis 
Pancreatitis 
Amylase/Lipase 
Management/Next Dose for Pembrolizumab 
≤ Grade 1 
Continue treatment at same level at investigator discretion.  
Grade 2 
Continue treatment at same level at investigator discretion if 
asymptomatic. 
Grade 3 
Hold until Grade< 2. Resume at same dose level if asymptomatic. 
Participants who develop symptomatic pancreatitis or DM should  stop 
pembrolizumab. . 
Grade 4 
Hold until Grade< 2. Resume at same dose level if asymptomatic. 
Participants who develop symptomatic pancreatitis or DM should stop 
pembrolizumab. . 
Participants may develop symptomatic and radiologic evidence of pancreatitis as well as DM 
and DKA. Lipase elevation may occur during the period of steroid withdrawal and with other 
immune mediated events or associated with colitis, hepatitis, and participants who have 
asymptomatic lipase elevation typically have self-limited course and may be retreated.  
For treatment management of symptomatic pancreatitis please follow the Hepatic Adverse 
Event Management Algorithm.
 
Table 4.5 Pembrolizumab dose delay for nausea and vomiting 
Other GI Nausea, 
Vomiting 
Management/Next Dose for Pembrolizumab 
≤ Grade 1
No change in dose.   
Grade 2 
Hold pending evaluation for gastritis duodenitis and other immune 
adverse events or other causes. Resume at investigator discretion. 
Grade 3 
Hold pending evaluation until ≤ Grade 2. Resume at same dose level. If 
symptoms do not resolve within 7 days with symptomatic treatment 
participants should stop pembrolizumab. 
Grade 4 
 Stop pembrolizumab 
Participants with grade 2 or 3 N-V should be evaluated for upper GI inflammation and other 
immune related events. 


54 
 
 
Table 4.6 Pembrolizumab dose delay for fatigue 
Fatigue 
Management/Next Dose for Pembrolizumab
≤ Grade 1 
No change in dose.   
Grade 2
No change in dose.   
Grade 3 
Hold until ≤ Grade 2. Resume at same dose level at investigator 
discretion. 
Grade 4 
 Stop pembrolizumab  
Fatigue is the most common adverse event associated with immune checkpoint therapy. Grade 
2 or greater fatigue should be evaluated for associated or underlying organ involvement 
including pituitary, thyroid, and hepatic, or muscle (CPK) inflammation 
 
Table 4.7 Pembrolizumab dose delay for neurological events 
Neurologic events* 
Management/Next Dose for Pembrolizumab 
≤ Grade 1 
Hold dose pending evaluation and observation. Resume with no change 
in dose when resolved to baseline at investigator discretion 
Grade 2 
Hold dose pending evaluation and observation. Hold until ≤ Grade 1. 
Stop pembrolizumab if treatment with steroids is required. Resume at 
same dose level for peripheral isolated n. VII (Bell’s palsy) 
Grade 3 
 Stop pembrolizumab 
Grade 4
 Stop Pembrolizumab 
*Participants with any CNS events including aseptic meningitis, encephalitis, symptomatic 
hypophysitis, or myopathy, peripheral demyelinating neuropathy, cranial neuropathy (other 
than peripheral n. VII), GB syndrome, myasthenia gravis should be off study. 
 
 
 
 
 
 
 
 
 
 


55 
 
 
Table 4.8 Pembrolizumab dose delay for infusion reactions 
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 participant is deemed 
medically stable in the opinion of the 
investigator.
None 
Grade 2 
Requires therapy or 
infusion interruption but 
responds promptly to 
symptomatic treatment 
(e.g., antihistamines, 
NSAIDs, narcotics, IV 
fluids); prophylactic 
medications indicated for 
≤24 hrs 
Stop Infusion. 
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 participant is deemed 
medically stable in the opinion of the 
investigator. 
If symptoms resolve within 1 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 participant 
should be premedicated for the next scheduled 
dose. 
Participants who develop Grade 2 toxicity 
despite adequate premedication should be 
permanently discontinued from further study 
drug treatment 
Participant may be premedicated 
1.5h (± 30 minutes) prior to 
infusion of _____ with: 
Diphenhydramine 50 mg po (or 
equivalent dose of 
antihistamine). 
Acetaminophen 500-1000 mg po 
(or equivalent dose of 
analgesic). 
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: 
Epinephrine** 
IV fluids 
Antihistamines 
NSAIDs 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Increase monitoring of vital signs as medically 
indicated until the participant is deemed 
medically stable in the opinion of the 
investigator. 
Hospitalization may be indicated. 
**In cases of anaphylaxis, epinephrine should be 
used immediately. 
Participant is permanently discontinued from 
further study drug treatment. 
No subsequent dosing 
Appropriate resuscitation equipment should be available at the bedside and a physician readily available during the period of 
drug administration. 
For further information, please refer to the Common Terminology Criteria for Adverse Events v5.0 (CTCAE) at 
http://ctep.cancer.gov 


56 
 
 
 
Table 4.9 Pembrolizumab dose delay for fever 
Fever 
Management/Next Dose for Pembrolizumab
≤ Grade 1 
Evaluate and continue at same dose level  
Grade 2
Continue at investigator discretion  
Grade 3 
Hold until ≤ Grade 1. Resume at same dose level at investigator 
discretion. 
Grade 4 
 Stop pembrolizumab 
Participants with fever should be evaluated as clinically appropriate. Participants may 
experience isolated fever during infusion reactions or up to several days after infusion. 
Evaluation over the course of 1-2 weeks should be done for other autoimmune events that may 
present as fever 
See section 5.10: Treatment of Pembrolizumab Infusion reactions
 
If treatment is delayed >8 weeks for an adverse event, the participant must be permanently 
discontinued from study therapy.  
Participants requiring high dose steroid treatment for autoimmune or inflammatory events should 
be managed as described in section 5.9, except for a short course of tapering steroids for infusion 
reaction, skin rash, or endocrine events.  
Participants with grade 3 thyroiditis and skin rash may continue therapy as for grade 2 events 
with resolution and stable replacement treatment.  
Participants with thyroiditis or hypopituitarism who are stable as above may be restarted with 
replacement hormones including thyroid hormone and physiologic doses of corticosteroids. 
Please note that grade for hypophysitis with symptoms of headache, visual, or neurologic 
changes or radiologic evidence of pituitary enlargement and other CNS events such as aseptic 
meningitis or encephalitis should be considered grade 3 events.  
Any participant who requires additional immune suppressive treatment beyond steroids should 
stop pembrolizumab.  
Participants requiring > two dose delays, other than for evaluation for the same event, should 
stop pembrolizumab. Participants may be dose-delayed for evaluation and restarted depending on 
results.  
Prior to starting corticosteroids or hormone replacement for any reason, appropriate endocrine 
testing including cortisol, ACTH, TSH and T4 must be obtained to document baseline.  
Please note that in some cases the treatment algorithms recommend steroids if symptoms do not 
resolve in 7 days. However, this recommendation is not meant to delay steroid treatment at any 
time it is clinically indicated.  


57 
 
 
Any participant started on corticosteroids initially who is determined to not require steroids 
treatment for an autoimmune adverse event may resume therapy after a 2-week observation 
period without further symptoms at the discretion of the PI or investigator.  
 ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of reported and/or potential AEs (Section 7.1) and the characteristics of an 
observed AE (Section 7.2) will determine whether the event requires expedited reporting in 
addition to routine reporting. 
 
7.1 
Expected Toxicities 
 
7.1.1 Adverse Events Lists 
 
7.1.1.1 
Adverse Event Lists for Pembrolizumab 
 
In the pembrolizumab monotherapy trials (P001/P002, P012, P013, and P028, plus 
the P011 monotherapy arm), the overall incidence of AEs ranged from 83.0% (73 of 
88 participants in P012) to 100% (10 of 10 participants in P011). Not all the adverse 
events in the following list are all-inclusive and refer to the Pembrolizumab 
investigator brochure for a complete list.48 The most commonly reported AEs 
included fatigue, diarrhea, decreased appetite, nausea, and anemia. The incidence of 
drug-related AEs (DRAEs) ranged from 39.8% (35 of 88 participants in P013) to 
80.0% (8 of 10 participants in P011). The most commonly reported DRAEs across all 
studies were nausea, fatigue, and diarrhea. The incidence of Grade 3-5 DRAEs across 
studies ranged from 6.8% (6 of 88 in P013) to 12.0% (187 of 1562 participants) in 
P001/P002. The most commonly reported Grade 3-5 DRAEs were anemia, alanine 
aminotransferase increased, and aspartate aminotransferase increased. Most 
participants who experienced an AE continued in the study, with the incidence of AEs 
leading to discontinuation ranging from 1.9% (8 of 430 participants in P028) to 
12.3% (192 of 1562 participants in P001/P002). The majority of AEs leading to 
discontinuation were not considered drug-related. Discontinuations due to a DRAE 
were infrequent and ranged from 0% (no participants in P011) to 4.5% (4 of 88 
participants in P013). The most commonly reported DRAEs leading to 
discontinuation were pneumonitis, alanine aminotransferase increased, and aspartate 
aminotransferase increased. 
  
List of AEs considered expected: 
  
 Endocrine disorders: Adrenal insufficiency, Hyperthyroidism, Hypophysitis, 
Hypopituitarism, Hypothyroidism, Secondary adrenal insufficiency, Thyroid 
disorder  
 Eye disorders: Uveitis  
 Gastrointestinal disorders: Abdominal pain, Colitis, Diarrhea, Pancreatitis  
 General disorders and administration site conditions: Asthenia, Pyrexia  


58 
 
 
 Hepatobiliary disorders: Autoimmune hepatitis, Hepatitis  
 Infusion related reaction  
 Metabolism and nutrition disorders: Diabetic ketoacidosis, Hyponatremia, 
Type 1 diabetes mellitus  
 Musculoskeletal and connective tissue disorders: Arthralgia, Back pain, 
Myositis  
 Nervous system disorders: Guillain-Barré syndrome  
 Renal and urinary disorders: Nephritis  
 Respiratory, thoracic and mediastinal disorders: Cough, Pneumonitis  
 Skin and subcutaneous tissue disorders: Pruritus, Rash, Severe skin reaction, 
Vitiligo  
 
7.1.1.2 
Adverse Event Lists for Eribulin 
 
Not all the adverse events in the following list are all-inclusive and refer to the 
Eribulin investigator brochure for a complete list.64 Most AEs on studies with eribulin  
are grade 1 or 2. Peripheral neuropathy was an important AE leading to 
discontinuation of therapy. The most common adverse reactions (≥25%) reported in 
participants receiving eribulin on the eribulin versus dacarbazine phase II trial in soft 
tissue sarcomas were fatigue, nausea, alopecia, constipation, peripheral neuropathy, 
abdominal pain, and pyrexia. The most common (≥5%) grade 3 to 4 laboratory 
abnormalities reported in participants receiving eribulin were neutropenia, 
hypokalemia, and hypocalcemia. The most common serious adverse reactions 
reported in participants receiving eribulin were neutropenia (4.9%) and pyrexia 
(4.5%). The most common adverse reactions resulting in discontinuation of eribulin 
were fatigue and thrombocytopenia. 26% of participants required at least one dose 
reduction. The most frequent adverse reactions that led to dose reduction were 
neutropenia (18%) and peripheral neuropathy (4%). 
The most frequently reported eribulin -related AEs were: 
 Asthenia/fatigue (all grade 62%) 
 Alopecia (all grades 35%) 
 Urinary Tract Infection (all grades 11%, grade 3 to 4 2.2%) 
 Neutropenia (all grades 63%, grade 3 to 4 32%) 
 Nausea (all grade 41%) 
 Anemia(all grades 70%, grade 3 to 4 4.1%) 
 Pyrexia(all grades 28%, grade 3 to 4 0.9%) 
 Leucopenia 
 Anorexia(all grade 19%) 
 Constipation(all grades 32%, grade 3 to 4 0.9%) 
 Abdominal Pain (all grades 29%, grade 3 to 4 1.8%) 
 Stomatitis (all grades 14%, grade 3 to 4 0.9%) 
 Vomiting(all grade 19%) 
 Diarrhea (all grade 17%) 


59 
 
 
 Headache (all grades 18%, grade 3 to 4 0%) 
 Peripheral Edema (all grade 12%) 
 Cough (all grade 18%) 
 Back Pain (all grade 16%) 
 Arthralgia/Myalgia (all grade 16%) 
 Peripheral neuropathy (all grades 29%, grade 3 to 4 3.1%) 
 Increased ALT (all grades 43%, grade 3 to 2.3%) 
 Increased AST (all grades 36%, grade 3 to 4 0.9%) 
 Hypokalemia (all grades 30%, grade 3 to 4 5.4%) 
 Hypocalcemia (all grades 28%, grade 3 to 4 5.0%) 
 Hypophosphatemia (all grades 20%, grade 3 to 4 3.2%) 
Less common adverse reactions (≥5% to < 10%) included thrombocytopenia, 
increased lacrimation, dyspepsia, hyperglycemia, muscle spasms, musculoskeletal 
pain, dizziness, dysgeusia, insomnia, anxiety, hypotension, and oropharyngeal pain.  
 
7.2 
Adverse Event Characteristics 
 
 CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
5.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 5.0.  A copy of the CTCAE version 5.0 can be 
downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
 For expedited reporting purposes, only:   
- 
AEs for the agent(s) that are listed above should be reported only if the adverse event 
varies in nature, intensity or frequency from the expected toxicity information which 
is provided. 
- 
Other AEs for the protocol that do not require expedited reporting are outlined in the 
next section (Expedited Adverse Event Reporting) under the sub-heading of Protocol-
Specific Expedited Adverse Event Reporting Exclusions. 
 
 Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
 
 
 
 
 


60 
 
 
7.3 
Expedited Adverse Event Reporting  
 
7.3.1 In the event of an unanticipated problem or life-threatening complications treating 
investigators must immediately notify the Overall PI. 
 
7.3.2 Investigators must report to the Overall PI any serious adverse event (SAE) that occurs 
after the initial dose of study treatment, during treatment, or within 30 days of the last 
dose of treatment on the local institutional SAE form.  
 
7.3.3 DF/HCC Expedited Reporting Guidelines 
 
Investigative sites within DF/HCC will report AEs directly to the DFCI Office for 
Human Research Studies (OHRS) per the DFCI IRB reporting policy.  
 
 
Table. 5 DF/HCC Reportable AEs 
 
 
 
Attribution 
DF/HCC Reportable AEs
Gr. 2 & 3 AE 
Expected 
Gr. 2 & 3 AE 
Unexpected 
Gr. 4 AE Expected
Gr. 4 AE 
Unexpected 
Gr. 5 AE 
Expected or 
Unexpected
Unrelated 
Unlikely 
Not required 
Not required 
5 calendar days# 
5 calendar days 
24 hours* 
Possible 
Probable 
Definite 
 
Not required 
 
5 calendar days 
 
5 calendar days# 
 
5 calendar days 
 
24 hours* 
# If listed in protocol as expected and not requiring expedited reporting, event does not need to be reported. 
 
* For participants enrolled and actively participating in the study or for AEs occurring within 30 days of the last 
intervention, the AE should be reported within 1 business day of learning of the event. 
 
 
 
7.3.4 Protocol-Specific Expedited Adverse Event Reporting Exclusions 
 
No expedited adverse event reporting exclusions. 
 
7.4 
Expedited Reporting to the Food and Drug Administration (FDA) 
 
The Overall PI, as study sponsor, will be responsible for all communications with the FDA. The 
Overall PI will report to the FDA, regardless of the site of occurrence, any serious adverse event 
that meets the FDA’s criteria for expedited reporting following the reporting requirements and 
timelines set by the FDA. 
 
7.5 
Expedited Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any participant 
safety reports or sentinel events that require reporting according to institutional policy.  
 


61 
 
 
7.6 
Expedited Reporting to MERCK 
 
A serious adverse event (SAE) is any adverse event occurring at any dose or during any use of 
Merck’s product that:  
 
 Results in death;  
 Is life threatening;  
 Results in persistent or significant disability/incapacity;  
 Results in or prolongs an existing inpatient hospitalization;  
 Is a congenital anomaly/birth defect;  
 Is a new cancer (that is not a condition of the study);  
 Is associated with an overdose;  
 Is another important medical event  
  
Any serious adverse event, or follow up to a serious adverse event, including death due to any 
cause other than progression of the cancer under study that occurs to any participant from the 
time the consent is signed through 90 days following cessation of treatment, or the initiation of 
new anti-cancer therapy, whichever is earlier, whether or not related to Merck product, must be 
reported within 24 hours to the Sponsor and within 2 working days to Merck Global Safety.  
 
Non-serious Events of Clinical Interest will be forwarded to Merck Global Safety and will be 
handled in the same manner as SAEs.  
 
Additionally, any serious adverse event, considered by an investigator who is a qualified 
physician to be related to Merck product that is brought to the attention of the investigator at any 
time outside of the time period specified in the previous paragraph also must be reported 
immediately to Merck.  
 
SAE reports and any other relevant safety information are to be forwarded to the Merck 
Global Safety.  
  
A copy of all 15 Day Reports and Annual Progress Reports is submitted as required by FDA, 
European Union (EU), Pharmaceutical and Medical Devices agency (PMDA) or other local 
regulators. Investigators will cross reference this submission according to local regulations to the 
Merck Investigational Compound Number (IND, CSA, etc.) at the time of submission. 
Additionally, investigators will submit a copy of these reports to Merck & Co., Inc. at the time of 
submission to FDA.  
 
All participants with serious adverse events must be followed up for outcome.  
7.6.1 Events of Clinical Interest (ECIs) 
 
Selected non-serious and serious adverse events are also known as Events of Clinical 
Interest (ECI) and must be reported within 24 hours to the Sponsor and within 2 working 
days to Merck Global Safety.  


62 
 
 
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 participant 
must be reported within 24 hours to the Sponsor and within 2 working days to Merck 
Global Safety if it causes the participant 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 
participant initiates new anticancer therapy, whichever is earlier, any ECI, or follow up to 
an ECI, whether or not related to Merck product, must be reported within 24 hours to the 
Sponsor and within 24 hours to Merck Global Safety.  
Events of clinical interest for this trial include:  
1. Overdose of Merck product, as defined in Section 7.6.2 - Definition of an Overdose for 
This Protocol and Reporting of Overdose to the Sponsor, that is not associated 
with clinical symptoms or abnormal laboratory results.  
2. An elevated AST or ALT lab value that is greater than or equal to 3X the upper limit of 
normal and an elevated total bilirubin lab value that is greater than or equal to 2X 
the upper limit of normal and, at the same time, an alkaline phosphatase lab value 
that is less than 2X the upper limit of normal, as determined by way of protocol-
specified laboratory testing or unscheduled laboratory testing. *  
*Note: These criteria are based upon available regulatory guidance documents. The 
purpose of the criteria is to specify a threshold of abnormal hepatic tests that may require 
an additional evaluation for an underlying etiology.  
7.6.2 Definition of an Overdose of Pembrolizumab for This Protocol and Reporting of 
Overdose to Merck 
 
For purposes of this trial, an overdose of pembrolizumab will be defined as any dose of 
1,000 mg or greater. No specific information is available on the treatment of overdose of 
pembrolizumab. Appropriate supportive treatment should be provided if clinically 
indicated. In the event of overdose, the participant should be observed closely for signs of 
toxicity.  
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.”  


63 
 
 
All reports of overdose with and without an adverse event must be reported within 24 
hours to the Sponsor and within 2 working days’ hours to Merck Global Safety. 
7.6.3 Reporting of Pregnancy and Lactation to Merck 
 
Although pregnancy and lactation are not considered adverse events, it is the 
responsibility of investigators or their designees to report any pregnancy or lactation in a 
participant (spontaneously reported to them) that occurs during the trial.  
Pregnancies and lactations that occur after the consent form is signed but before 
treatment allocation/randomization must be reported by the investigator if they cause the 
participant to be excluded from the trial, or are the result of a protocol-specified 
intervention, including but not limited to washout or discontinuation of usual therapy, 
diet, placebo treatment or a procedure.  
Pregnancies and lactations that occur from the time of treatment allocation/randomization 
through 120 days following cessation of Sponsor’s product, or 30 days following 
cessation of treatment if the participant initiates new anticancer therapy, whichever is 
earlier, must be reported by the investigator. All reported pregnancies must be followed 
to the completion/termination of the pregnancy. Pregnancy outcomes of spontaneous 
abortion, missed abortion, benign hydatidiform mole, blighted ovum, fetal death, 
intrauterine death, miscarriage and stillbirth must be reported as serious events (Important 
Medical Events). If the pregnancy continues to term, the outcome (health of infant) must 
also be reported.  
Such events must be reported within 24 hours to the Sponsor and within 2 working days 
to Merck Global Safety. 
7.7 
Expedited Reporting to Eisai 
 
SAEs where the Overall PI considers a relationship to the eribulin therapy to be at least a 
reasonable possibility, will be reported to EISAI on a Medwatch 3500A form within one 
business day of the notification of the event. Serious adverse events (SAEs) that are not related 
to eribulin therapy and non-serious AEs will be provided to Eisai in the final study report and 
any interim reports provided.  
A serious adverse event is any adverse event occurring at any dose or during any use of Eisai’s 
product that:  
 
 Results in death;  
 Is life threatening;  
 Results in persistent or significant disability/incapacity;  
 Results in or prolongs an existing inpatient hospitalization;  
 Is a congenital anomaly/birth defect;  
 Is a new cancer (that is not a condition of the study);  
 Is associated with an overdose;  
 Is another important medical event  


64 
 
 
  
Any serious adverse event, or follow up to a serious adverse event, including death due to any 
cause other than progression of the cancer under study that occurs to any participant from the 
time the consent is signed through 90 days following cessation of treatment, or the initiation of 
new anti-cancer therapy, whichever is earlier, whether or not related to Eisai’s product, must be 
reported within 24 hours to the Sponsor.  
 
Additionally, any serious adverse event, considered by an investigator who is a qualified 
physician to be related to Eisai product that is brought to the attention of the investigator at any 
time outside of the time period specified in the previous paragraph also must be reported 
immediately to Eisai.  
 
Events not considered to be serious adverse events are hospitalizations for:  
 Routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition, or for elective procedures  
 Elective or pre-planned treatment for a pre-existing condition that did not worsen  
 Emergency outpatient treatment for an event not fulfilling the serious criteria outlined 
above and not resulting in inpatient admission  
 Respite care  
 
The reports will be sent on MedWatch 3500A form to EISAI  
 
7.8 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions to the Overall PI on the 
toxicity case report forms.  AEs reported through expedited processes (e.g., reported to the 
IRB, FDA, etc.) must also be reported in routine study data submissions. 
 
 PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational or other agents 
administered in this study can be found in Section 7.1. 
 
8.1 
Pembrolizumab 
 
8.1.1 Description 
 
Classification: Anti-PD-1Mab, Pembrolizumab is a humanized monoclonal antibody of 
the IgG4/kappa isotype.  
 
Other names: MK-3475, Keytruda.  
 
Amino Acid Sequence: 4 polypeptide chains, which include 2 identical heavy chains and 
2 identical light chains. 
 


65 
 
 
Mode of Action: Pembrolizumab targets the programmed death–1 (PD-1, cluster of 
differentiation 279 [CD279]) cell surface membrane receptor. PD-1 is a negative 
regulatory receptor expressed by activated T and B lymphocytes. Binding of PD-1 to its 
ligands, programmed death–ligand 1 (PD-L1) and 2 (PD-L2), results in the down-
regulation of lymphocyte activation. Pembrolizumab inhibits the binding of PD-1 to PD-
L1 and PD-L2. Inhibition of the interaction between PD-1 and its ligands promotes 
immune responses and antigen-specific T-cell responses to both foreign antigens as well 
as self-antigens. 
 
The molecular weight of Pembrolizumab is 148.9-149.5 KDa. 
 
The pharmacokinetics (PK) of pembrolizumab was characterized using a population PK 
analysis with concentration data collected from 2841 participants with various cancers 
who received pembrolizumab doses of 1 to 10 mg/kg every 2 weeks or 2 to 10 mg/kg 
every 3 weeks. Pembrolizumab clearance (CV%) is approximately 21% lower [geometric 
mean, 196 mL/day (41%)] at steady state than that after the first dose [249 mL/day 
(38%)]; this decrease in clearance with time is not considered clinically important. The 
geometric mean value (CV%) for volume of distribution at steady state is 6.0 L (21%) 
and for terminal half-life (t1/2) is 22 days (32%). 
 
Steady-state concentrations of pembrolizumab were reached by 16 weeks of repeated 
dosing with an every 3-week regimen and the systemic accumulation was 2.2-fold. The 
peak concentration (Cmax), trough concentration (Cmin), and area under the plasma 
concentration versus time curve at steady state (AUCs) of pembrolizumab increased dose 
proportionally in the dose range of 2 to 10 mg/kg every 3 weeks. 
 
8.1.2 Form 
 
Clinical supplies will be manufactured and provided by Merck as summarized below. 
 
Product Name & Potency Dosage Form 
Pembrolizumab 100 mg/ 4mL (25mg/ml concentration) Solution for Injection in single-
dose vials. Pembrolizumab for injection is a sterile, preservative-free, clear to slightly 
opalescent, colorless to slightly yellow solution that requires dilution for intravenous 
infusion. Each vial contains 100 mg of pembrolizumab in 4 mL of solution. Each 1 mL of 
solution contains 25 mg of pembrolizumab and is formulated in: L-histidine 
(1.55 mg), polysorbate 80 (0.2 mg), sucrose (70 mg), and Water for Injection, USP. 
 
8.1.3 Storage and Stability 
 
Store intact vials between 2°C-8°C (36°F-46°F). Do not freeze. Protect from light by 
storing in the original box. 
 
Stability testing of the intact vials is ongoing. 
 
Administer prepared solutions immediately after preparation. If not administered 


66 
 
 
immediately, prepared solutions may be stored refrigerated for up to 24 hours. 
PEMBROLIZUMAB solutions may be stored at room temperature for a cumulative time 
of up to 6 hours. This includes room temperature storage of liquid drug product solution 
in vials, room temperature storage of infusion solution in the IV bag, and the duration of 
infusion. 
 
8.1.4 Compatibility 
 
Compatible IV bag materials: PVC plasticized with DEHP, non-PVC (polyolefin), EVA, 
or PE lined polyolefin. 
 
8.1.5 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.1.6 Availability 
 
Pembrolizumab is FDA approved and will be supplied free of charge from 
Merck. 
 
8.1.7 Preparation 
 
Pembrolizumab solution for infusion must be diluted prior to administration. Allow the 
required number of vials to equilibrate to room temperature. Do not shake the vials. Do 
not use if opaque or extraneous particulate matter other than translucent to white 
proteinaceous particles are observed. Do not use if discolored. To prepare the infusion 
solution add the dose volume of Pembrolizumab to an infusion bag containing 0.9% 
Sodium Chloride Injection, USP of 5% Dextrose Injection, USP. Gently invert the bag 
10-15 times to mix the solution. The final concentration must be between 1 mg/mL to 
10 mg/mL. Discard any unused portion left in the vial. 
 
8.1.8 Administration 
 
Pembrolizumab is FDA approved and will be administer per Institutional Standard 
administration guidelines. 
 
8.1.9 Ordering 
 
Pembrolizumab will be obtained directly from Merck. 
 
8.1.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, should maintain a 
careful record of the inventory and disposition of the agent using the NCI Drug 


67 
 
 
Accountability Record Form (DARF) or another comparable drug accountability form.  
(See the NCI Investigator’s Handbook for Procedures for Drug Accountability and 
Storage.) 
 
8.1.11 Destruction and Return 
 
At the end of the study, unused or expired supplies of Pembrolizumab should be 
destroyed according to institutional policies. Destruction will be documented in the Drug 
Accountability Record Form. 
 
8.2 
Eribulin 
 
8.2.1 Description 
 
Classification: Microtubule inhibitor 
 
Other names: Halaven, E7389, ER-086526, US NCI designation NSC-707389  
 
Chemical Name: The chemical name for eribulin mesylate is 
(2R,3R,3aS,7R,8aS,9S,10aR,11S,12R,13aR,13bS,15S,18S,21S,24S,26R,28R 
,29aS)-2-[(2S)-3-Amino-2-hydroxypropyl]-3-methoxy-26-methyl-20,27- 
dimethylidenehexacosahydro-11,15:18,21:24,28-triepoxy-7,9-ethano- 
12,15-methano-9H,15H-furo[3,2-i]furo[2',3':5,6]pyrano[4,3- 
b][1,4]dioxacyclopentacosin-5(4H)-one methanesulfonate (salt) 
 
 
Chemical Structure: 
 
 
 
Mode of Action: Eribulin is a fully synthetic macrocyclic ketone analogue of the marine 
natural product of halichondrin B, from the Halichondria genus of sponges, specifically 
Halichondria okadai. Eribulin inhibits the growth phase of microtubules without 
affecting the shortening phase and sequesters tubulin into nonproductive aggregates, by 
binding to a small number of high affinity sites at the plus ends of existing microtubules. 


68 
 
 
Eribulin exerts its effects via a tubulin-based antimitotic mechanism leading to G2/M 
cell-cycle block, disruption of mitotic spindles, and, ultimately, apoptotic cell death after 
prolonged mitotic blockage. Eribulin has both cytotoxic and non-cytotoxic mechanisms 
of action. Eribulin can cause vascular remodeling that leads to increase tumor perfusion, 
and phenotypic changes consistent with the reversal of the epithelial-mesenchymal 
transition.  
 
Description: 
The molecular weight of Eribulin is 826.00 KDa. 
The molecular formula of Eribulin is C41H63NO14S (C40H59NO11*CH4O3S) 
 
Eribulin is a white powder. Eribulin is freely soluble in water, methanol, ethanol. Eribulin 
drug product is as a clear, colorless, sterile solution, packaged in a glass vial, for 
intravenous administration. 
 
The pharmacokinetics (PK) of eribulin is linear with a mean elimination half-life of 
approximately 40 hours, a mean volume of distribution of 43 L/m2 to 114 L/m2 and 
mean clearance of 1.16 L/hr/m2 to 2.42 L/hr/m2 over the dose range of 0.25 mg/m2 to 
4.0 mg/m2. The human plasma protein binding of eribulin at concentrations of 100 
ng/mL to 1,000 ng/mL ranges from 49% to 65%. Eribulin exposure after multiple dosing 
is comparable to that following a single dose. No accumulation of eribulin is observed 
with weekly administration. 
 
Elimination 
 
Metabolism 
Unchanged eribulin was the major circulating species in plasma following administration 
of 14C-eribulin to participants. Metabolite concentrations represented <0.6% of parent 
compound, confirming that there are no major human metabolites of eribulin. 
Cytochrome P450 3A4 (CYP3A4) negligibly metabolizes eribulin in vitro. 
 
Excretion 
Eribulin is eliminated primarily in feces unchanged. After administration of 14C-eribulin 
to participants, approximately 82% of the dose was eliminated in feces and 9% in urine. 
Unchanged eribulin accounted for approximately 88% and 91% of total eribulin in feces 
and urine, respectively. 
 
Drug Interaction Studies 
 
Effect of Strong Inhibitors or Inducers of CYP3A4 on Eribulin: The effect of a strong 
CYP3A4 inhibitor and a P-gp inhibitor, ketoconazole, on the PK of eribulin was studied 
in a crossover trial of 12 participants with advanced solid tumors. No clinically relevant 
PK interaction was observed when eribulin was administered with or without 
ketoconazole (the geometric mean ratio of the AUC: 0.97; 90% CI: 0.83, 1.12). 
 


69 
 
 
The effect of a CYP3A4 inducer, rifampin, on the PK of eribulin was studied in a 
crossover trial of 14 participants with advanced solid tumors. No clinically relevant PK 
interaction was observed when eribulin was administered with or without rifampin (the 
geometric mean ratio of the AUC: 1.10; 90 CI%: 0.91, 1.34). 
 
Effect of Eribulin on CYP Substrates: Eribulin shows no induction potential for CYP1A, 
CYP2B6, CYP2C9, CYP2C19, and CYP3A in primary human hepatocytes. Eribulin 
inhibits CYP3A4 activity in human liver microsomes, but it is unlikely that eribulin will 
substantially increase the plasma levels of CYP3A4 substrates. No significant inhibition 
of CYP1A2, CYP2C9, CYP2C19, CYP2D6, or CYP2E1 was detected with eribulin 
concentrations up to 5 μM in pooled human liver microsomes. In vitro drug interaction 
studies indicate that eribulin does not inhibit drugs that are substrates of these enzymes 
and it is unlikely that eribulin will affect plasma levels of drugs that are substrates of 
CYP enzymes. 
 
Effect of Transporters on Eribulin: In vitro data suggest that eribulin at clinically relevant 
concentrations is a substrate of P-gp, but is not a substrate of breast cancer resistance 
protein (BCRP), multidrug resistance proteins (MRP2, MRP4), bile salt extrusion pump 
(BSEP), organic anion transporting polypeptides (OATP1B1, OATP1B3), organic anion 
transporters (OAT1, OAT3), organic cation transporters (OCT1, OCT2), or multidrug 
and toxin extrusion 1 (MATE1). 
Effect of Eribulin on Transporters: In vitro data suggest that eribulin at clinically relevant 
concentrations may inhibit P-gp, but does not inhibit BCRP, OATP1B1, OCT1, OAT1, 
OAT3, or MATE1. 
 
8.2.2 Form 
 
Clinical supplies will be manufactured and provided by Eisai as summarized below. 
 
Product Name & Potency Dosage Form 
Eribulin 0.5mg/ml solution in ethanol: water (5:95). 
 
Eribulin is a sterile, ready-to-use, clear, colorless aqueous solution for i.v. 
administration. 
 
Eribulin for i.v. injection will be supplied on an open-label basis by the sponsor in single-
use vials. Each single-use vial contains 1 mg/2 mL (0.5mg/ml concentration) of clear, 
colorless solution. Each single-use vial of eribulin is primarily packaged in a 5 mL 
nominal volume United States Pharmacopeia (USP) Type 1 Flint glass, stoppered with a 
FluroTec® plug stopper and sealed with an aluminum seal and a flip-off cap. Six labeled 
vials of eribulin are packaged in a labeled carton. Each of the 6 eribulin vials within a 
given labeled carton may be assigned individually to 6 different participants or to the 
same participant, as required by the study site or as clinical supply inventory demands. 
Three to four vials of Eribulin will be required per participant for each dose on the study 
protocol. Exact dose determined by participant body-surface-area calculation. 
 


70 
 
 
8.2.3 Storage and Stability 
 
Eribulin must be stored in accordance with labeled storage conditions. Intact and 
unopened vials must be stored at ambient room temperature 25ºC. Do NOT refrigerate 
or freeze. Shelf-life surveillance of the intact vials is ongoing. The 0.5 mg/mL solution 
has been shown to be stable in syringes at ambient temperature and ambient lighting for 
up to 4 hours, or under refrigeration for up to 24 hours. The drug is also stable at 
concentrations ranging from 0.005 ng/mL to 0.2 mg/mL when diluted in normal saline 
(0.9% sodium chloride [NaCl]) and kept refrigerated in syringes or i.v. bags for up to 48 
hours at ambient temperature and ambient lighting, or under refrigeration. It is not 
compatible with solutions with dextrose. Photostability studies have demonstrated that 
protection from light is not necessary for the eribulin drug product. 
 
Product vials that are opened and refrigerated between 2°C to 8°C (36°F – 46°F) must be 
used within 24 hours of being opened, and the remaining drug solution discarded. 
Temperature monitoring for eribulin is required at the storage location to ensure that the 
study drug is maintained within an established temperature range. The investigator is 
responsible for ensuring that the temperature is monitored throughout the total duration of 
the trial and that records are maintained; the temperature should be monitored 
continuously by using either an in-house validated data acquisition system, a mechanical 
recording device such as a calibrated chart recorder, or by manual means, such that 
minimum and maximum thermometric values over a specific time period can be recorded 
and retrieved as required. 
 
8.2.4 Compatibility 
 
Eribulin is not compatible with solutions with dextrose. Infused after Pembrolizumab. 
 
8.2.5 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.2.6 Availability 
 
Eribulin (Halaven) is FDA approved, and will be supplied free of charge from 
Eisai. 
 
8.2.7 Preparation 
 
Dosing is 1.4mg/m2. Each single-use vial contains 1 mg/2 mL of Eribulin. Eribulin may 
be diluted in 100ml of normal saline.  
 
 


71 
 
 
8.2.8 Administration 
 
Eribulin is FDA approved and will be administer per Institutional Standard 
administration guidelines. 
 
8.2.9 Ordering 
 
Eribulin will be obtained directly from Eisai. 
 
8.2.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, should maintain a 
careful record of the inventory and disposition of the agent using the NCI Drug 
Accountability Record Form (DARF) or another comparable drug accountability form.  
(See the NCI Investigator’s Handbook for Procedures for Drug Accountability and 
Storage.) 
 
8.2.11 Destruction and Return 
 
At the end of the study, unused or expired supplies of Eribulin should be destroyed 
according to institutional policies. Destruction will be documented in the Drug 
Accountability Record Form. 
 
 
 BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
All participants will be asked to provide archival tumor tissue (either paraffin blocks or 20 
unstained slides, ideally 4 micron thickness) if available. If no archival tumor tissue is 
available, a new tumor biopsy may be performed if feasible. The feasibility of the biopsy 
procedure, in terms of patient safety and tumor accessibility, will be determined by the 
Investigator.  An optional pre-treatment biopsy for fresh tumor tissue may be collected. 
Biopsies will be encouraged but are optional. Plan to perform optional pre-treatment biopsy 
for fresh tumor tissue in approximately 10 participants in each cohort (10 LPS, 10 LMS, 10 
UPS), for a total of 30 participant biopsies. Archival tissue and fresh frozen tissue will be 
used for immune profiling assays to ascertain baseline values in participants treated with 
eribulin and pembrolizumab. Additionally, specimens we will be banked for planned 
correlative studies. Fresh tumor tissue obtained will be allocated as below: 
 
 1 to 2 adequate cores fixed and paraffin embedded for immunohistochemial analysis 
 1 core adequate core fixed and paraffin embedded for targeted genomic analysis via 
DFCI Oncopanel 
 1 core adequate core fresh frozen tissue for RNA sequencing analysis 
 
Serial blood draws for correlative science are required on this trial as well; blood draws will 
be obtained prior to the first administration of study drug on Cycle 1 Day 1, then Cycle 1 
Day 8, Cycle 2 Day 1, and Cycle 3 Day 1, and at the end-of-treatment visit in participants 


72 
 
 
who go off-study for progressive disease. All efforts will be made to obtain a sample at the 
time of progressive disease from participants who went off-study for anything other than 
progressive disease.  
 
A stool sample will be obtained during the study screening period for evaluation of the 
tumor microbiome. 
  
An optional research tumor biopsy at the time of progression will be collected for 
participants who consent and have biopsy accessible tumor. These biopsies will undergo the 
same characterization testing as described for baseline biopsies.  
 
9.1 
Summary table: Research tissue and blood specimen collection 
 
Table 6. Research Tissue and Blood Specimen Collection 
Research Sampling
Time Point
Contents
Blood
Cycle 1 Day 1 (pre-treatment)
5- purple top tubes (EDTA), total 30ml
Cycle 1 Day 8
3- purple top tubes (EDTA), total 15 ml
Cycle 2 day 1
3- purple top tubes (EDTA), total 15 ml
Cycle 3 day 1
3- purple top tubes (EDTA), total 15 ml
Off-Treatment (if off for PD)
3- purple top tubes (EDTA), total 15 ml
 
At PD (for participants who go 
off-treatment for a reason other 
than PD)
3- purple top tubes (EDTA), total 15 ml 
Stool Sample
Pre-treatment
1 Stool sample
Fresh Tissue
Optional pre-treatment biopsy
3 to 4 adequate cores
 
Optional post-treatment biopsy 
for participants with PD
3 to 4 adequate cores 
Archival Tissue 
Anytime  
1 block, or 20, 4 micron unstained 
slides
 
 
9.2 
Biomarker Studies 
 
9.2.1 Immunohistochemical Staining for PD-L1 (CD274), PD-L2 (CD273), and PD-1 (CD279) 
 
We hypothesize that CD274, CD273 and CD279 protein expression in tumor tissues 
might be associated with favorable clinical response to immune checkpoint inhibition, 
and might serve as biomarkers for participant selection for CD279 blockade in clinical 
treatment. PDL1 assessment will be considered an integrated biomarker for this study 
because PDL1 assessment by this method has been used across multiple studies 
evaluating pembrolizumab and therefore will support standardization, reproducibility, 
and comparison across studies. Additional staining for PDL1 by the antibody method 
noted below will occur in parallel for exploratory comparison of these two techniques. 
 
 
 
 


73 
 
 
9.2.1.1 
Collection of Tissue Specimens 
 
Participant and specimen information 
Immunohistochemical (IHC) staining of CD274 will be used as an integrated 
biomarker in this clinical trial, and to identify a group of participants most likely to 
respond to the immune checkpoint inhibition with eribulin and pembrolizumab. This 
information may be used in the future phase II trials as a stratification variable. IHC 
staining of CD273, CD279 will also be performed as exploratory biomarkers to 
explore a possible relationship between expression and response to eribulin and 
pembrolizumab in this population. Pre-treatment archival tumor material or fresh 
tumor biopsy should be collected for all eligible participants. In addition, because 
expression of these markers may change over time, immediate pre-treatment tumor 
biopsies will be paired with the optional post-treatment tumor biopsies when possible. 
Collection and handling of biopsy specimens 
At the site of origin (prior to shipment to BWH), 2 to 3 adequate cores, and any 
additional tissue will be fixed in 4% buffered formalin overnight at room temperature, 
to adequately preserve tissue morphology. Of note, one core will be saved as fresh 
frozen tissue for RNA sequencing analysis. Additionally, a 2nd core will be used for 
DFCI Oncopanel, targeted gene-expression profiling, per standard DFCI Oncopanel 
procedure. Then, the tissue will be transferred in 70% ethanol at room temperature for 
at least 48 hours. After fixation, the tissue will be processed, using an automated 
tissue processor following standard protocols within histology laboratories.  To 
summarize this procedure, the tissue will be exposed to increasing concentration of 
ethanol (80%, 96% and 100%) and then to xylene for at least 2 hours. The tissue will 
be then infiltrated several times in hot paraffin and afterwards will be embedded in 
paraffin. Tissue section of 4-5 microns will be cut using a microtome and placed on 
"plus" (charged) glass slides amenable to IHC, and at 4C.  A minimum of 15 
unstained slides for BWH analysis will be generated per case.  Batched cases (slides) 
will then be via overnight mail to BWH for further studies. Four-micrometer-thick 
sections will be cut. The paraffin blocks and unstained slides will be stored at room 
temperature. All IHC staining will be performed in the Center for Immuno-Oncology 
Pathology Core at Dana-Farber/Harvard Cancer Center. 
Pre-treatment research tumor core biopsies are optional, and time of progression 
research core biopsies of an accessible lesion are optional. Guidelines for biopsy from 
various metastatic sites can be found in Appendix D. Biopsies should not be 
performed on Friday afternoons, as there may not be time for processing of the fresh 
tissue.  
 
 
 
 


74 
 
 
9.2.1.2 
Site Preforming Correlative Studies 
 
Laboratory information  
The DF/HCC Specialized Histopathology Core will be a central research laboratory 
for this clinical trial. The IHC and immunofluorescent staining, including the Cell 
Signaling PD-L1 40.59All mouse ab, 29122S, will be conducted at the DFCI Center 
for Immuno-Oncology, Immune Assessment Laboratory, by Dr. Evisa Gjini, PhD, 
and Dr. Scott Rodig, MD, PhD. Peripheral blood analysis for cytokines and flow 
cytometry, as well as tumor microbiome, will be conducted by Mariano Severgnini, 
PhD at the DFCI Center for Immuno-Oncology, Immune Assessment Laboratory.  
Targeted genomic profiling will be conducted utilizing the standard DFCI Oncopanel. 
RNA sequencing will be performed under the direction of Dr. Matthew Hemming, 
MD, PhD. 
9.3 
Tumor Tissue Exploratory/Ancillary Correlative Studies 
 
All of the below-mentioned analyses may be altered based on novel developments in the field of 
cancer immune profiling at the time of correlative science. Additional markers or alternative 
technologies (based on scientific developments and/or novel technologies) may also be used, to 
explore potential prognostic or predictive candidate markers/panels or markers related to 
treatment benefit and/or safety, to improve diagnostic tests, or to understand sarcoma biology.  
 Tumor Infiltrating Lymphocytes and Tumor Infiltrating Macrophages and Myeloid 
derived suppressors cells.  
 
Paraffinized, hematoxylin and eosin-stained slides taken from two tissue planes will be 
derived from each biopsy and will be reviewed by certified pathologists. The extent of 
lymphocytic infiltrate in tumor tissue will be assessed, and stromal TIL percentage will 
be determined. Subsets of TIL will be determined, CD3+, CD4+, CD8+, FOXP3, too 
evaluate T regulatory cells. The percentages of tumor infiltrating macrophages will be 
determined as well, particularly in leiomyosarcoma participants. The percentages of 
tumor infiltrating myeloid derived suppressors cells will be determined as well. More 
detailed guidelines for the quantification of stromal TILs in sarcoma can be found in the 
recommendations from the International TILs Working Group 2014. 
 
 Additional Immunohistochemistry will be performed for potential markers of immune 
response, such as IDO, and MHC class I expression.  
 
 Targeted gene-expression profiling will be conducted using Oncopanel to evaluate 
specific mutations, mutation burden, MMR signature, and copy number variations as 
potential markers of immune response. One core biopsy sample from each participant 
biopsy may be paraffin embedded and saved for this analysis. 
 
 RNA sequencing, as an exploratory biomarker, will be performed as well on available 
fresh frozen tumor samples. One core biopsy sample from each participant biopsy, fresh 
frozen, will be saved for this analysis. 


75 
 
 
 
9.4 
Microbiome Exploratory Correlative Studies 
 
Each participant will provide one stool sample, pre-treatment, obtained during screening. 
Participants should be instructed to collect the stool sample once eligibility has been confirmed. 
This will be proceeded and analyzed by the DFCI Center for Immuno-Oncology, Immune 
Assessment Laboratory, under the direction of Mariano Severgnini, PhD. The purpose of which 
is to evaluate participant’s microbiome as a possible predictive marker for immunotherapy 
treatment.  
 
9.5 
Laboratory Exploratory Correlative Studies 
 
9.5.1 Monitoring Peripheral Blood for Changes in Immune Function 
 
9.5.1.1 
Collection of Specimens 
 
Serial blood/serum samples will be collected Cycle 1 Day 1 (pre-treatment), on-
treatment (Cycle 1 Day 8, Cycle 2 Day 1, Cycle 3 Day 1), and off-treatment. 
Peripheral blood will be collected as whole blood and separated into plasma and 
buffy coat for circulating tumor DNA analysis, cytokine analysis and for generation 
of PBMCs. 
A panel of cytokines and chemokines will be tested in serum using Luminex cytokine 
assay. Changes in cytokine production in immune cell subsets as a function of 
treatment will be determined by ELISA and intracellular cytokine staining. Absolute 
lymphocyte count (ALC) will be monitored. Research blood collection is mandatory 
for all participants for flow cytometry and DNA isolation. The samples will be 
banked in the DF/HCC Clinical Trials Core Laboratory for these and for optional 
future research purposes. These specimens will become the property of the DF/HCC. 
Blood draws should not be performed on Friday afternoons, as there may not be time 
for processing of the blood.  
Peripheral blood mononuclear cells (PBMCs) will be collected from whole blood to 
assess immune cell populations. Surface staining with a panel of antibodies (CD3, 
CD4, CD8, CD25, FoxP3, CD11c, CD83, CD86, CD56) and intracytoplasmic 
cytokine staining, followed by flow cytometry will be performed in order to identify 
different T cell populations, their activation status, and the production of different 
cytokines as well as other immune cell populations as described below. Whole blood 
collection protocol, plasma and buffy coat collection protocol, and PBMCs collection 
protocols below: 
Once collected in K2EDTA tubes, peripheral blood should be placed at 4 degrees 
Celsius until processing. Buffy coat/plasma isolation should be performed within 4 
hours of peripheral blood collection to ensure optimal results for circulating cell free 
DNA analyses. Samples may be stored at 4 degrees Celsius up to 24hrs prior to 
processing. 


76 
 
 
Whole Blood Processing 
Normal DNA can be obtained through whole blood. A venous blood draw of 10 
milliliters of blood is sufficient. Blood should be drawn into a K2EDTA lavender top 
tube and gently rocked back and forth to mix the blood and the preservatives. Do not 
spin blood tube and do not freeze the blood tube at -80 degrees Celsius or through 
flash freezing.  For long term storage samples may be stored at 4 degrees Celsius for 
less than 1 month. Samples that are to be stored for more than 1 month should be 
frozen at -20 degrees Celsius first and then transferred to a -80 degrees Celsius 
freezer.  Do not place the tubes in Styrofoam holders for freezing.   
Blood collection tube should be labeled with a unique identifier and date and time of 
blood draw.  Tube should be wrapped in an absorbent paper towel and placed within a 
biohazard bag. Tube should be packed in a foam container delivered overnight at 4 
degrees Celsius.   
 
Plasma and buffy coat isolation from peripheral blood processed within 24 hours 
from collection 
 
Normal DNA and circulating cell free tumor DNA can be obtained through whole 
blood. A venous blood draw of 20 milliliters of blood is sufficient. Blood should be 
drawn into a K2EDTA lavender top tube and gently rocked back and forth to mix the 
blood and the preservatives.   
 
Once collected in K2EDTA tubes, peripheral blood should be placed at 4 degrees 
Celsius until processing. Buffy coat/plasma isolation should be performed within 4 
hours of peripheral blood collection to ensure optimal results for circulating cell free 
DNA analyses. Samples may be stored at 4 degrees Celsius up to 24hrs prior to 
processing.     
 
1. Use a minimum of 20cc of peripheral blood.  
2. Centrifuge at 800 rcf at 4 degrees Celsius for 10 min.  
3. Aspirate supernatant and transfer to new 5ml tubes.  
4. Collect the buffy coat (extract from the middle whitish layer by going slightly 
under the layer with the tip) and aliquot in 0.5-1ml pellets in labeled 1.5ml tubes. 
5. Centrifuge the supernatant at 18000 rcf for 10 min at room temperature.  
6. Collect the top layer of plasma into 5ml cryo tubes  
7. Store the plasma samples into -80°C 
 
For shipment, plasma samples should be packed in cryoboxes within a foam container 
and shipped overnight on dry ice.  
 
Plasma and buffy coat isolation from peripheral blood processed within 5 days 
from collection.  
 
In case blood samples cannot be processed locally as per protocol above, blood samples 
should be collected in Streck tubes and shipped to DFCI Center for Immuno-Oncology 


77 
 
 
at room temperature within 5 days from collection (up to 3 days is preferred).  
 
1. If a butterfly is used for venipuncture, an EDTA (or non-additive) tube should be 
connected first to eliminate air from the tubing before the Streck tube is connected. 
2. Collect 20cc of whole blood in 2 10cc Streck tubes.  
3. Immediately mix collected blood by gentle inversion 8 to 10 times.  
4. Local transportation, storage and subsequent shipping of Streck tube samples should 
be performed at room temperature within 5 days from collection.    
 
Protocol for Generation of PBMC’s 
 
1. Pour blood from green-cap, or purple tubes (heparin or EDTA treated tubes) into two 
50 ml conical tubes (Corning, 430290). 
2. Spin tubes at 1500 rpm for 10 min (Sorvall Legend XTR centrifuge). 
3. Aspirate 2 ml plasma/tube and aliquot into 4 tubes mircocentrifuge tubes 
(Fisherbrand, 05-408-138)  
4. Spin plasma at 3000 RPM for 5 minutes (Sorvall Legend Micro 21R centrifuge) 
5. Aspirate plasma into Cryogenic tubes 2 ml plasma/ tube (Corning, 430488). 
6. Dilute blood 1:1 with PBS. (Blood amount should not exceed 25 ml per tube.) 
7. Take 2 new 50 ml conical tubes and add 12 ml ficoll-paque (Cat# 17144003; GE 
Healthcare) per tube. 
8. Slowly and gently layer the diluted blood on top of the ficoll-paque of the tube with a 
maximum volume of 35 ml. 
9. Centrifuge the tube at 1900 rpm for 20 min at room temperature with slow 
acceleration (#7) and deceleration (#7) (Sorvall Legend XTR centrifuge). 
10. Remove the PBMC layer from between the upper layer (diluted plasma) and middle 
layer (ficoll-paque) and transfer into a 50 ml conical tube. The lower layer is 
composed of red blood cells. 
11. Completely fill conical tube containing isolated PBMC with PBS, mixing well. 
12. Count viable cells by mixing 10 µl Trypan Blue with 10µl PBMC/PBS dilution in a 
microcentrifuge tube. Load 10 µl of mixture onto Countess Cell Counting Chamber 
Slide (Invitrogen, C10283) and read with Countess Automated Cell Counter 
(Invitrogen).  
13. Centrifuge the tubes containing PBMC/PBS mixture at 1500 rpm for 5 min at room 
temperature (Sorvall Legend XTR centrifuge).  
14. Remove PBS, and resuspend PBMC pellet in appropriate amount of freezing solution 
so that there are approx 5 × 106 cells/cryo vial in 300-500 µl of Fetal Bovine Serum 
(heat inactivated) plus 15% DMSO.    
15. Put vials in CoolCell container (Biocision Inc.) and transfer to -80C freezer overnight.  
16. Transfer cells to liquid nitrogen tank. 
 
Serum marker levels will be summarized descriptively and graphically for the 
participant population. The time course of expression levels will also be summarized 
graphically by participant, noting times of disease response and disease progression.  
 


78 
 
 
9.5.1.2 
Handling of Specimens 
 
All samples should be de-identified and labeled with the Participant initials, 
Participant Study ID number and date of collection and time point (e.g., “Baseline” or 
“Cycle 1” or “Progressive Disease”). Must be processed within 3-4hrs of its being 
drawn.  
 
9.5.1.3 
Shipping of Specimens 
 
  
 
 
 
9.5.1.4 
Site Performing Correlative Study 
 
 
DFCI Center for Immuno-Oncology  
 
DFCI Clinical Trials Core Laboratory  
9.5.1.5 
Blood and tissue banking 
 
If the participant agrees, any leftover blood or tissue may be banked in the lab of 
Mariano Severgnini or the DF/HCC Clinical Trials Core Laboratory, respectively, as 
per standard lab protocol, such that it can be used for additional or future analyses as 
needed.  
 STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 2 weeks (14 days) prior to start of protocol 
therapy.  Baseline assessments include: hematology panel, serum chemistry/LFT panel, 
pregnancy test, EKG, thyroid studies, performance status, HIV, Hep B, C testing, physical 
examination, medical history, concurrent medications evaluations, vital signs, demographics, 
weight, and height. Scans and x-rays should be done <2 weeks prior to the start of therapy.  CBC 
and serum chemistries must be obtained on Cycle 1 Day 1to determine safety of study drug 
administration as per section 5.2.1.. In the event that the participant’s condition is deteriorating, 
laboratory evaluations should be repeated within 48 hours prior to initiation of the next cycle of 
therapy. 
 
Assessments must be performed prior to administration of any study agent. Study assessments 
and agents should be administered within +  3 days of the protocol-specified date, unless 
otherwise noted. Please reference section 6.1 table 2 for window restrictions due to eribulin 
dosing.  
 
 


79 
 
 
Table 7. Study Calendar 
 
Pre- 
Study 
Cycle 1 
Cycle 2 
Cycle 3 
Cycle 4 and beyondj 
Off 
Treatmentc 
Day 
1 
Day 
8 
Day 
15 
Day 
1 
Day 
8 
Day 
15 
Day 
1 
Day 
8 
Day 
15 
Day 
1 
Day 
8 
Day 
15 
Eribulin
A
A
A
A
A
A
A
A
Pembrolizumab
B
B
B
B
Informed consent
X
Demographics
X
Medical history
X
Concurrent meds
Xf 
Xe---------------------------------------------------------------------------------------------Xe 
Physical exam
Xf 
Xe 
Xe
Xe
Xe
Xe
Xe
Xe
Xe
X
Vital signs
Xf 
Xe
Xe
Xe
Xe
Xe
Xe
Xe
Xe
X
Height
Xf 
Weight
Xf 
Xe
Xe
Xe
Xe
Xe
Xe
Xe
Xe
X
Performance status
Xf 
X
X
X
X
X
X
X
X
X
CBC w/diff, plts
Xf 
Xe
Xe
Xe
Xe
Xe
Xe
Xe
Xe
X
Serum chemistrya
Xf 
Xe
Xe
Xe
Xe
Xe
Xe
Xe
Xe
X
Thyroid studiesd
X
Xd 
EKGp
X
X
X
X
X
X
X
X
X
Adverse event evaluationi 
X---------------------------------------------------------------------------------------------X
X
Tumor measurements 
Xh 
Tumor measurements are repeated every 2 cycles +/- 3 days.  Documentation 
(radiologic) must be provided for participants removed from study for progressive 
disease.
X 
Radiologic evaluation
Xh 
Radiologic measurements should be performed every 2 cycles +/- 3 days.
X
Serum pregnancy (B-HCG) 
testb 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
HIV, Hep C, B Screenn 
X
Tumor Biopsy
Xk 
Xl 
Correlative blood biomarker 
studiesm 
 
X 
X 
 
X 
 
 
X 
 
 
 
 
 
X 
Stool sample for microbiome
Xo
A: 
Eribulin initial dosing 1.4mg/m2 Day 1 and 8 of each 21-day cycle 
 
B: 
Pembrolizumab dosing 200mg, Day 1 of each 21-day cycle  
 
a: 
Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, magnesium, 
potassium, total protein, SGOT [AST], SGPT [ALT], sodium, lipase, amylase. 
 
b: 
Serum pregnancy test in women of childbearing potential. 
 
c:      Off-treatment evaluation. Participants will return to clinic within 4 weeks after progression, for end of study visit and for AE related 
assessment.  
         Immune AE assessment will be performed at ~100 days following last dose of study drug. This may be done by phone. Participants who  
         complete all planned protocol therapy will continue to be monitored for tumor measurements beyond completion of treatment until  
         disease progression or the initiation of a new anticancer therapy. Scans will be performed as standard of care approximately every 2  
         months or 8 weeks. Participants will be followed for survival with telephone calls approximately every 3 months from off treatment visit. 
For participants who come off study for reasons other than progression, or completion of all planned protocol therapy, they will be monitored 
with standard of care scans until progression or the initiation of a new anticancer therapy. 


80 
 
 
NOTE:  With Protocol Version 15MAY2024, further long-term follow-up is being terminated. 
 
d:      TSH, free T4, obtained during study screening, then Cycle 3 Day 1, and then every 6-8 weeks thereafter. 
 
e:      Assessments done prior to drug administration within 48 hours. 
 
f:       Repeat screening tests if >2 weeks of 14 days from Cycle 1 Day 1. 
 
h:      Initial imaging CT or MRI Tumor measurements should be within 2 weeks from Cycle 1 Day 1. 
 
i:       Including specific focus on immune-related adverse events. 
 
j:       Schedule post Cycle 4 will repeat as per Cycles 1 -4, with the exception of pre/post tumor biopsy and correlative studies. Participants will 
         continue to receive the study treatment each cycle (Day 1, Day 8) until progression or discontinuation with physical exam and  
         laboratory evaluation prior to each drug administration, and repeat imaging (same as baseline) every 6 weeks/2 cycles for up to two years 
         of treatment, or 35 cycles. For participants beyond Cycle 8, repeat imaging may be obtained every 12 weeks/4 cycles. If patients stop         
eribulin for treatment related effects and are continuing pembrolizumab alone, day 8 assessments will not be required. 
 
k:    If archival tissue is available, collect approximately 20 slides as described in section 9. If archival tissue is not available, a biopsy may be 
collected if determined feasible by the Investigator. The biopsy would be collected after eligibility is confirmed and prior to first dose of 
pembrolizumab.   
 
l:      Optional Tumor Biopsy on progression for correlative biomarker assay’s. 
 
m:    Peripheral blood will be drawn prior to the first administration of study drug on Cycle 1 Day 1, Cycle 1 Day 8, Cycle 2 Day 1, Cycle 3   
        Day 1,  and at off-treatment, to assess changes in immune function as per section 9.2.  
 
n:      Testing for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS), hepatitis B virus surface    
         antigen (HBV sAg) and hepatitis C virus ribonucleic acid (HCV antibody) indicating acute or chronic infection. These tests do not need 
to be re-drawn if a participant has to re-screen. 
 
o:     Participants should be instructed to collect a stool sample once they are deemed eligible.   
 
p:     EKG’s should be collected pre-dose and do not need to be collected if dose is missed/held. 
 
 
 


81 
 
 
 MEASUREMENT OF EFFECT 
 
11.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, participants should be re-evaluated for response every 6 weeks 
(+/- 3 days).  In addition to a baseline scan, confirmatory scans should also be obtained at 6 
weeks (+/- 3 days) following initial documentation of objective response. For participants who 
are beyond Cycle 8, restaging scans may be obtained at 12 week intervals (+/- 3 days).  
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 
1.1)1.  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. 
 
All participants who receive at least one dose of eribulin and pembrolizumab will be included in 
the toxicity analysis. This includes participants who receive study drug and are ultimately 
deemed ineligible to measure response.  
 
Pembrolizumab, like other immunotherapeutic agents, may produce antitumor effects by 
inducing or potentiating the endogenous cancer-specific immune response. The response to 
treatment with immunotherapy may differ from traditional cytotoxic agents. Reponses may be 
seen after the typical time course predicted with cytotoxic agents. Additionally, responses may 
be seen after initial tumor increase in size or burden or even the appearance of new lesions. To 
account for these potential response patterns, imaging data will be collected to potentially 
evaluate for response by irRECIST, in addition to standard RECIST 1.1 assessments. On prior 
sarcoma immunotherapy trials, such as SARC028, there has not been a significant difference 
between responses per RECIST 1.1 or irRECIST. Comparison of RECIST 1.1 and irRECIST on 
this trial may help to clarify if immune response patterns are seen in sarcoma participant’s 
receiving immunotherapy. Clinical decision-making regarding progressive disease and trial 
discontinuation will still utilize RECIST 1.1. 
 
For any participant who showed first radiologic evidence of progressive disease (PD) by 
RECIST 1.1 and is deemed clinically stable, it is at the discretion of the investigator to 
continue treating the participant until progression is confirmed at the next scheduled restaging 
(or with a confirmatory completed at least 4 weeks from the initial date of PD). If progression is 
not confirmed on the subsequent scan, the participant should continue to receive treatment and 
have radiographic scans performed according to the study calendar (every 6 weeks). If radiologic 
progression is confirmed, then the participant should be discontinued from all study treatment. If 
the treating investigator feels that the participant is clinically stable, demonstrates improved 
condition, or is clearly continuing to benefit from the treatment; the PI may approve the 
participant to continue to receive study treatment. In all participants, the date of progression will 
be documented as the first date progression was observed. 
 
11.1.1 Definitions 
 
Evaluable for Target Disease response.  Only those participants who have measurable 


82 
 
 
disease present at baseline, have received at least one cycle of therapy, and have had their 
disease re-evaluated will be considered evaluable for target disease response.  These 
participants will have their response classified according to the definitions stated below.  
(Note:  Participants who exhibit objective disease progression prior to the end of cycle 1 
will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Participants who have lesions present at 
baseline that are evaluable but do not meet the definitions of measurable disease, have 
received at least one cycle of therapy, and have had their disease re-evaluated will be 
considered evaluable for non-target disease.  The response assessment is based on the 
presence, absence, or unequivocal progression of the lesions.  
 
Evaluable for toxicity. All participants will be evaluable for toxicity from the time of 
their first treatment with eribulin and pembrolizumab. 
 
11.1.2 Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as ≥ 20 mm by 
chest x-ray or ≥10 mm with CT scan, MRI, or calipers by clinical exam.  All tumor 
measurements must be recorded in millimeters (or decimal fractions of centimeters). 
 
Note: Tumor lesions that are situated in a previously irradiated area will not be 
considered measurable, unless there is clear evidence of progression of the lesion since 
completion of radiation and prior to enrollment on study. 
 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a 
lymph node must be ≥15 mm (≥1.5cm) in short axis when assessed by CT scan (CT scan 
slice thickness recommended to be no greater than 5 mm(0.5cm).  At baseline and in 
follow-up, only the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions 
(longest diameter <10 mm (<1.0 cm) or pathological lymph nodes with ≥10 to <15 mm 
(≥1.0 cm to <1.5 cm) short axis), are considered non-measurable disease.  Bone lesions, 
leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis 
cutis/pneumonitis, inflammatory breast disease, abdominal masses (not followed by CT 
or MRI), and cystic lesions are all considered non-measurable. 
 
Note: Cystic lesions that meet the criteria for radiographically defined simple cysts 
should not be considered as malignant lesions (neither measurable nor non-measurable) 
since they are, by definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable 
lesions, if they meet the definition of measurability described above. However, if non-
cystic lesions are present in the same participant, these are preferred for selection as 
target lesions. 


83 
 
 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 
lesions in total, representative of all involved organs, should be identified as target 
lesions and recorded and measured at baseline.  Target lesions should be selected on the 
basis of their size (lesions with the longest diameter), be representative of all involved 
organs, but in addition should be those that lend themselves to reproducible repeated 
measurements. It may be the case that, on occasion, the largest lesion does not lend itself 
to reproducible measurement in which circumstance the next largest lesion which can be 
measured reproducibly should be selected. A sum of the diameters (longest for non-nodal 
lesions, short axis for nodal lesions) for all target lesions will be calculated and reported 
as the baseline sum diameters. If lymph nodes are to be included in the sum, then only the 
short axis is added into the sum. The baseline sum diameters will be used as reference to 
further characterize any objective tumor regression in the measurable dimension of the 
disease.  
 
Non-target lesions.  All other lesions (or sites of disease) including any measurable 
lesions over and above the 5 target lesions should be identified as non-target lesions and 
should also be recorded at baseline. Measurements of these lesions are not required, but 
the presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow up.  
 
11.1.3 Methods for Evaluation of Disease 
 
All measurements should be taken and recorded in metric notation using a ruler, calipers, 
or a digital measurement tool.  All baseline evaluations should be performed as closely as 
possible to the beginning of treatment and never more than 4 weeks before the beginning 
of the treatment. 
 
The same method of assessment and the same technique should be used to characterize 
each identified and reported lesion at baseline and during follow-up. Imaging-based 
evaluation is preferred to evaluation by clinical examination unless the lesion(s) being 
followed cannot be imaged but are assessable by clinical exam.  
 
Clinical lesions. Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and ≥10 mm (≥1.0cm) in 
diameter as assessed using calipers (e.g., skin nodules).  In the case of skin lesions, 
documentation by color photography, including a ruler to estimate the size of the lesion, 
is recommended.  
 
Conventional CT and MRI are the preferred imaging modalities on this study. 
 
Chest x-ray.  Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung; however, CT is preferable.  
 
Conventional CT and MRI. This guideline has defined measurability of lesions on CT 
scan based on the assumption that CT thickness is 5mm or less. If CT scans have slice 


84 
 
 
thickness greater than 5 mm, the minimum size of a measurable lesion should be twice 
the slice thickness. MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which 
greatly impact image quality, lesion conspicuity, and measurement.  Furthermore, the 
availability of MRI is variable globally.  As with CT, if an MRI is performed, the 
technical specifications of the scanning sequences used should be optimized for the 
evaluation of the type and site of disease.  Furthermore, as with CT, the modality used at 
follow-up should be the same as was used at baseline and the lesions should be 
measured/assessed on the same pulse sequence.  It is beyond the scope of the RECIST 
guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases.  Ideally, the same type of scanner should be used and the image 
acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
 
11.1.4 Response Criteria 
 
11.1.4.1 
Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm (<1.0 cm). 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of 
target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study).  In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm.  (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. 
 
11.1.4.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization 
of tumor marker level.  All lymph nodes must be non-pathological in size (<10 mm 
(<1.0cm) short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a participant to be considered in complete clinical response. 


85 
 
 
 
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 PI). 
 
11.1.4.3 
Evaluation of New Lesions 
 
The finding of a new lesion should be unequivocal (i.e. not due to difference in 
scanning technique, imaging modality, or findings thought to represent something 
other than tumor (for example, some ‘new’ bone lesions may be simply healing or 
flare of pre-existing lesions). However, a lesion identified on a follow-up scan in an 
anatomical location that was not scanned at baseline is considered new and will 
indicate PD. If a new lesion is equivocal (because of small size etc.), follow-up 
evaluation will clarify if it truly represents new disease and if PD is confirmed, 
progression should be declared using the date of the initial scan on which the lesion 
was discovered. 
 
11.1.4.4 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The participant's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria. 
 
For Participants with Measurable Disease (i.e., Target Disease) 
 
Table 8.1 RECIST Target Lesions 
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-
No
SD
Documented at least once >4 


86 
 
 
PD/not 
evaluated
wks from baseline** 
PD
Any
Yes or No
PD
no prior SD, PR or CR 
Any
PD***
Yes or No
PD
Any
Any
Yes
PD
 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
**        Only for non-randomized trials with response as primary endpoint. 
***      In exceptional circumstances, unequivocal progression in non-target lesions may be 
            accepted as disease progression. 
 
Note:  Participants with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.”  Every effort should be made to document the 
objective progression even after discontinuation of treatment.
 
For Participants with Non-Measurable Disease (i.e., Non-Target Disease) 
 
Table 8.2 RECIST Non-Target Lesions 
Non-Target Lesions 
New Lesions 
Overall Response 
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD
 
‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign 
this category when no lesions can be measured is not advised
 
11.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first 
date that recurrent or progressive disease is objectively documented (taking as reference 
for progressive disease the smallest measurements recorded since the treatment started, or 
death due to any cause. Participants without events reported are censored at the last 
disease evaluation). 
 
Duration of overall complete response: The duration of overall CR is measured from the 
time measurement criteria are first met for CR until the first date that progressive disease 
is objectively documented, or death due to any cause. Participants without events 
reported are censored at the last disease evaluation. 
 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment 
until the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started, including the baseline measurements.  
 


87 
 
 
 
11.1.6 Overall Survival, Progression-Free Survival, Time-to-Progression 
 
Overall Survival: Overall Survival (OS) is defined as the time from randomization (or 
registration) to death due to any cause, or censored at date last known alive. 
 
Progression-Free Survival: Progression-Free Survival (PFS) is defined as the time from 
randomization (or registration) to the earlier of progression or death due to any cause. 
Participants alive without disease progression are censored at date of last disease 
evaluation. 
 
Time to Progression: Time to Progression (TTP) is defined as the time from 
randomization (or registration) to progression, or censored at date of last disease 
evaluation for those without progression reported. 
 
11.1.7 Response Review 
 
At study completion, all objective responses (RECIST PR or CR) will be reviewed by the 
tumor imaging metrics core (TIMC) at the Dana-Farber Harvard Cancer Center. 
Participant files will be available to the readers for concurrent review. 
 
 
11.2 
Other Response Parameters: irRECIST 
 
11.2.1 Definition of Tumor Response Using Immune-Related Response Criteria (irRECIST) 
 
The sum of the longest diameter of lesions (SPD) at tumor assessment using the immune 
related response criteria (irRECIST) for progressive disease incorporate the contribution 
of new measurable lesions. Each net Percentage Change in Tumor Burden per 
assessment using irRC criteria accounts for the size and growth kinetics of both old and 
new lesions as they appear. 
 
11.2.1.1 
Impact of New Lesions on irRECIST 
 
New lesions in and of themselves do not qualify as progressive disease. However, 
their contribution to total tumor burden is included in the SPD which in turn feeds 
into the irRECIST criteria for tumor response. Therefore, new non-measurable lesions 
will not discontinue any participant from the study. 
 
11.2.1.2 
Definition of Target Lesions Response Using irRECIST 
 
-irRECIST Complete Response (irRECIST CR): Complete disappearance of all 
target lesions. This category encompasses exactly the same participants as “CR” by 
the WHO criteria. 
 


88 
 
 
-irRECIST Partial Response (irRECIST PR): Decrease, relative to baseline, or 
50% or greater in the sum of the products of the two largest perpendicular diameters 
of all target and all new measurable target lesions (i.e., Percentage Change in Tumor 
Burden). Note: the appearance of new measurable lesions is factored into the overall 
tumor burden, but does not automatically qualify as progressive disease until the SBD 
increases by >25% when compared to SPD at nadir. 
 
-irRECIST Stable Disease (irRECIST SD): Does not meet criteria for irRECIST 
RC or irPR, in the absence of progressive disease. 
 
-irRECIST Progressive Disease (irRECIST PD): At least 25% increase Percentage 
Change in Tumor Burden (i.e. taking SPD of all target lesions and any new lesions) 
when compared to SPD at nadir. 
 
11.2.1.3 
Definition of Non-Target Lesions Response Using irRECIST 
 
-irRECIST Complete Response (irRECIST CR): Complete disappearance of all 
non-target lesions. This category encompasses exactly the same participants as “CR” 
by WHO criteria. 
 
-irRECIST Partial Response (irRECIST PR) or irRECIST Stable Disease 
(irRECIST SD): Non-target lesion(s) are not considered in the definition of PR; 
these terms do not apply. 
 
-irRECIST Progressive Disease (irRECIST PD): Increases in number or size of 
non-target lesion(s) does not constitute progressive disease unless/until the 
Percentage Change in Tumor Burden increases by 25% (i.e. the SPD at nadir of the 
target lesions increases by the required amount). 
 
11.2.1.4 
Definition of Overall Response Using irRECIST 
 
Overall response using irRECIST will be based on these criteria: 
 
-Immune-Related Complete Response (irRECIST CR): Complete disappearance 
of all tumor lesions (target a non-target) together with no new 
measurable/unmeasurable lesions for at least 4 weeks from the date of documentation 
of complete response. 
 
-Immune-Related Partial Response (irRECIST PR): The sum of the products of 
the two largest perpendicular diameters of all target lesions is measured and captured 
as the SPD baseline. At each subsequent tumor assessment, the SPD of the two 
largest perpendicular diameters of all target lesions and of new measurable lesions are 
added together to provide the Immune Response Sum of Product Diameters 
(irRECIST SPD). A decrease, relative to baseline, of the irRECIST SPD compared to 
the previously SPD baseline of 50% or greater is considered an irRECIST PR. 
 


89 
 
 
-Immune-Related Stable Disease (irRECIST SD): irRECIST SD is defined as the 
failure to meet criteria for immune complete response or immune partial response, in 
the absence of progressive disease 
 
-Immune-Related Progressive Disease (irRECIST PD): It is recommended in 
difficult cases to confirm PD by serial imaging. Any of the following will constitute 
PD: 
-At least 25% increase in the SPD of all target lesions over nadir SPD 
calculated for the target lesions. 
 
-At least 25% increase in the SPD of all target lesions and new measurable 
lesions (irRECIST SPD) over the baseline SPD calculated for the target 
lesions. 
 
 
11.2.1.5 
Criteria for determining overall response by irRECIST are summarized as follows: 
 
Immune-Related Best Overall Response Using irRECIST (irRECIST BOR) 
irRECIST BOR is the best confirmed overall response over the study as a whole, 
recorded between the date of first dose until the last tumor assessment before 
subsequent therapy (except for local palliative radiotherapy for painful bone lesions) 
for the individual participant in the study. For the assessment of irBOR, all available 
assessments per participant are considered. irRECIST CR or irRECIST PR 
determinations included in the irRECIST BOR assessment must be confirmed by a 
second (confirmatory) evaluation meeting the criteria for response and performed no 
less than 4 weeks after the criteria for response are first met. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


90 
 
 
 
 
Table 9. irRECIST 
 
 
 DATA REPORTING / REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Data Reporting 
 
12.1.1 Method 
 
The Office of Data Quality (ODQ) will collect, manage, and perform quality checks on 
the data for this study. 
 
12.1.2 Responsibility for Data Submission 
 
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or 
data forms to the Office of Data Quality in accordance with DF/HCC SOPs. 
 
12.2 
Data Safety Monitoring 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity 
and accrual data from this study. The committee is composed of clinical specialists with 
experience in oncology and who have no direct relationship with the study. Information that 
raises any questions about participant safety will be addressed with the Overall PI and study 
team. 
 


91 
 
 
The DSMC will review each protocol up to four times a year or more often if required to review 
toxicity and accrual data. Information to be provided to the committee may include: up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or higher 
unexpected adverse events that have been reported; summary of all deaths occurring with 30 
days of intervention for Phase I or II protocols; for gene therapy protocols, summary of all deaths 
while being treated and during active follow-up; any response information; audit results, and a 
summary provided by the study team. Other information (e.g. scans, laboratory values) will be 
provided upon request.  
 
 STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Endpoints 
 
We have designed a single stage phase II, three-arm study for the primary endpoint of 
progression-free rate at 12 weeks.  Participants will be stratified among three-arms based upon 
participant diagnosis.  Arm A will consist of leiomyosarcoma participants.  Arm B will consist of 
liposarcoma participants.  Arm C will consist of undifferentiated pleomorphic sarcoma/other 
sarcomas.   
 
The primary endpoint is the 12-week progression-free survival. The progression-free survival is 
defined as the absence of disease progression at 12 weeks from study enrollment. Participants 
without stable disease or complete or partial response, with deaths of any cause within 12 weeks, 
with progression within 12 weeks, or without confirmatory scans at 12 weeks’ post baseline 
evaluation will be counted as failures.  We will enroll 19 participants in each arm following a 
single stage approach.   
 
Toxicity is an important secondary endpoint.  With 19 participants in each arm, there is at least 
86% probability of observing one or more toxicities with a true rate as low as 10%.  With 19 
treated participants in each arm, the maximum width of a 90% two-sided confidence interval for 
any estimated adverse event proportion is ± 20%. 
 
Progression-free survival (PFS) and overall survival (OS) of participants receiving combination 
therapy will be described using the method of Kaplan and Meier and 90% confidence intervals 
for PFS and OS will be reported. 
 
NOTE:  With Protocol Version 15MAY2024, further long-term follow-up is being 
terminated. 
 
13.2 
Sample Size, Accrual Rate and Study Duration 
 
Arm A (Leiomyosarcoma) 
We will assess the progression-free rate at 12 weeks (null: 30%, alternative: 60%).  We will need 
to observe at least 9 participants absent of disease progression out of 19 participants to accept the 
treatment.  The overall power for the progression-free rate at 12 weeks is 91% using the exact 
binomial distribution.  The operating characteristics of this design are calculated using a one-
sided exact test with 10% type I error. 


92 
 
 
 
Arm B (Liposarcoma) 
We will assess the progression-free rate at 12 weeks (null: 30%, alternative: 60%).  We will need 
to observe at least 9 participants absent of disease progression out of 19 participants to accept the 
treatment.  The overall power for the progression-free rate at 12 weeks is 91% using the exact 
binomial distribution.  The operating characteristics of this design are calculated using a one-
sided exact test with 10% type I error. 
 
Arm C (Undifferentiated Pleomorphic Sarcoma/Other Sarcomas) 
We will assess the progression-free rate at 12 weeks (null: 30%, alternative: 60%).  We will need 
to observe at least 9 participants absent of disease progression out of 19 participants to accept the 
treatment.  The overall power for the progression-free rate at 12 weeks is 91% using the exact 
binomial distribution.  The operating characteristics of this design are calculated using a one-
sided exact test with 10% type I error. Additionally, response to individual sarcomas histologic 
subtypes will be reported descriptively. 
 
Table 10. Accrual Targets 
Accrual Targets 
Ethnic Category 
Sex/Gender
Females
Males
Total
Hispanic or Latino
1
+
1
=
2
Not Hispanic or Latino
27
+
28
=
55
Ethnic Category: Total of all 
participants 
28 
+
29 
=
57 
Racial Category 
 
American Indian or Alaskan Native
1
+
1
=
2
Asian
1
+
1
=
2
Black or African American
1
+
1
=
2
Native Hawaiian or other Pacific 
Islander
1 
+
1 
=
2 
White
24
+
25
=
49
Racial Category: Total of all 
participants
28 
+
29 
=
57 
 
 
 
13.3 
Stratification Factors 
 
There are no planned stratification factors within each cohort of this study. 
 
13.4 
Interim Monitoring Plan 
 
No planned interim efficacy analysis. This is a single stage study in each of three liposarcoma, 
leiomyosarcoma, and undifferentiated pleomorphic sarcoma cohorts/other sarcomas. 
 


93 
 
 
13.5 
Analysis Plan 
 
Participants’ demographic characteristics including age, gender, and race will be analyzed, with 
categorical variables summarized in frequency tables while continuous variables will be 
summarized using mean (±s.d.) and median (range).  The student t-test/Wilcoxon test and 
ANOVA/Kruskal-Wallis test [Woolson and Clarke, 2000] will be used to compare continuous 
variables between different participant groups.  The chi-square test or the Fisher’s exact test 
[Woolson and Calrke, 2000] will be applied to assess the association between two categorical 
variables. 
 
13.6 
Analysis of Primary Endpoints 
 
For the analysis of the primary endpoint (PFS12 weeks), we will provide respective point estimate 
along with 90% confidence interval for each of the combinations. PFS is defined as the time 
from baseline disease evaluation to either disease progression as defined by RECIST or death 
from any cause, whichever occurs first. For events that have not occurred by the time of data 
analysis, times will be censored at the last contact at which the participant was known to be 
progression-free. Log-rank test (Mantel, 1966) will be performed to test the difference in 
survival between groups. Regression analyses will be conducted of survival data based on the 
Cox proportional hazards model (Cox, 1972). The proportional hazards assumption will be 
evaluated graphically and analytically, and regression diagnostics (e.g., martingale and 
Shoenfeld residuals) will be examined to ensure that the models are appropriate. 
 
13.7 
Analysis of Secondary Endpoints 
 
OS is defined as the time from treatment onset to death. For events that have not occurred by the 
time of data analysis, times will be censored at the last contact at which the participant was 
known to be progression-free for PFS, or the last time the participant was known to be alive for 
OS. PFS and OS will be estimated using the Kaplan-Meier method (Kaplan,1958) and 90% 
confidence intervals for PFS and OS will be reported. Log-rank test (Mantel, 1966) will be 
performed to test the difference in survival between groups. Regression analyses of survival data 
based on the Cox proportional hazards model (Cox, 1972) will be conducted on PFS or OS. The 
proportional hazards assumption will be evaluated graphically and analytically, and regression 
diagnostics (e.g., martingale and Shoenfeld residuals) will be examined to ensure that the models 
are appropriate. 
 
NOTE:  With Protocol Version 15MAY2024, further long-term follow-up is being 
terminated. 
 
13.8 
Analysis of Correlative Biomarkers 
 
Paired pre- and post-treatment biopsies will be obtained when available in consenting 
participants.  We will explore the relationship between integrated biomarkers PDL1/PD1/PD2 
status (PDL1 status, PDL1 in infiltrating lymphocytes, PD2 status in archival tumor) and the 
absence of disease progression to combination treatment eribulin and pembrolizumab. We will 
use Fisher’s Exact Test to assess the relationship between each biomarker and the absence of 


94 
 
 
disease progression to combination treatment. Each is expected to have similar characteristics. 
For example, with this design, assuming tissue is available on 90% of the sample, the probability 
of concluding combination treatment eribulin and pembrolizumab response is related to the 
exploratory biomarker is 82%; given the unknown true response is 65% and 4% in positive 
marker versus negative marker participants, respectively, assuming 45% of the population is 
over-expressed for PDL1. The power to detect the relationship of interest increases as the 
prevalence of the biomarker increases. The operating characteristics of this design are calculated 
using a two-sided exact test with 10% type I error. 
 
13.9 
Reporting and Exclusions 
 
All participants will be evaluable for toxicity from the time of their first treatment with eribulin 
and pembrolizumab. All participants who receive at least one dose of eribulin and 
pembrolizumab will be included in the toxicity analysis. This includes participants who receive 
study drug and are ultimately deemed ineligible.  
 
13.9.1 Evaluation of Toxicity 
 
Toxicity data will be summarized by frequency tables.  For the toxicity endpoint, per-treated 
analysis will be used to include any participant who received the treatment regardless of the 
eligibility nor the duration or dose of the treatment received. Toxicity rate will be estimated with 
95% credible interval.  
 
13.9.2 Evaluation of the Primary Efficacy Endpoint 
 
All analyses will be intent-to-treat analyses. All the analyses will be conducted separately by each 
cohort, leiomyosarcoma, liposarcoma, and undifferentiated pleomorphic sarcoma/other sarcomas.  
 
13.9.3 Evaluation or Response 
 
All eligible participants included in the study must be assessed for response to treatment, even if 
there are major protocol treatment deviations or if they are ineligible. Each participant will be 
assigned one of the following categories: 1) complete response, 2) partial response, 3) stable 
disease, 4) progressive disease, 5) early death from malignant disease, 6) early death from 
toxicity, 7) early death because of other cause, or 9) unknown (not assessable, insufficient data). 
[Note: By arbitrary convention, category 9 usually designates the “unknown” status of any type 
of data in a clinical database.]  All of the participants who met the eligibility criteria (with the 
possible exception of those who received no study medication) should be included in the main 
analysis of the response rate. Participants in response categories 4-9 should be considered to 
have a treatment failure (disease progression). Thus, an incorrect treatment schedule or drug 
administration does not result in exclusion from the analysis of the response rate. Precise 
definitions for categories 4-9 will be protocol specific.  All conclusions should be based on all 
eligible participants. Sub-analyses may then be performed on the basis of a subset of participants, 
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 


95 
 
 
efficacy, and the reasons for excluding participants from the analysis should be clearly reported. 
The 95% confidence intervals should also be provided.  
Statistical References: 
1. Cox DR: Regression models and life tables (with discussion). J. R. Statistical Soc, B 
34:187,220, 1972. 
2. Kaplan EL, Meier P: Nonparametric estimator from incomplete observations. J. 
American Statistical Association 53:457-81, 1958. 
3. Mantel N: Evaluation of survival data and two new rank order statistics arising in its 
consideration. Cancer Chemotherapy Reports 60:163-170, 1966. 
4. Liang, K.Y., Zeger, S.L. Longitudinal data analysis using generalized linear models. 
Biometrika 73:13-22, 1986. 
5. Lee, J.J., Tu, Z.N.: “A versatile one-dimensional distribution plot: the BLiP plot.” The 
American Statistician, 51:353-358, 1997. 
6. Simon R. Optimal two-stage designs for phase II clinical trials. Controlled clinical trials 
1989;10(1):1-10. 
7. Thall PF, Simon RM, Estey EH. New statistical strategy for monitoring safety and 
efficacy in single-arm clinical trials. J Clin Oncol 1996;14(1):296-303. 
8. Wathen JK, Thall PF, Cook JD, Estey EH. Accounting for participant heterogeneity in 
phase II clinical trials. Stat Med. 2008;27(15):2802-15. doi: 10.1002/sim.3109. PubMed 
PMID: 17948869. 
9. Woolson, RF and Calrke, WR. Statistical Methods for the Analysis of Biomedical Data. 
2nd Edition, John Wiley & Sons, New York, 2000. 
 
 PUBLICATION PLAN 
 
The results should be made public within 24 months of reaching the end of the study. The end of 
the study is the time point at which the last data items are to be reported, or after the outcome 
data are sufficiently mature for analysis, as defined in the section on Sample Size, Accrual Rate 
and Study Duration. If a report is planned to be published in a peer-reviewed journal, then that 
initial release may be an abstract that meets the requirements of the International Committee of 
Medical Journal Editors. A full report of the outcomes should be made public no later than three 
(3) years after the end of the study.  
 
 


96 
 
 
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101 
 
 
 APPENDIX A:  PERFORMANCE STATUS CRITERIA 
 
Table 11. Performance Status 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade
Descriptions
Percent
Description
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease.
90 
Able to carry on normal activity; 
minor signs or symptoms of disease.
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work.
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs.
50 
Requires considerable assistance and 
frequent medical care.
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance.
30 
Severely disabled, hospitalization 
indicated.  Death not imminent.
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent.
10 
Moribund, fatal processes 
progressing rapidly.
5
Dead.
0
Dead.
 
 
 
 
 
 
 
 
 
 
 


102 
 
 
 APPENDIX B:  MANAGEMENT ALGORITHMS FOR ENDOCRINOPATHY, 
GASTROINTESTINAL, HEPATIC, NEUROLOGICAL, PULMONARY, RENAL, 
AND SKIN ADVERSE EVENTS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


103 
 
 
 


104 
 
 
 
 
 
 


105 
 
 
 
 
 
 
 
 
 


106 
 
 
 APPENDIX C:  INFORMATION ON POSSIBLE DRUG INTERACTIONS 
 
The list provided below is not exhaustive. For a more comprehensive, frequently updated list, 
please visit: http://medicine.iupui.edu/clinpharm/ddis/table.aspx. 
 
Medications that strongly inhibit CYP3A: 
Amprenavir 
Atazanavir 
Boceprevir 
Clarithromycin 
Conivaptan 
Delavirdine 
Diltiazem 
Erythromycin 
Fosamprenavir 
Indinavir 
Itraconazole 
Ketoconazole 
Lopinavir 
Mibefradil 
Miconazole 
Nefazodone 
Nelfinavir 
Posaconazole 
Ritonavir 
Saquinavir 
Telaprevir 
Telithromycin 
Verapamil 
Voriconazole 
Grapefruit, grapefruit juice, or any product containing grapefruit 
 
Medications that strongly induce CYP3A: 
Carbamazepine 
Felbamate 
Nevirapine 
Phenobarbital 
Phenytoin 
Primidone 
Rifabutin 
Rifampin 
Rifapentin 
St. John’s wort 
 
 
 


107 
 
 
 APPENDIX D:  INFORMATION ON POSSIBLE INTERACTIONS WITH OTHER 
AGENTS FOR PATIENTS AND THEIR CAREGIVERS AND NON-STUDY 
HEALTHCARE TEAM 
 
The participant ____________________________ is enrolled on a clinical trial using the 
experimental agents eribulin and pembrolizumab. This clinical trial is sponsored by the National 
Cancer Institute.  This form is addressed to the participant, but includes important information 
for others who care for this participant.  
 
Eribulin and pembrolizumab interacts with many drugs that are processed by your liver.  
Because of this, it is very important to tell your study doctors about all of your medicine before 
you start this study.  It is also very important to tell them if you stop taking any regular medicine, 
or if you start taking a new medicine while you take part in this study.  When you talk about your 
medicine with your study doctor, include medicine you buy without a prescription at the drug 
store (over-the-counter remedy), or herbal supplements such as St. John’s wort.  
 
Many health care prescribers can write prescriptions.  You must also tell your other prescribers 
(doctors, physicians’ assistants or nurse practitioners) that you are taking part in a clinical trial. 
Bring this paper with you and keep the attached information card in your wallet.  These are 
the things that you and they need to know:  
 
Eribulin interacts with certain specific enzymes in your liver.  
  Eribulin must be used very carefully with other medicines that need these liver enzymes to 
be effective or to be cleared from your system.   
 Other medicines may also affect the activity of the enzyme.   
 You and healthcare providers who prescribe drugs for you must be careful about adding or 
removing any drug in this category.  
 Your prescribers should look at this web site 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx or consult a medical reference to see 
if any medicine they want to prescribe is on a list of drugs to avoid.   
 Please be very careful!  Over-the-counter drugs have a brand name on the label—it’s 
usually big and catches your eye.  They also have a generic name—it’s usually small and 
located above or below the brand name, and printed in the ingredient list.  Find the 
generic name and determine, with the pharmacist’s help, whether there could be an 
adverse interaction.   
 Be careful:  
o If you take acetaminophen regularly:  You should not take more than 4 grams a 
day if you are an adult or 2.4 grams a day if you are older than 65 years of age.  
Read labels carefully!  Acetaminophen is an ingredient in many medicines for 
pain, flu, and cold. 
o If you drink grapefruit juice or eat grapefruit:  Avoid these until the study is over.  
o If you take herbal medicine regularly:  You should not take St. John’s wort while 
you are taking eribulin and pembrolizumab. 
 
Other medicines can be a problem with your study drugs.  
 


108 
 
 
 You should check with your doctor or pharmacist whenever you need to 
use an over-the-counter medicine or herbal supplement.  
 
 Your regular prescriber should check a medical reference or call your 
study doctor before prescribing any new medicine for you.  Your study 
doctor’s name is  
 
 
 
 
 
_____________________________________  
 
 
 
 
and he or she can be contacted at  
 
 
 
 
_____________________________________ 
 
 


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 APPENDIX E:  PARTICIPANT INFORMATION CARD 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INFORMATION ON POSSIBLE DRUG INTERACTIONS  
You are enrolled on a clinical trial using the experimental agent 
__________________.  This clinical trial is sponsored by the Suzanne 
George, MD.  __________________ interacts with drugs that are 
processed by your liver.  Because of this, it is very important to: 
 Tell your doctors if you stop taking regular medicine or if you start 
taking a new medicine. 
 Tell all of your prescribers (doctor, physicians’ assistant, nurse 
practitioner, and pharmacist) that you are taking part in a clinical 
trial. 
 Check with your doctor or pharmacist whenever you need to use 
an over-the-counter medicine or herbal supplement. 
__________________ interacts with a specific liver enzyme called 
CYP______, and must be used very carefully with other medicines 
that interact with this enzyme.  
 Before you start the study, your study doctor will work with your 
regular prescriber to switch any medicines that are considered 
“strong inducers/inhibitors or substrates of CYP______.” 
 Before prescribing new medicines, your regular prescribers should 
go to http://medicine.iupui.edu/clinpharm/ddis/table.aspx for a 
list of drugs to avoid, or contact your study doctor.   
 Your study doctor’s name is _____________________________ 
and can be contacted at _________________________________.  


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 APPENDIX F:  GUIDELINES FOR COLLECTING RESEARCH BIOPSY TISSUE 
 
Tissue specimens will be collected from metastatic lesions using standard institutional 
procedures. The amount of tissue collected may follow the guidelines listed below:  
Skin/chest wall: A goal of 2 to 3 5-mm punch biopsies will be obtained.  
Soft Tissue or Liver: A goal of 3-4 core biopsy specimens will be obtained using an 18-gauge 
needle.  
Lung: Because of the risk of pneumothorax associated with core needle biopsies of lung nodules, 
no core biopsies of lung nodules are mandated on this protocol, unless they are clinically 
indicated.  
Bone: Because the yield of malignant tissue from bone biopsies tends to be relatively low, if a 
participant has another accessible site of disease (i.e. skin, lymph node, liver), that site should be 
biopsied preferentially. If bone is the only biopsy-accessible site, then a goal of 3-6 core biopsy 
specimens will be obtained using an 11-13 gauge needle.  
Please note that the above are guidelines for the amount of tissue to be obtained, and are 
not meant to replace clinical judgment at the time the procedure is performed. Less than the 
goal quantity of tissue is accepted for each type of biopsy, and will be left to the clinical 
judgment of the physician performing the procedure.  
If a participant is undergoing resection of a lesion for clinical reasons (i.e. wedge resection 
of a new lung lesion for confirmation of diagnosis; or, resection of a chest wall lesion; or, 
resection of a liver or bone lesion), then the participant may opt to have a portion of that tissue 
(roughly equivalent to the goal amount of tissue listed in the guidelines above, i.e. the equivalent 
of two 5-mm punch biopsies of the skin, or 3-6 18-gauge core biopsies) stored for research at the 
time of the procedure (provided that the tissue is processed as specified), in which case, the 
participant would not be required to undergo a separate research biopsy at baseline on this 
protocol.  
Coded laboratory specimens will be stored in the Tumor Bank of the DFCI. These specimens 
will become the property of DFCI. Participants will be informed that their specimens may be 
used for research by investigators at DF/HCC and other approved collaborators. Shared 
specimens will be identified with a sample ID number; all participant identifying material will be 
removed.  
Risks of Research Biopsy and Procedures for Minimizing Risk  
Potential risks according to site are:  
Skin/chest wall (punch biopsy):  
 Likely: local discomfort and minor bleeding  
 Less likely: moderate or major bleeding, or infection  


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Liver, or bone (core needle biopsy):  
  Likely: local discomfort and minor bleeding  
 Less likely: moderate or major bleeding, need for blood transfusion, hospitalization 
 due to bleeding or other complications, infection, damage to adjacent organs. 
Additional risks may be present if intravenous conscious sedation is required  
Prior to the procedure, the physician performing the procedure will discuss the risks with each 
study participant, answer any questions, and obtain separate procedure consent. Participants will 
be evaluated for comorbidities or concomitant medications that may increase the risk of potential 
complications. For biopsies of lesions that are not superficial and clearly palpable, imaging 
studies such as CT or ultrasound will be used to guide the biopsy in order to minimize the risk of 
damage to adjacent structures. After liver biopsies, participants will be observed a minimum of 4 
hours (range 4-6 hours) after the procedure, or according to standard institutional guidelines. 
Less than the goal quantity of tissue is accepted for each type of biopsy, and will be left to the 
clinical judgment of the physician performing the procedure. 
Risks of Anesthesia 
Local Anesthesia  
All biopsy procedures require local anesthesia using lidocaine, xylocaine, or related compounds. 
There is a small risk of an allergic reaction associated with these drugs. In order to minimize the 
risk of local anesthesia, only qualified personnel will perform the biopsy procedure. Participants 
will be queried if they have had previous allergic   reactions to local anesthetics.  
Intravenous Conscious Sedation  
Certain biopsy procedures, such as liver or bone biopsies, may require intravenous conscious 
sedation (IVCS). IVCS is a minimally depressed level of consciousness that retains the 
participant’s ability to maintain a patent airway independently and continuously and respond 
appropriately to physical stimulation and verbal commands. The risks of intravenous conscious 
sedation include: inhibition of the gag reflex and concomitant risk of aspiration, 
cardiopulmonary complications (myocardial infarction, cardiac arrhythmias, hypoxemia), and 
allergic reactions to the sedative or analgesic medications. These risks are small but real; for 
example, in a prospective study of 14,149 participants undergoing IVCS during upper 
gastrointestinal endoscopies, the rate of immediate cardiopulmonary events was 2 in 1000. The 
30-day mortality was 1 per 2,000 cases. In this study, there was a strong association between 
lack of monitoring and use of high-dose benzodiazepines with adverse outcomes. There was also 
an association between the use of local anesthetic sprays to the oropharynx and the development 
of pneumonia. In order to minimize the risk of intravenous conscious sedation, only qualified 
personnel will be responsible for conscious sedation. A minimum of two individuals will be 
involved in the care of participants undergoing conscious sedation—the physician performing 
the biopsy procedure, and the individual (M.D. or R.N.) who monitors the participants and 
his/her response to both the sedation and the procedure, and who is capable of assisting with any 
supportive or resuscitative measures. The room where the procedure utilizing IVCS takes place 


112 
 
 
will have adequate equipment to provide supplemental oxygen, monitor vital signs, and maintain 
an airway should this be necessary. An emergency cart will also be immediately accessible to the 
room where the procedure is to take place, and emergency support services will be available on 
page. Participants will be screened and evaluated for their fitness to undergo conscious sedation 
by a trained physician. Participants with active cardiac disease are excluded from this study. No 
local anesthetic spray to the oropharynx will be necessary, given that endoscopy is not a planned 
procedure. Following the procedure, participants will be observed closely in the recovery room 
for a minimum of 2 hours.  
General Anesthesia  
Because of the higher risk of general anesthesia compared with local anesthesia or intravenous 
conscious sedation, biopsies that would require general anesthesia in order to be performed are 
not permitted on this protocol, unless they are being done for clinical reasons, and excess tissue 
that otherwise would have been discarded is then banked for the purpose of this protocol.  
For Fresh Frozen Biopsies of Soft Tissue, Liver, Bone, Etc:  
1. After biopsy is performed, the tissue mass is placed on a sterile gauze 
2. Using forceps, separate the tumor tissue 
3. Place 2 pieces (cores) of tumor tissue in each cassette (typically end up with 3 cassettes per 
biopsy); the last cassette will contain many small pieces of tumor tissue 
4. Fill cassettes with OCT  
a. Completely cover tissue  
b. Limit the amount of bubbles 
5. Place cassettes on dry ice and prepare for transport by limiting OCT leakage 
6. Return samples to the lab and complete freezing of samples in OCT with dry ice (about 10 
minutes freezing time) 
7. Once samples are frozen, place in plastic bag; label bag with date, protocol number, 
participant number, and number of initials included 
8. Store in –80C freezer  
For Paraffin Embedded Tissue:  
At the site of origin (prior to shipment to BWH), 2 to 3 adequate cores, and any additional tissue 
will be fixed in 4% buffered formalin overnight at room temperature, to adequately preserve 
tissue morphology. Of note one core will be saved as fresh frozen tissue for RNA sequencing 
analysis. Additionally, a 2nd core will be used for DFCI Oncopanel, targeted gene-expression 
profiling, per standard DFCI Oncopanel procedure. Then, the tissue will be transferred in 70% 


113 
 
 
ethanol at room temperature for at least 48 hours. After fixation, the tissue will be processed, 
using an automated tissue processor following standard protocols within histology 
laboratories.  To summarize this procedure, the tissue will be exposed to increasing 
concentration of ethanol (80%, 96% and 100%) and then to xylene for at least 2 hours. The tissue 
will be then infiltrated several times in hot paraffin and afterwards will be embedded in paraffin. 
 


114 
 
 
 APPENDIX G:  CONTRACEPTIVE GUIDANCE AND PREGNANCY TESTING 
 
Woman of Childbearing Potential (WOCBP) 
A woman is considered fertile following menarche and until becoming post-menopausal unless 
permanently sterile (see below)  
Women in the following categories are not considered WOCBP: 
● 
Premenarchal 
● 
Premenopausal female with 1 of the following: 
○ Documented hysterectomy 
○ Documented bilateral salpingectomy 
○ Documented bilateral oophorectomy 
Note:  Documentation can come from the site personnel’s review of the participant’s medical 
records, medical examination, or medical history interview. 
● 
Postmenopausal female 
○ A postmenopausal state is defined as no menses for 12 months without an alternative 
medical cause.  
▪ 
A high follicle stimulating hormone (FSH) level in the postmenopausal range may be 
used to confirm a postmenopausal state in women not using hormonal contraception 
or hormonal replacement therapy (HRT). However, in the absence of 12 months of 
amenorrhea, confirmation with two FSH measurements in the postmenopausal range 
is required.  
○ Females on HRT and whose menopausal status is in doubt will be required to use one of 
the non-hormonal highly effective contraception methods if they wish to continue their 
HRT during the study. Otherwise, they must discontinue HRT to allow confirmation of 
postmenopausal status before study enrollment. 
Contraception Requirements 
Male Participants: 
Male participants with female partners of childbearing potential are eligible to participate if they 
agree to one of the following during the protocol defined time frame in section 3.1.10:  
● Be abstinent from penile-vaginal intercourse as their usual and preferred lifestyle (abstinent 
on a long term and persistent basis) and agree to remain abstinent 
● Use a male condom plus partner use of a contraceptive method with a failure rate of <1% per 
year as described in Table 12 when having penile-vaginal intercourse with a woman of 
childbearing potential who is not currently pregnant. 
○ Note: Men with a pregnant or breastfeeding partner must agree to remain abstinent from 
penile-vaginal intercourse or use a male condom during each episode of penile 
penetration. 
 
Female Participants: 
Female participants of childbearing potential are eligible to participate if they agree to use a 
highly effective method of contraception consistently and correctly as described in Table 12 
during the protocol-defined time frame in Section 3.1.10.  
 
 


115 
 
 
Table 12 Highly Effective Contraception Methods 
 
Highly Effective Contraceptive Methods That Are User Dependent a  
Failure rate of <1% per year when used consistently and correctly.
● Combined (estrogen- and progestogen- containing) hormonal contraception b, c 
○ Oral  
○ Intravaginal  
○ Transdermal  
○ Injectable 
● Progestogen-only hormonal contraception b, c 
○ Oral  
○ Injectable  
Highly Effective Methods That Have Low User Dependency  
Failure rate of <1% per year when used consistently and correctly. 
● Progestogen- only contraceptive implant b, c  
● Intrauterine hormone-releasing system (IUS) b  
● Intrauterine device (IUD) 
● Bilateral tubal occlusion 
● Vasectomized partner  
A vasectomized partner is a highly effective contraception method provided that the partner is the sole 
male sexual partner of the WOCBP and the absence of sperm has been confirmed. If not, an additional 
highly effective method of contraception should be used. 
● Sexual abstinence  
Sexual abstinence is considered a highly effective method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study treatment. The 
reliability of sexual abstinence needs to be evaluated in relation to the duration of the study and the 
preferred and usual lifestyle of the participant.) 
Notes:  
Use should be consistent with local regulations regarding the use of contraceptive methods for 
participants of clinical studies.  
 
a) Typical use failure rates are lower than perfect-use failure rates (i.e. when used consistently and 
correctly).  
b) If hormonal contraception efficacy is potentially decreased due to interaction with study treatment, 
condoms must be used in addition to the hormonal contraception during the treatment period and for at 
least 20 weeks corresponding to time needed to eliminate study treatment plus 30 days after the last 
dose of study treatment. 
c) If locally required, in accordance with Clinical Trial Facilitation Group (CTFG) guidelines, 
acceptable hormonal contraceptives are limited to those which inhibit ovulation. 
 
 
Pregnancy Testing 
WOCBP should only be included after a negative highly sensitive serum pregnancy test.  
Following initiation of treatment, pregnancy testing will be performed whenever an expected 
menstrual cycle is missed or when pregnancy is otherwise suspected; at the time points specified 


116 
 
 
in the Schedule of Activities, and as required locally. 
Pregnancy testing will be performed whenever an expected menstrual cycle is missed or when 
pregnancy is otherwise suspected.