Conditions: Advanced Cholangiocarcinoma
Keywords: cholangiocarcinoma Pembrolizumab MK-3475 Sylatron peginterferon alfa-2b
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 4
Healthy volunteers: no

Brief summary:
This is an open-label, single-arm, multicenter Phase II safety and efficacy study of combination therapy with pembrolizumab and Sylatron (Peginterferon alpha-2b) in patients with advanced cholangiocarcinoma who have progressed on or cannot tolerate frontline chemotherapy.

Detailed description:
Pembrolizumab and Sylatron Administration:

Pembrolizumab has been evaluated at 2 mg/kg every 3 weeks (Q3W), 10 mg/kg Q3W, or 10 mg/kg Q2W in multiple previous studies for different types of cancer, the response rate at higher dose level seems not improved compared to that of lower dose level. With concerns of increased toxicities from the combination pembrolizumab and sylatron therapy, the pembrolizumab dose is selected to be 200mg administered every three weeks. The approved dose of sylatron for melanoma is induction treatment at 6 μg/kg/week for 8 doses followed by 5 year of maintenance treatment at 3 μg/kg/week for up to 5 years. The approved dose of sylatron for chronic hepatitis C infection in combination with ribavirin is 1.5μg/kg weekly for 24 to 48 weeks.

Each cycle = 21 days or 3 weeks. Based on the approved dosage of sylatron, we decided to treat patients at 200mcg weekly up to 12 weeks (3 weeks as single agent, and 9 weeks in combination of pembrolizumab). Sylatron will start Cycle 1 Day 1 and continue on a weekly basis. We have prepared to reduce the dose of sylatron to 120mcg weekly, or 60mcg weekly if patients experience unacceptable toxicities at the higher dose level of sylatron.

Pembrolizumab will be administered intravenously as a 30 minute infusion at a dose of 200 mg every 3 weeks starting Week 4. Pembrolizumab will start Cycle 2 Day 1 and continue every 3 weeks. All trial treatments will be administered on an outpatient basis.

Sites should make every effort to target infusion timing to be as close to 30 minutes as possible. However, given the variability of infusion pumps from site to site, a window of -5 minutes and +10 minutes is permitted (i.e., infusion time is 30 minutes: -5 min/+10 min).

With concerns about toxicity while using long-term sylatron, if no additional benefit is seen beyond 12 weeks of treatment on top of that expected from pembrolizumab alone, patients will discontinue sylatron treatment after they have received 12 weeks of this therapy (3 weeks as single agent and 9 weeks in combination with pembrolizumab). Pembrolizumab should be continued in the absence of unacceptable toxicity (based on CTCAE v4) until disease progression-based on RECIST 1.1. In patients who had responded to the combination therapy, when patient shows disease progression while on single agent pembrolizumab treatment, Sylatron may be resumed at the discretion of the site investigator after discussion with the sponsor-investigator.

Arms:
arm 1: Pembrolizumab will be administered intravenously at a dose of 200 mg every 3 weeks starting week 4. Sylatron will be administered at a dose of 200mcg subcutaneously weekly starting at week 1.

Interventions: intervention 1: Pembrolizumab intervention 2: Sylatron
Intervention descriptions: intervention 1: Pembrolizumab will be administered intravenously. intervention 2: Sylatron will be administered subcutaneously.

Protocol document:
Prot_SAP_000.pdf: 
Clinical Study Protocol 
HCRN GI16-263 
Protocol Title 
A phase II multi-center study evaluating combination immunotherapy for advanced 
cholangiocarcinoma with pembrolizumab and Sylatron (peginterferon alfa-2b) 
Sponsor Investigator 
Aiwu Ruth He, MD, PhD 
Lombardi Comprehensive Cancer Center 
Georgetown University 
3800 Reservoir Road, NW 
Washington DC, 20007 
Tel: 202-444-8642 
Fax:202-444-9429 
arh29@georgetown.edu 
Co-Investigators 
Iyer Renuka MD 
Roswell Park Cancer Institute 
646 Main St, Buffalo, NY 14202 
Telephone (716) 845-2300 
Renuka.Iyer@RoswellPark.org 
Davendra P. S. Sohal, MD, MPH 
Cleveland Clinic Clinical Genomics Program 
Taussig Cancer Institute 
9500 Euclid Avenue, R35 
Cleveland, OH - 44195 
Telephone: (216) 444-8258 
sohald@ccf.org
Statistician 
Hongkun Wang, PhD 
4000 Reservoir Road, NW 
Washington DC, 20057 
202-687-4146 
Hongkun.Wang@georgetown.edu 
Trial Management Provided by  
Hoosier Cancer Research Network, Inc. 
500 N. Meridian, Suite 100 
Indianapolis, IN 46204 
Trial Supported by: Merck Sharp and Dohme Corp. (“Merck”) 
Investigational New Drug (IND) # 129815 
Initial Protocol Version Date: 12/9/15 
Protocol Amendment Version Date:  
30DEC2016 
10FEB2017 
15DEC2017 
11APR2017 
07JUN2017 
19SEP2017 


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Version Date: 15DEC2017 
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PROTOCOL SIGNATURE PAGE 
 
A phase II multi-center study evaluating combination immunotherapy for advanced 
cholangiocarcinoma with pembrolizumab and Sylatron (peginterferon alfa-2b) 
 
VERSION DATE:  15DEC2017 
I confirm I have read this protocol, I understand it, and I will work according to this protocol and 
to the ethical principles stated in the latest version of the Declaration of Helsinki, the applicable 
guidelines for good clinical practices, whichever provides the greater protection of the 
individual. I will accept the monitor’s overseeing of the study. I will promptly submit the 
protocol to applicable institutional review board(s). 
 
 
 
 
____________________________________ 
________________________ 
 Signature of Site Investigator 
 
 
  
 Date 
 
 
____________________________________ 
 Site Investigator Name (printed) 
 
 
____________________________________ 
 Site Investigator Title 
 
 
____________________________________ 
 Name of Facility 
 
 
____________________________________ 
 Location of Facility (City and State) 
 
 
 
 PLEASE COMPLETE AND EMAIL A COPY TO HCRN 
 
 
 


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SYNOPSIS 
TITLE 
A phase II multi-center study evaluating combination 
immunotherapy for advanced cholangiocarcinoma with 
pembrolizumab and Sylatron (peginterferon alfa-2b) 
 
SHORT TITLE 
Phase II study evaluating pembrolizumab and sylatron for the 
treatment of advanced cholangiocarcinoma 
 
PHASE  
II 
OBJECTIVES 
Primary Objectives: 
• Assess objective response rate of patients receiving 
pembrolizumab and Sylatron combination therapy based 
RECIST 1.1. 
 
Secondary Objectives: 
• Assess progression free survival of patients receiving 
pembrolizumab and Sylatron. 
• Assess overall survival of patients receiving pembrolizumab 
and Sylatron 
• Assess the objective response rate of patients receiving 
pembrolizumab and Sylatron combination therapy based on 
irRECIST. 
• Assess the safety and tolerability of combined pembrolizumab 
and Sylatron therapy 
 
Exploratory Objectives: 
• Determine the effect of Sylatron on anti- programmed death 
ligand-1 (PD-L1) level, immune score as determined by the 
density of CD3 and CD8 in the tumor interior and invasive 
margin(s) of the tumor, and the clonality of the T-cell 
repertoire. 
• Determine the effect of Sylatron on anti-cancer immunity by 
measuring proliferation of CD8+ T cells, Granzyme B+ cells 
and proliferation of tumor cells, and correlating these changes 
with clinical response as determined by RECIST 1.1. 
 
STUDY 
DESIGN 
This is an open-label, single-arm, multicenter Phase II safety and 
efficacy study of combination therapy with pembrolizumab and 
Sylatron (Peginterferon alpha-2b) in patients with advanced 
cholangiocarcinoma who have progressed on or cannot tolerate 
frontline chemotherapy. 


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ELIGIBILITY 
CRITERIA  
Inclusion Criteria: 
1. Be willing and able to provide written informed 
consent/assent for the trial. 
2. Be  18 years of age on day of signing informed consent. 
3. Patients must have received 1 line of prior systemic therapy 
for metastatic or resectable disease (i.e. patients may have 
received adjuvant gemcitabine and then later 
gemcitabine/cisplatin for recurrent metastatic disease) 
4. Histological confirmation of cholangiocarcinoma.  
5. Have measurable disease based on RECIST 1.1.   
6. Be willing to provide tissue from a newly obtained core or 
excisional biopsy of a tumor lesion. Newly obtained is 
defined as a specimen obtained up to 6 weeks (42 days) prior 
to initiation of treatment on Day 1. Subjects for whom newly 
obtained samples cannot be provided (e.g. inaccessible or 
subject safety concern) may submit an archived specimen 
only upon agreement from the sponsor-investigator. 
7. Have a performance status of 0 or 1 on the ECOG 
Performance Scale. 
8. Demonstrate adequate organ function as defined in  
9. Table 1.  All screening labs will be performed within 28 days 
of registration.  
System 
Laboratory Value 
Hematological 
Absolute neutrophil count (ANC) 
≥ 1,500 /μL 
Platelets 
≥ 100,000 / μL 
Hemoglobin 
≥ 9 g/dL or ≥ 5.6 mmol/L without 
transfusion or EPO dependency 
(within 7 days of assessment) 
Renal 
Serum creatinine OR 
Measured or calculated CrCl 
(GFR can also be used in place of 
creatinine or CrCl) 
≤ 1.5 X upper limit of normal (ULN) 
OR ≥ 60 mL/min for subject with 
creatinine levels > 1.5 x institutional 
ULN 
Hepatic 
Serum total bilirubin 
≤ 2.0 X ULN  
AST (SGOT) and ALT (SGPT) 
≤ 3.0 X ULN OR 
≤ 5 X ULN for subjects with liver 
metastases 
Albumin 
> 2.5 mg/dL 
Coagulation 
International Normalized Ratio (INR) 
or Prothrombin Time (PT) 
 
Activated Partial Thromboplastin 
Time (aPTT) 
≤ 1.5 X ULN unless subject is 
receiving anticoagulant therapy as 
long as PT or PTT is within 
therapeutic range of intended use of 
anticoagulants ≤ 1.5 X ULN unless 
subject is receiving anticoagulant 
therapy as long as PT or PTT is 
within therapeutic range of intended 
use of anticoagulants 


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10. Female subject of childbearing potential should have a 
negative urine or serum pregnancy within 72 hours prior to 
receiving the first dose of study medication. If the urine test 
is positive or cannot be confirmed as negative, a serum 
pregnancy test will be required.  
  
11. Female subjects of childbearing potential should be willing 
to use adequate birth control or be surgically sterile, or 
abstain from heterosexual activity for the course of the study 
through 120 days after the last dose of study medication. 
Subjects of childbearing potential are those who have not 
been surgically sterilized or have not been free from menses 
for > 1 year.  
 
12. Male subjects should agree to use an adequate method of 
contraception starting with the first dose of study therapy 
through 120 days after the last dose of study therapy. 
 
Exclusion Criteria 
 
1. Has symptomatic congestive heart failure, unstable angina 
pectoris, symptomatic or poorly controlled cardiac 
arrhythmia.  Symptomatic heart failure (NYHA Class II-IV) 
 
2. A history of anaphylaxis to peginterferon alfa-2b or 
interferon alfa-2b 
 
3. Is currently participating and receiving study therapy or has 
participated in a study of an investigational agent and 
received study therapy or used an investigational device 
within 4 weeks of the first dose of treatment. 
 
4. Has a diagnosis of immunodeficiency or is receiving 
systemic steroid therapy or any other form of 
immunosuppressive therapy within 7 days prior to the first 
dose of trial treatment. 
 
5. Has a known history of active TB (Bacillus Tuberculosis) 
 
6. Hypersensitivity to pembrolizumab or any of its excipients. 
 
7. Has had a prior anti-cancer monoclonal antibody (mAb) 
within 4 weeks prior to study Day 1 or who has not 
recovered (i.e., ≤ Grade 1 or at baseline) from adverse events 
due to agents administered more than 4 weeks earlier. 
 


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8. Has had prior chemotherapy, targeted small molecule 
therapy, or radiation therapy within 2 weeks prior to study 
Day 1 or who has not recovered (i.e., ≤ Grade 1 or at 
baseline) from adverse events due to a previously 
administered agent. 
• NOTE:  Subjects with ≤ Grade 2 neuropathy are an 
exception to this criterion and may qualify for the 
study. 
• NOTE:  If subject received major surgery, they must 
have recovered adequately from the toxicity and/or 
complications from the intervention prior to starting 
therapy.   
 
9. Has a known additional malignancy that is progressing or 
requires active treatment. Exceptions include basal cell 
carcinoma of the skin or squamous cell carcinoma of the skin 
that has undergone potentially curative therapy or in situ 
cervical cancer. 
 
10. Has known active central nervous system (CNS) metastases 
and/or carcinomatous meningitis. Subjects with previously 
treated brain metastases may participate provided they are 
stable (without evidence of progression by imaging for at 
least four weeks prior to the first dose of trial treatment and 
any neurologic symptoms have returned to baseline), have no 
evidence of new or enlarging brain metastases, and are not 
using steroids for at least 7 days prior to trial treatment. This 
exception does not include carcinomatous meningitis, which 
is excluded regardless of clinical stability.   
 
11. Has active autoimmune disease that has required systemic 
treatment in the past 2 years (i.e. with use of disease 
modifying agents, corticosteroids, or immunosuppressive 
drugs). Replacement therapy (e.g., thyroxine, insulin, or 
physiologic corticosteroid replacement therapy for adrenal or 
pituitary insufficiency, etc.) is not considered a form of 
systemic treatment.  
 
12. Has known history of, or any evidence of active, non-
infectious pneumonitis. 
 
13. Has an active infection requiring systemic therapy. 
 
14. Has a history or current evidence of any condition, therapy, 
or laboratory abnormality that might confound the results of 
the trial, interfere with the subject’s participation for the full 


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duration of the trial, or is not in the best interest of the 
subject to participate, in the opinion of the site investigator.   
 
15. Has known psychiatric or substance abuse disorders that 
would interfere with cooperation with the requirements of 
the trial. 
 
16. Is pregnant or breastfeeding, or expecting to conceive or 
father children within the projected duration of the trial, 
starting with the pre-screening or screening visit through 120 
days after the last dose of trial treatment. 
 
17. Has received prior therapy with an anti-PD-1, anti-PD-L1, or 
anti-PD-L2 agent. 
 
18. Has a known history of Human Immunodeficiency Virus 
(HIV) (HIV 1/2 antibodies). 
 
19. Has known active Hepatitis B without HBV treatment (HBV 
infection with ongoing HBV treatment is allowed); has 
persistent chronic Hepatitis C infection (successfully treated 
HCV infection is allowed).  
 
20. Has received a live vaccine within 30 days of planned start 
of study therapy. 
Note:  Seasonal influenza vaccines for injection are 
generally inactivated flu vaccines and are allowed; however, 
intranasal influenza vaccines (e.g., Flu-Mist®) are live 
attenuated vaccines, and are not allowed. 
 
21. Has history of bipolar disorder or major depression as 
identified by the enrolling physician. See Study Procedures 
Manual (SPM) for additional information. 
 
22. Has history of not tolerating interferon treatment. 
 
23. Has known serious neuropsychiatric condition. 
 


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STATISTICAL 
CONSIDER 
ATIONS 
 
The primary objective of the study is to test that addition of Sylatron 
will improved the response rate of pembrolizumab from 17% to 
35% in patients with advanced cholangiocarcinoma. The sample size 
is based on the number of patients that are anticipated to complete 
the primary objective. 
 
We propose that the addition of Sylatron to a pembrolizumab 
regimen will improve the response rate of pembrolizumab from 17% 
to 35%. Simon’s two-stage optimum design will be used to test the 
null hypothesis of P <= 0.17 versus the alternative hypothesis of P 
>= 0.350. At the first stage, 16 patients will be treated with the 
combination of Sylatron and pembrolizumab. The trial will be 
terminated if 3 or fewer respond. If there are at least 4 responders, 
the trial will go on to the second stage and 28 patients will be 
enrolled to a total of 44 patients. If the total number responding 
among the 44 patients is less than or equal to 11, the null hypothesis 
will not be rejected and the combination of Sylatron plus 
pembrolizumab will not be investigated further. Using this statistical 
method, there is a 0.046 (4.6%) probability of erroneously 
concluding that this drug combination is effective when it actually is 
not (targeted value of 0.05). If the drug is actually effective, there is 
a 0.191 (1.9%) probability of concluding that it is not (targeted value 
of 0.2). The power of the design is 80% with a one-sided 
significance level of 0.05. 
 
We anticipate that 2 patients will be recruited per month and total 
time for study recruitment will be 24 months, with each patient 
followed for a minimum of 6 months, the anticipated time to 
complete the study will be 24 – 30 months.  Allowing for a 4% drop 
out rate, a total of 46 patients will be enrolled for this trial. 
TOTAL  
NUMBER OF 
SUBJECTS 
N = 44 
ESTIMATED 
ENROLLMENT 
PERIOD 
Estimated 24 months 
ESTIMATED 
STUDY 
DURATION  
Estimated 30 months 
 
 


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TABLE OF CONTENTS 
 
 
Schema ............................................................................................................................. 10 
1. 
Background and Rationale.................................................................................... 11 
2. 
Study Objectives and Endpoints........................................................................... 19 
3. 
Eligibility Criteria .................................................................................................. 21 
4. 
Subject Registration............................................................................................... 25 
5. 
Treatment Plan....................................................................................................... 25 
6. 
Toxicities and Dose Delays/Dose Modifications .................................................. 32 
7. 
Study Calendar & Evaluations ............................................................................. 38 
8. 
Biospecimen Studies and Procedures ................................................................... 42 
9. 
Criteria for Disease Evaluation ............................................................................ 44 
10. Drug Information ................................................................................................... 50 
11 
Adverse Events ....................................................................................................... 53 
12 
Statistical Methods ................................................................................................. 57 
13 
Trial Management ................................................................................................. 60 
14 
Data Handling and Record Keeping .................................................................... 61 
15 
Ethics ....................................................................................................................... 62 
16 
References ............................................................................................................... 63 
 
 
 
 
 


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SCHEMA 
 
 
1. Sylatron at 200mcg will be administered subcutaneously weekly starting Cycle 1 Day 1. 
2. Pembrolizumab will be administered intravenously at 200mg every 3 weeks starting Cycle 2 Day 
1 (Week 4). 
 
 
 
 
 


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1. 
BACKGROUND AND RATIONALE 
 
1.1 
Cholangiocarcinoma 
Cholangiocarcinoma has been steadily increasing in incidence worldwide over the last decade [9]. 
It is difficult to establish the diagnosis of early stage cholangiocarcinoma as symptoms are not 
prominent until the disease is far advanced. Patients with unresectable tumors have a dismal 
prognosis, with a median survival time of nine months [10.11]. Surgical resection is considered 
to be the most viable approach to attempting a “cure” for cholangiocarcinoma but even after 
surgery, five-year survival rates range from only 25% to 48% due to incomplete resection and 
subsequent high recurrence rate (~50%) [12–14]. New approaches are urgently needed to prevent 
tumor recurrence after surgical resection in an attempt to further improve patient survival. 
 
1.1.1 Chemotherapy and Cholangiocarcinoma 
A recent randomized and controlled trial (ABC-02 study) proved that gemcitabine combined 
with cisplatin (GC-therapy) performed better than gemcitabine monotherapy for 
cholangiocarcinoma [15]. However, the benefit of GC-therapy is modest with progression free 
survival (PFS) of 8.1 months of and overall survival (OS) of 11.7 months in patients treated in 
ABC-02 study. Furthermore, there is no effective second line therapy for patients with advanced 
cholangiocarcinoma. In a Phase II study of second line gemcitabine monotherapy for 
cholangiocarcinoma patients refractory to 5-fluorouracil treatment, the median time to 
progression (TTP) was 1.6 months (95% CI: 1.3-1.9 months), and the median overall survival 
(OS) time was 4.1 months (95% CI: 2.7-5.5 months) [16]. A retrospective analysis of metastatic 
gallbladder cancer and cholangiocarcinoma that were treated second-line FOLFOX4 
chemotherapy, after disease progression from gemcitabine based first line chemotherapy, showed 
stable disease in 22% of patients, and the median disease free survival (DFS) and OS were 96 
(13 weeks) and 138 (19 weeks) days respectively.  
 
1.2 
Pembrolizumab 
Pembrolizumab (MK-3475) is a potent humanized IgG4 mAb with high specificity of binding to 
the PD-1 receptor, thus inhibiting its interaction with PD-L1 and 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 being advanced for clinical 
development as an IV immunotherapy for advanced malignancies. 
 
1.2.1 Pharmaceutical and Therapeutic Background 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades.  Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in 
various malignancies.  In particular, the presence of CD8+ T-cells and the ratio of CD8+ effector 
T-cells / FoxP3+ regulatory T-cells seems to correlate with improved prognosis and long-term 
survival in many solid tumors. 
 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune 
control.  The normal function of PD-1, expressed on the cell surface of activated T-cells under 
healthy conditions, is to down-modulate unwanted or excessive immune responses, including 
autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig superfamily member related 


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to CD28 and CTLA-4 which has been shown to negatively regulate antigen receptor signaling 
upon engagement of its ligands (PD-L1 and/or PD-L2).  The structure of murine PD-1 has been 
resolved.  PD-1 and family members are type I transmembrane glycoproteins containing an Ig 
Variable-type (V-type) domain responsible for ligand binding and a cytoplasmic tail which is 
responsible for the binding of signaling molecules.  The cytoplasmic tail of PD-1 contains 2 
tyrosine-based signaling motifs, an immunoreceptor tyrosine-based inhibition motif (ITIM) and 
an immunoreceptor tyrosine-based switch motif (ITSM).  Following T-cell stimulation, PD-1 
recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif within its cytoplasmic 
tail, leading to the dephosphorylation of effector molecules such as CD3ζ, PKCθ and ZAP70 
which are involved in the CD3 T-cell signaling cascade.  The mechanism by which PD-1 down 
modulates T-cell responses is similar to, but distinct from that of CTLA-4 as both molecules 
regulate an overlapping set of signaling proteins.  PD-1 was shown to be expressed on activated 
lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer 
cells.  Expression has also been shown during thymic development on CD4-CD8- (double 
negative) T-cells as well as subsets of macrophages and dendritic cells.  The ligands for PD-1 
(PD-L1 and PD-L2) are constitutively expressed or can be induced in a variety of cell types, 
including non-hematopoietic tissues as well as in various tumors.  Both ligands are type I 
transmembrane receptors containing both IgV- and IgC-like domains in the extracellular region 
and contain short cytoplasmic regions with no known signaling motifs.  Binding of either PD-1 
ligand to PD-1 inhibits T-cell activation triggered through the T-cell receptor.  PD-L1 is 
expressed at low levels on various non-hematopoietic tissues, most notably on vascular 
endothelium, whereas PD-L2 protein is only detectably expressed on antigen-presenting cells 
found in lymphoid tissue or chronic inflammatory environments.  PD-L2 is thought to control 
immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen unwarranted T-
cell function in peripheral tissues.  Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor.  It has 
been suggested that PD-1 regulates tumor-specific T-cell expansion in subjects with melanoma 
(MEL).  This suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune 
evasion and should be considered an attractive target for therapeutic intervention. 
 
Pembrolizumab (MK-3475) is a potent and highly selective humanized monoclonal antibody 
(mAb) of the IgG4/kappa isotype designed to directly block the interaction between PD-1 and its 
ligands, PD-L1 and PD-L2. KeytrudaTM (pembrolizumab) has recently been approved in the 
United Stated for the treatment of patients with unresectable or metastatic melanoma and disease 
progression following ipilimumab and, if the melanoma is BRAF V600 mutation positive, a 
BRAF inhibitor. 
 
1.2.2 Preclinical and Clinical Trial Data 
 
1.2.2.1 
Non-Clinical Toxicology Summary of Results  
In the 1-month and 6-month toxicology study in cynomologus monkeys, pembrolizumab, 
intravenously administered once a week and once every other week respectively up to a dose of 
200 mg/kg, resulted in no adverse treatment-related effects. In tissue cross-reactivity studies of 
pembrolizumab in human and monkey tissues, the expected on-target staining of mononuclear 
leukocytes membranes was demonstrated in both species. Off-target cross-reactivity staining was 
also noted in both species but was limited to the cytoplasm of various cell types/tissues and the 


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stroma (extracellular connective tissue matrix), and was considered related to experimental 
methodological artifacts, i.e. tissue processing for IHC, which are well recognized limitations of 
tissue cross-reactivity studies and, thus not considered toxicologically relevant. No reproductive 
or developmental toxicity studies are planned with pembrolizumab. Therefore, inclusion of 
women of childbearing potential in clinical trials should be avoided in accordance with the study 
protocol and applicable regulatory guidance (e.g., ICH M3(R2): Nonclinical Safety Studies for 
the Conduct of Human Clinical Trials and Marketing Authorization for Pharmaceuticals). 
 
1.2.2.2 
Clinical Summary of Results 
As of 18-Oct-2013, 1,000 patients have been treated with pembrolizumab at several dose 
schedules, including 10 mg/kg every 2 weeks. Pembrolizumab has been generally well tolerated, 
as expected based on preclinical findings and other anti-PD-1 monoclonal antibodies. As of 18-
Oct-2013 no serious infusion reactions have been reported in PN001, however, as the potential 
exists in anti-PD-1 monoclonal antibodies, investigators should be vigilant to this possibility. 
Less than 1% of patients assayed thus far have had confirmed positive ADA samples and among 
these, no clear impact on exposure has been observed. There is no contraindication to further 
clinical investigation with pembrolizumab. Pharmacokinetics were as expected, based on 
pembrolizumab being an IgG mAb, and preclinical data support dosing once every 2 or 3 weeks. 
Pembrolizumab monotherapy induces an ORR of between 25% and 27% in patients with 
ipilimumab-exposed melanoma by central independent RECIST and oncology 
review/investigator assessed irRC, respectively. Pembrolizumab monotherapy induces an ORR 
of 39% and 43% in patients with ipilimumab-naive melanoma by central independent RECIST 
and oncology review/investigator assessed irRC, respectively. These responses are remarkably 
durable. The preliminary 1-year survival rate for patients who receive pembrolizumab, many of 
whom have had multiple prior therapies, including ipilimumab, is 81%. Pembrolizumab 
monotherapy induces an ORR of 21% and 24% in patients with previously-treated NSCLC by 
central independent RECIST and investigator assessed irRC, respectively, with these responses 
also remarkably durable. Preliminary data suggest that higher levels of PD-L1 expression in 
tumors of NSCLC are associated with increased activity (ORR 67% by investigator assessed 
irRC and 57% by central independent RECIST); additional data are required to define the 
optimal PD-L1 assay cut-off point. The most commonly experienced treatment emergent AEs 
are reportedly fatigue (43.8%), nausea (26.7%), cough (25.3%), pruritus (24.6%), diarrhea 
(22.3%) and rash (21.5%). Immune-related adverse events were reported in 21.4% of melanoma 
patients; most of these events (15.8%) were considered drug-related by the investigator. The 
most commonly reported, immune-related adverse events across the dose-schedules are rash 
(3.2%), pruritus (2.9%), vitiligo (2.9%), hypothyroidism (2.7%), arthralgia (2.2%), diarrhea 
(2.2%), and pneumonitis (1.9%). Review of the overall benefit:risk ratio of pembrolizumab 
favors enrollment of eligible patients into clinical trials of pembrolizumab. The preliminary data 
suggest that a dose of pembrolizumab at 2 mg/kg Q3W is appropriate for patients with 
melanoma. 
 
1.2.2.3 
Dosage and Administration 
Pembrolizumab is provided as a white to off white lyophilized powder (50 mg/vial) or as a liquid 
solution (100 mg/vial) in Type I glass vials intended for single use only. Pembrolizumab Powder 
for Solution for Infusion, 50 mg/vial, is reconstituted with sterile water for injection prior to use. 
Pembrolizumab is formulated with L-histidine as buffering agent, polysorbate 80 as surfactant, 


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sucrose as stabilizer/tonicity modifier, and hydrochloric acid (HCl) and/or sodium hydroxide 
(NaOH) for pH adjustment (if necessary). The drug product is stored as a stable lyophilized 
powder or liquid solution under refrigerated conditions (2°C - 8°C). The product after 
reconstitution with sterile water for injection and the liquid drug product is a clear to opalescent 
solution which may contain extraneous and proteinaceous particulates. The reconstituted product 
and liquid product is intended for IV administration. The reconstituted drug product solution and 
liquid drug product can be further diluted with normal saline in IV containers made of polyvinyl 
chloride (PVC) or non-PVC material. Reconstituted vials should be immediately used to prepare 
the infusion solution in the IV bag and the infusion solution should be immediately administered. 
If not used immediately, vials and/or IV bags may be stored at 2-8 °C for up to a cumulative time 
of 20 hours. If refrigerated, the vials and/or IV bags should be allowed to equilibrate to room 
temperature prior to subsequent use. Pembrolizumab solutions may be stored at room 
temperature for a cumulative time of up to 4 hours. This includes room temperature storage of 
reconstituted drug product solution and liquid drug product in vials, room temperature storage of 
infusion solution in the IV bag and the duration of infusion. 
 
1.3 
Sylatron 
SYLATRON™ is an alpha interferon indicated for the adjuvant treatment of melanoma with 
microscopic or gross nodal involvement within 84 days of definitive surgical resection, including 
complete lymphadenectomy. Sylatron (Peginterferon alfa-2b) is a pleiotropic cytokine; the 
mechanism by which it exerts its effects in patients with melanoma is unknown. The FDA-
recommended dose for this indication is 6 mcg/kg/week subcutaneously for 8 doses, followed by 
3 mcg/kg/week subcutaneously for up to 5 years. 
 
1.3.1 Pharmaceutical and Therapeutic Background 
The pharmacokinetics of Sylatron was studied in 32 patients receiving adjuvant therapy for 
melanoma with the agent according to the recommended dose and schedule (6 mcg/kg/week for 
8 doses, followed by 3 mcg/kg/week thereafter). At a dose of 6 mcg/kg/week once weekly, the 
geometric mean Cmax was 4.4 ng/mL (CV 51%) and the geometric mean AUCtau was 430 
ng•hr/mL (CV 35%) at week 8. The mean terminal half-life was approximately 51 hours (CV 
18%). The mean accumulation from week 1 to week 8 was 1.7. After administration of 3 
mcg/kg/week once weekly, the mean geometric Cmax was 2.5 ng/mL (CV 33%) and the 
geometric mean AUCtau was 228 ng•hr/mL (CV 24%) at week 4. The mean terminal half-life 
was approximately 43 hours (CV 19%). Renal clearance accounts for approximately 30% of total 
Sylatron clearance. The effect of renal impairment on the pharmacokinetics of Sylatron was 
studied in 24 subjects with normal or impaired renal function after a single 4.5 mcg/kg dose. 
Compared to subjects with normal renal function (CLcr > 80 mL/min/1.73 m²), the geometric 
mean AUClast to Sylatron increased by 1.4-fold in subjects with moderate renal impairment 
(CLcr 30 to 50 mL/min/1.73m²) and 2.1-fold in subjects with severe renal impairment (CLcr < 
30 mL/min/1.73m²) or ESRD requiring dialysis. No clinically meaningful amounts of Sylatron 
were removed during hemodialysis following a single 1 mcg/kg dose in subjects with renal 
impairment. 
 
 
 


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1.3.2 Clinical Summary of Results: 
The data described below reflect exposure to Sylatron in 608 patients with surgically resected, 
AJCC Stage III melanoma. Sylatron was studied in an open label, multicenter, randomized, 
observation controlled trial. The median age of the population was 50 years with 10% of patients 
65 years or older, and 42% being female. Fourteen percent of patients completed the 5 year 
treatment schedule. 
 
Patients randomized to Sylatron were to receive total doses of 48 mcg/kg (6 mcg/kg 
subcutaneous once weekly for 8 doses), and 780 mcg/kg (3 mcg/kg subcutaneous once weekly 
until disease recurrence or for up to 5 years), as tolerated. The median total dose received was 42 
mcg/kg (range: 6 to 78 mcg/kg) for the first 8 doses, and 136 mcg/kg (range: 1 to 774 mcg/kg) 
for doses 9 to 260. 
 
Because clinical trials are not all conducted under identical conditions, adverse reaction rates 
observed in the clinical trials of one drug cannot be directly compared to adverse reaction rates in 
the clinical trials of another drug, and may not reflect the rates observed in clinical practice. In 
the current combination phase II study, since Sylatron is administrated to potentiate the effect of 
pembrolizumab, the total doses of 2400 mcg will be administered over 12 week period of time, 
which is less than 20% of the median total dose of Sylatron administered in a patient who 
weighed 70kg and was enrolled in the Sylatron phase III melanoma registration study. Therefore, 
patients enrolled in the current combination phase II study are not expected to have the level of 
side effects and toxicities as patients experienced in the phase III melanoma study as described 
below.  
 
Serious adverse events were reported in 199 (33%) patients who received Sylatron and 94 (15%) 
patients in the observation group. The most common adverse reactions experienced by Sylatron-
treated patients were fatigue (94%), increased ALT (77%), increased AST (77%), pyrexia (75%), 
headache (70%), anorexia (69%), myalgia (68%), nausea (64%), chills (63%), and injection site 
reaction (62%). The most common serious adverse reactions were fatigue (7%), increased ALT 
(3%), increased AST (3%), and pyrexia (3%) in the Sylatron-treated group vs. <1% in the 
observation group for these reactions. 
 
Thirty three percent of patients receiving Sylatron discontinued treatment due to adverse 
reactions. The most common adverse reactions present at the time of treatment discontinuation 
were fatigue (27%), depression (17%), anorexia (15%), increased ALT (14%), increased AST 
(14%), myalgia (13%), nausea (13%), headache (13%), and pyrexia (11%). 
 
1.4 
Rationale for the Study 
 
1.4.1 Overall Rationale 
If we are to further improve the survival of patients with cholangiocarcinoma, new approaches 
are urgently needed to prevent tumor recurrence after surgical resection of cholangiocarcinomas.  
Pembrolizumab is a monoclonal antibody that binds to the programmed death-1 (PD-1) receptor 
and blocks its interaction with ligands PD-L1 and PD-L2, thereby releasing PD-1 pathway-
mediated inhibition of the immune response, including a strong anti-tumor immune response. 
Prognostic impact of tumor-infiltrating immune cells on biliary tract cancer was studied in a 


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retrospective study of 375 patients with cholangiocarcinoma. [19] High levels of tumor 
infiltrating lymphocytes in cholangiocarcinoma were associated with good clinical outcome. 
Therapies that target the PD-1 receptor have shown yet unmatched rates of lasting clinical 
responses in patients with a number of cancer types. [1-5].  The response rate of pembrolizumab 
in patients with advanced cholangiocarcinoma was 17% in a phase I study (internal 
communication with research team in Merck, unpublished data).  Interferon alpha 2b has been 
shown to increase tumor immune infiltrates [20,21]. We propose to combine Sylatron with 
pembrolizumab to improve the response rate of pembrolizumab. We hypothesize that Sylatron 
will improved the response rate of pembrolizumab from 17% to 35% by increasing the immune 
cell infiltrate into the tumor. 
 
1.4.2 Rationale – Effect of Pembrolizumab on Immune Function 
Studies reveal a direct causal relationship between cancer and immune dysfunction, whereby 
tumor cells and their microenvironment are able to evade immune attack by exploiting various 
immunoregulatory mechanisms in a process termed cancer immunoediting (22).  Regulatory 
pathways that limit the immune response to cancer are becoming increasingly well characterized 
and provide new strategies in cancer therapy. Monoclonal antibodies targeting PD-1 that boost 
the immune system are being developed for the treatment of a number of cancers. On September 
4, 2014, the U.S. Food and Drug Administration granted accelerated approval to pembrolizumab 
(KeytrudaTM, Merck Sharp & Dohme Corp.) for the treatment of patients with unresectable or 
metastatic melanoma (23). Pembrolizumab is a monoclonal antibody that binds to the PD-1 
receptor and blocks its interaction with ligands PD-L1 and PD-L2, thereby releasing PD-1 
pathway-mediated inhibition of the immune response, including anti-tumor immune response.   
 
Evasion of the immune surveillance and metastatic spread can be achieved through a number of 
complex mechanisms. Targeting multiple sites should overcome tumor immune evasion. IFNs 
activate immune cells, such as natural killer cells and macrophages, and they increase host 
defenses by up-regulating tumor antigen presentation by virtue of increasing the expression of 
major histocompatibility complex (MHC) antigens.  Blockade of tumor immune checkpoints by 
pembrolizumab augments anti-tumor immunity. Activation of IFN signaling in combination with 
the blockade of immune-inhibitory receptors should increase the exposure of 
cholangiocarcinoma to cellular immune surveillance, and enhance anti-tumor activity. 
 
The B7-H1/PD-1 pathway has recently been found to contribute to immune evasion of cancer 
cells from host immune system. Expression of B7-H1 and PD-1 was found to be up-regulated in 
cholangiocarcinoma tissues compared with adjacent tissues. Tumor-related B7-H1 expression 
was significantly correlated with both tumor differentiation and pTNM stage and was inversely 
correlated with CD8+ tumor infiltrative lymphocytes (TILs) but not CD4+ TILs. TILs in primary 
carcinoma showed a high level of apoptosis suggesting that promotion of anti-tumor immunity 
may be a novel therapeutic strategy in the treatment of cholangiocarcinoma [24]. Therapies that 
boost host anti-tumor activity have shown promising activity against cholangiocarcinoma. A 
phase II study evaluating the efficacy of intravenous 5-FU and subcutaneous IFN- for 
cholangiocarcinoma produced a 34% response rate, the median time to disease progression was 
9.5 months, and the median survival time was 12 months [25]. The response rate of 
pembrolizumab in patients with advanced cholangiocarcinoma was 17% in a phase I study 
(internal communication with research team in Merck, unpublished data).   


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IFN-has been used to treat certain types of leukemias and lymphomas, skin melanomas, and 
Kaposi sarcoma. IFNs activate immune cells, such as natural killer cells and macrophages, and 
thus increase host defenses by up-regulating antigen presentation by virtue of increasing the 
expression of major histocompatibility complex (MHC) antigens.  In addition, IFN- also 
induces the immune-inhibitory interaction between PD-L1 and PD-1 receptors [26]. 
Interconnections between IFNs and immune-inhibitory receptors serve as targets for combination 
immunotherapies. 
 
1.4.3 Rationale – Pembrolizumab Dose Selection/Regimen/Modification  
An open-label Phase I trial (Protocol 001) was conducted to evaluate the safety and clinical 
activity of single agent pembrolizumab.  The dose escalation portion of this trial evaluated three 
dose levels, 1 mg/kg, 3 mg/kg, and 10 mg/kg, administered every 2 weeks (Q2W) in subjects 
with advanced solid tumors.  All three dose levels were well tolerated and no dose-limiting 
toxicities were observed.  This first in human study of pembrolizumab showed evidence of target 
engagement and objective evidence of tumor size reduction at all dose levels (1 mg/kg, 3 mg/kg 
and 10 mg/kg Q2W).  No MTD has been identified to date.  Recent data from other clinical 
studies within the pembrolizumab program has shown that a lower dose of pembrolizumab and a 
less frequent schedule may be sufficient for target engagement and clinical activity. 
 
PK data analysis of pembrolizumab administered Q2W and Q3W showed slow systemic 
clearance, limited volume of distribution, and a long half-life (refer to IB).  Pharmacodynamic 
data (IL-2 release assay) suggested that peripheral target engagement is durable (>21 days).  This 
early PK and pharmacodynamic data provides scientific rationale for testing a Q2W and Q3W 
dosing schedule.   
 
A population pharmacokinetic analysis has been performed using serum concentration time data 
from 476 patients. Within the resulting population PK model, clearance and volume parameters 
of pembrolizumab were found to be dependent on body weight. The relationship between 
clearance and body weight, with an allometric exponent of 0.59, is within the range observed for 
other antibodies and would support both body weight normalized dosing or a fixed dose across 
all body weights.  Pembrolizumab has been found to have a wide therapeutic range based on the 
melanoma indication.  The differences in exposure for a 200 mg fixed dose regimen relative to a 
2 mg/kg Q3W body weight based regimen are anticipated to remain well within the established 
exposure margins of 0.5 – 5.0 for pembrolizumab in the melanoma indication. The exposure 
margins are based on the notion of similar efficacy and safety in melanoma at 10 mg/kg Q3W vs. 
the proposed dose regimen of 2 mg/kg Q3W (i.e. 5-fold higher dose and exposure). The 
population PK evaluation revealed that there was no significant impact of tumor burden on 
exposure. In addition, exposure was similar between the NSCLC and melanoma indications. 
Therefore, there are no anticipated changes in exposure between different indication settings. 
 
The rationale for further exploration of 2 mg/kg and comparable doses of pembrolizumab in 
solid tumors is based on: 1) similar efficacy and safety of pembrolizumab when dosed at either 2 
mg/kg or 10 mg/kg Q3W in melanoma patients, 2) the flat exposure-response relationships of 
pembrolizumab for both efficacy and safety in the dose ranges of 2 mg/kg Q3W to 10 mg/kg 
Q3W, 3) the lack of effect of tumor burden or indication on distribution behavior of 


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pembrolizumab (as assessed by the population PK model) and 4) the assumption that the 
dynamics of pembrolizumab target engagement will not vary meaningfully with tumor type. 
 
The choice of the 200 mg Q3W as an appropriate dose for the switch to fixed dosing is based on 
simulations performed using the population PK model of pembrolizumab showing that the fixed 
dose of 200 mg every 3 weeks will provide exposures that 1) are optimally consistent with those 
obtained with the 2 mg/kg dose every 3 weeks, 2) will maintain individual patient exposures in 
the exposure range established in melanoma as associated with maximal efficacy response and 3) 
will maintain individual patients exposure in the exposure range established in melanoma that 
are well tolerated and safe.  
 
A fixed dose regimen will simplify the dosing regimen to be more convenient for physicians and 
to reduce potential for dosing errors.  A fixed dosing scheme will also reduce complexity of the 
trial at treatment facilities and reduce wastage. 
 
1.4.3.1 
The safety of combining pembrolizumab and Sylatron  
The safety of combining pembrolizumab and Sylatron has been evaluated in a phase I study. This 
safety and dose-seeking study of combination pembrolizumab and Sylatron for patients ( ≥ 18) 
with recurrent inoperable AJCC stage III and metastatic stage IV melanoma. Pembrolizumab is 
given 2 mg/kg q3 weeks for 2 years while Sylatron is given SC at 3 dose levels (1, 2 and 3 
mcg/kg) to identify the recommended phase 2 dose (RP2D) prior to dose expansion up to 32 
patients. Results: Twelve patients have been enrolled in this trial (4 patients at each dose level). 
No dose limiting toxicity has been observed to date. Most common side adverse events were 
grade 1 liver toxicities (n = 4), grade 1 neutropenia (n = 4), grade 1 skin rash (n = 3) and grade 1 
anemia (n = 2). The only grade 3/4 toxicities were lymphopenia (n = 2) and hyponatremia (n = 
1). Six out of 12 patients were evaluated for clinical responses at week 12 and we observed 1CR, 
4SD and 1PD with mixed clinical responses (NCT02112032)[27]. In this current phase II study, 
the dosage of pembrolizumab and Sylatron are selected based on the data from the phase I study. 
Pembrolizumab will be administered at 200mg q 3 weeks, which is close to the dosage of 
pembrolizumab at 3mg/kg for a patient of 70 kg; Sylatron will be administered at 200mcg 
weekly, which is close to the dose of Sylatron at 3mcg/kg for a patient of 70 kg.  
 
1.4.4 Rationale - Efficacy Endpoints 
As stated in the Overall Rationale, prognostic impact of tumor-infiltrating immune cells on 
biliary tract cancer was studied in a retrospective study including a cohort of 375 patients with 
cholangiocarcinoma.[19] High levels of tumor infiltrating lymphocytes in cholangiocarcinoma 
were associated good clinical outcome. Therapies that target the PD-1 receptor have shown 
unprecedented rates of durable clinical responses in patients with various cancer types. [1-5] Pre-
existing CD8+ T cells distinctly located at the invasive tumor margin are associated with 
expression of the PD-1/PD-L1 immune inhibitory axis and seems to predict response to 
therapy.[8] In previous retrospective study, 48.4% of cases showed high levels of CD8+ T 
lymphocytes and 36.3% of cases had high levels of CD4+ T lymphocyte infiltrates [28]. An 
increase in tumor immune infiltrate may be a strategy to improve the responsiveness of cancer to 
anti-PD-1 treatment. The response rate of pembrolizumab in patients with advanced 
cholangiocarcinoma was 17% in a phase I study (internal communication with research team in 
Merck, unpublished data).  Interferon alpha 2b has shown to increase the tumor immune 


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infiltrates.[20,21] We propose to combine Sylatron and pembrolizumab to improve the response 
rate of pembrolizumab. Interferon alpha 2b in combination with 5-Flurouracil produced a 
response rate of 34% in patients with cholangiocarcinoma in a phase II study. However, 5-
Flurouracil as single agent induced a response rate of 32% in patients with advanced 
cholangiocarcinoma in another phase II study. Interferon alpha 2b is likely to have minimal 
activity against cholangiocarcinoma as a single agent. We hypothesize that Sylatron will 
improved the response rate of pembrolizumab from 17% to 35% by increasing the immune cell 
infiltrate into the tumor. 
 
After first-line treatment with gemcitabine-based regimen, there is no standard second-line 
chemotherapy for patients with metastatic gallbladder cancer and cholangiocarcinoma. A 
retrospective analysis of metastatic gallbladder cancer and cholangiocarcinoma that were treated 
with second-line FOLFOX4 chemotherapy after disease progression on gemcitabine-based first 
line chemotherapy, showed stable disease in 22% of patients, and the median disease free 
survival (DFS) and OS were 96 days (13 weeks) and 138 days (19 weeks), respectively [18]. 
Immune checkpoint inhibitors have shown durable disease control in multiple types of cancer, 
e.g., melanoma, renal cell carcinoma, non small cell lung cancer, etc. We propose that a PFS of 
24 weeks and OS of 40 weeks in patients who receive the combination of pembrolizumab and 
Sylatron after cancer progression or intolerance of frontline treatment will be considered clinical 
meaningful. 
 
2. 
STUDY OBJECTIVES AND ENDPOINTS 
 
2.1 
Objectives 
 
2.1.1 Primary Objective 
Assess objective response rate of patients receiving pembrolizumab and Sylatron combination 
therapy based RECIST 1.1. 
 
Hypothesis: 
The addition of Sylatron to a pembrolizumab regimen will improve the response rate of 
pembrolizumab from 17% to 35% in patients with advanced cholangiocarcinoma based on 
RECIST1.1. 
 
2.1.2 Secondary Objectives 
• Assess progression free survival of patients receiving pembrolizumab and Sylatron. 
• Assess overall survival of patients receiving pembrolizumab and Sylatron 
• Assess the objective response rate of patients receiving pembrolizumab and Sylatron 
combination therapy based irRECIST. 
• Assess the safety and tolerability of combined pembrolizumab and Sylatron therapy. 
 
Hypothesis: 
We propose that a PFS of 24 weeks and an OS of 40 weeks is clinically meaningful in patients 
who receive the combination of pembrolizumab and Sylatron following failure on frontline 
therapy (due to cancer progression or intolerance of treatment).  
 


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2.1.3 Correlative/Exploratory Objectives 
• Determine the effect of Sylatron on anti- programmed death ligand-1 (PD-L1) level, 
immune score as determined by the density of CD3 and CD8 in the tumor interior and 
invasive margin(s) of the tumor, and the clonality of the T-cell repertoire. 
• Determine the effect of Sylatron on anti-cancer immunity by measuring proliferation of 
CD8+ T cells, Granzyme B+ cells and proliferation of tumor cells, and correlating these 
changes with clinical response as determined by RECIST 1.1. 
 
Hypothesis: 
Therapies that target the programmed death-1 (PD-1) receptor have shown unprecedented rates 
of durable clinical responses in a sub-group of patients with various cancer types [1-5]. 
Biomarkers in patient tumor that will predict response to anti-PD-1 therapy are being actively 
investigated. One mechanism by which cancer tissues limit the host immune response is via 
upregulation of PD-1 ligand (PD-L1) and its ligation to PD-1 on antigen-specific CD8+ T cells 
[6, 7]. Recent research has reported that tumor regression after therapeutic PD-1 blockade 
requires pre-existing CD8+ T cells that are negatively regulated by PD-1/PD-L1-mediated 
adaptive immune resistance [8]. We propose that Sylatron will increase the response of 
pembrolizumab by increasing the tumor infiltrating CD3 and CD8 cells, and the level of PD-L1 
and PD-1 expression in immune cells and cancer cells. In this study, we will first test the effect 
of Sylatron on tumor infiltrating lymphocytes, the level of PD-1 and PD-L1 expression, and 
clonality of the T-cell repertoire by comparing the tumor biopsies from baseline and three weeks 
of Sylatron treatment. Then we will examine whether the change of tumor infiltrating 
lymphocytes, the level of PD-1 and PD-L1 expression from Sylatron treatment correlates with 
clinical response in patient treated with pembrolizumab and Sylatron combination therapy.  
 
2.2 
Endpoints 
 
2.2.1 Primary Endpoint 
• The objective response rate is the proportion of all subjects with confirmed PR or CR 
according to RECIST 1.1, from the start of treatment until disease progression/recurrence 
(taking as reference for progressive disease the smallest measurements recorded since the 
start of treatment). 
 
2.2.2 Secondary Endpoints 
• PFS defined as measurement from the date of registration until the criteria for disease 
progression is met as defined by RECIST 1.1 or death occurs. Subjects who have not 
progressed will be right-censored at the date of the last disease evaluation. 
• OS is defined as the time of registration until death as a result of any cause.  
• Objective response rate is defined as the sum of complete response (CR) + confirmed 
partial response (PR) and will be determined as per irRECIST.  
• Grade 3 and 4 toxicities as defined by the NCI Common Terminology Criteria for 
Adverse Events (NCI CTCAE) v4. 
 
 
 


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2.2.3 Exploratory Endpoints 
• The density of CD3 and CD8 in the tumor interior and invasive margin of the tumor, and 
the clonality of the T-cell repertoire. 
• Proliferation of CD8+ T cells, Granzyme B+ cells and proliferation of tumor cells. 
 
3. 
ELIGIBILITY CRITERIA 
This trial is a multi-institutional study, enrolling patients with cholangiocarcinoma, manifesting 
as either intrahepatic, extrahepatic or gallbladder cancer, that is unresectable, metastatic, or has 
either failed to respond to or demonstrated progression despite prior therapy. Patients must be, in 
the opinion of the site investigator, an appropriate candidate for experimental therapy. Patients 
should be evaluated for the need to undergo biliary drainage by stent placement prior to study 
participation. Patients should have adequate biliary drainage with no unresolved biliary 
obstruction. 
 
The target recruitment for this study is 44 patients. As the trial is opening at several centers, 
recruitment is anticipated to take 21 months, and the anticipated time to complete follow-up of 
all patients will be 36 months.   
 
3.1 
Inclusion Criteria 
Subject must meet all of the following applicable inclusion criteria to participate in this study: 
 
1. Be willing and able to provide written informed consent/assent for the trial. 
 
2. Be  18 years of age on day of signing informed consent. 
 
3. Patients must have received 1 line of prior systemic therapy for metastatic or resectable 
disease (i.e. patients may have received adjuvant gemcitabine and then later 
gemcitabine/cisplatin for recurrent metastatic disease) 
 
4. Histological confirmation of cholangiocarcinoma.  
 
5. Have measurable disease based on RECIST 1.1.   
 
6. Be willing to provide tissue from a newly obtained core or excisional biopsy of a tumor 
lesion. Newly obtained is defined as a specimen obtained up to 6 weeks (42 days) prior to 
initiation of treatment on Day 1. Subjects for whom newly obtained samples cannot be 
provided (e.g. inaccessible or subject safety concern) may submit an archived specimen 
only upon agreement from the sponsor-investigator. 
 
7. Have a performance status of 0 or 1 on the ECOG Performance Scale. 
 
 
 


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8. Demonstrate adequate organ function as defined in Table 1. All screening labs will be 
performed within 28 days of registration.  
 
Table 1:  Adequate Organ Function Laboratory Values 
System 
Laboratory Value 
Hematological 
Absolute neutrophil count (ANC) 
≥ 1,500 /μL 
Platelets 
≥ 100,000 / μL 
Hemoglobin 
≥ 9 g/dL or ≥ 5.6 mmol/L without transfusion or 
EPO dependency (within 7 days of assessment) 
Renal 
Serum creatinine OR 
Measured or calculateda creatinine 
clearance 
(GFR can also be used in place of 
creatinine or CrCl) 
≤ 1.5 X upper limit of normal (ULN) OR 
 
≥ 60 mL/min for subject with creatinine levels 
> 1.5 x institutional ULN 
Hepatic 
Serum total bilirubin 
≤ 2.0 X ULN  
AST (SGOT) and ALT (SGPT) 
≤ 3.0 X ULN OR 
≤ 5 X ULN for subjects with liver metastases 
Albumin 
> 2.5 mg/dL 
Coagulation 
International Normalized Ratio 
(INR) or Prothrombin Time (PT) 
 
Activated Partial Thromboplastin 
Time (aPTT) 
≤ 1.5 X ULN unless subject is receiving 
anticoagulant therapy 
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants 
≤ 1.5 X ULN unless subject is receiving 
anticoagulant therapy 
as long as PT or PTT is within therapeutic range of 
intended use of anticoagulants 
aCreatinine clearance should be calculated per institutional standard. 
 
9. Female subject of childbearing potential should have a negative urine or serum pregnancy 
within 72 hours prior to receiving the first dose of study medication. If the urine test is 
positive or cannot be confirmed as negative, a serum pregnancy test will be required.  
  
10. Female subjects of childbearing potential should be willing to use adequate birth control 
or be surgically sterile, or abstain from heterosexual activity for the course of the study 
through 120 days after the last dose of study medication (Reference Section 5.5.2). 
Subjects of childbearing potential are those who have not been surgically sterilized or 
have not been free from menses for > 1 year.  
 
11. Male subjects should agree to use an adequate method of contraception starting with the 
first dose of study therapy through 120 days after the last dose of study therapy. 
 
 
 


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3.2 
Subject Exclusion Criteria 
The subject must be excluded from participating in the trial if the subject: 
 
1. Has symptomatic congestive heart failure, unstable angina pectoris, symptomatic or 
poorly controlled cardiac arrhythmia.  Symptomatic heart failure (NYHA Class II-IV)  
 
2. Has a history of anaphylaxis to peginterferon alfa-2b or interferon alfa-2b 
 
3. Is currently participating and receiving study therapy or has participated in a study of an 
investigational agent and received study therapy or used an investigational device within 
4 weeks of the first dose of treatment. 
 
4. Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any 
other form of immunosuppressive therapy within 7 days prior to the first dose of trial 
treatment. 
 
5. Has a known history of active TB (Bacillus Tuberculosis) 
 
6. Hypersensitivity to pembrolizumab or any of its excipients. 
 
7. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study 
Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due 
to agents administered more than 4 weeks earlier. 
 
8. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy within 
2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) 
from adverse events due to a previously administered agent. 
a. NOTE:  Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and 
may qualify for the study. 
b. NOTE:  If subject received major surgery, they must have recovered adequately 
from the toxicity and/or complications from the intervention prior to starting 
therapy.   
 
9. Has a known additional malignancy that is progressing or requires active treatment. 
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the 
skin that has undergone potentially curative therapy or in situ cervical cancer. 
 
10. Has known active central nervous system (CNS) metastases and/or carcinomatous 
meningitis. Subjects with previously treated brain metastases may participate provided 
they are stable (without evidence of progression by imaging for at least four weeks prior 
to the first dose of trial treatment and any neurologic symptoms have returned to 
baseline), have no evidence of new or enlarging brain metastases, and are not using 
steroids for at least 7 days prior to trial treatment. This exception does not include 
carcinomatous meningitis, which is excluded regardless of clinical stability.   
 


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11. Has active autoimmune disease that has required systemic treatment in the past 2 years 
(i.e. with use of disease modifying agents, corticosteroids, or immunosuppressive drugs). 
Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement 
therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic 
treatment.  
 
12. Has known history of, or any evidence of active, non-infectious pneumonitis. 
 
13. Has an active infection requiring systemic therapy. 
 
14. Has a history or current evidence of any condition, therapy, or laboratory abnormality 
that might confound the results of the trial, interfere with the subject’s participation for 
the full duration of the trial, or is not in the best interest of the subject to participate, in 
the opinion of the site investigator.   
 
15. Has known psychiatric or substance abuse disorders that would interfere with cooperation 
with the requirements of the trial. 
 
16. Is pregnant or breastfeeding, or expecting to conceive or father children within the 
projected duration of the trial, starting with the pre-screening or screening visit through 
120 days after the last dose of trial treatment. 
 
17. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent. 
 
18. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies). 
 
19. Has known active Hepatitis B without HBV treatment (HBV infection with ongoing 
HBV treatment is allowed); has persistent chronic Hepatitis C infection (successfully 
treated HCV infection is allowed).  
 
20. Has received a live vaccine within 30 days of planned start of study therapy. 
NOTE:  Seasonal influenza vaccines for injection are generally inactivated flu vaccines 
and are allowed; however, intranasal influenza vaccines (e.g., Flu-Mist®) are live 
attenuated vaccines, and are not allowed. 
 
21. Has history of bipolar disorder or major depression as identified by the enrolling 
physician. See SPM for additional information. 
 
22. Has history of not tolerating interferon treatment. 
 
23. Has known serious neuropsychiatric condition. 
 
24. Has a history of organ or stem cell transplantation 
 
 
 


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4. 
SUBJECT REGISTRATION 
All subjects must be registered through HCRN’s electronic data capture (EDC) system. A subject 
is considered registered when an “On Study” date is entered into the EDC system. Subjects must 
be registered prior to starting protocol therapy.  
 
5. 
TREATMENT PLAN 
 
5.1 
Pre-medication and Hydration 
There are no pre-medications for sylatron or pembrolizumab 
 
5.2 
Pembrolizumab and Sylatron Administration 
Each cycle = 21 days or 3 weeks.  Sylatron will be administered at 200mcg subcutaneously every 
week for up to 12 weeks (3 weeks as single agent, and 9 weeks in combination of 
pembrolizumab) starting Cycle 1 Day 1. The dose of sylatron may be reduced to 120mcg 
weekly, or 60mcg weekly if patients experience unacceptable toxicities at the higher dose levels.  
Patients will be premedicated with acetaminophen 500 to 1000 mg orally 30 minutes prior to the 
first dose of sylatron and as needed for subsequent doses. Injection sites will be rotated. During 
the Cycle 1 Day 1 visit, subjects will be provided education on how to manage sylatron 
injections at home.  
 
Pembrolizumab will be administered intravenously as a 30 minute infusion at a dose of 200 mg 
every 3 weeks starting Week 4 (Cycle 2 Day 1).  All trial treatments will be administered on 
an outpatient basis. On the days that sylatron and pembrolizumab are given together, sylatron 
should be administered prior to the pembrolizumab infusion. 
 
Sites should make every effort to target infusion timing to be as close to 30 minutes as possible. 
However, given the variability of infusion pumps from site to site, a window of -5 minutes and 
+10 minutes is permitted (i.e., infusion time is 30 minutes: -5 min/+10 min).  The Pharmacy 
Manual contains specific instructions for the preparation of the pembrolizumab infusion fluid 
and administration of infusion solution. 
 
With concerns about toxicity while using long-term sylatron, if no additional benefit is seen 
beyond 12 weeks of treatment on top of that expected from pembrolizumab alone, patients will 
discontinue sylatron treatment after they have received 12 weeks of this therapy (3 weeks as 
single agent and 9 weeks in combination with pembrolizumab). Pembrolizumab should be 
continued in the absence of unacceptable toxicity (based on CTCAE v4) until disease 
progression-based on RECIST 1.1. In patients who had responded to the combination therapy, 
when patient shows disease progression while on single agent pembrolizumab treatment, sylatron 
may be resumed at the discretion of the site investigator after discussion with the sponsor-
investigator. 
 
 
 
 


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Medication Administration (Cycle = 21 days or 3 weeks) 
Drug 
Dose 
Route 
Schedule 
Regimen 
Treatment 
Period 
Cycle 
Sylatron 
200mcg 
Subcutaneous 
injection 
Q1W 
starting 
C1D1 
Day 1, 8 and 15 
of each cycle 
(weekly) 
21 days 
Pembrolizumab 
200mg 
Intravenous 
Infusion (IV) 
over 30 minutes 
Q3W 
starting 
C2D1 
Day 1 of each 
cycle 
21 days 
Dosing interruptions are permitted in the case of medical/surgical events or logistical reasons not 
related to study therapy (e.g., elective surgery, unrelated medical events, patient vacation, and/or 
holidays). Subjects should be placed back on study therapy within 3 weeks of the scheduled 
interruption, unless otherwise discussed with the sponsor-investigator. The reason for interruption 
should be documented in the subject’s chart and electronic case report forms (eCRFs). 
 
5.3 
Treatment Beyond Radiological Disease Progression with Pembrolizumab 
Accumulating clinical evidence indicates that some subjects treated with immune system 
stimulating agents may develop disease progression by conventional response criteria before 
demonstrating clinical objective responses and/or stable disease. This phenomenon was observed 
in the Phase I study of nivolumab, CA209003. Two hypotheses explain this phenomenon. First, 
enhanced inflammation within tumors could lead to an increase in tumor size, which would 
appear as enlarged index lesions and as newly visible small non-index lesions. Over time, both 
the malignant and inflammatory portions of the mass may then decrease leading to overt signs of 
clinical improvement. Alternatively, in some individuals, the kinetics of tumor growth may 
initially outpace anti-tumor immune activity. With sufficient time, the anti-tumor activity will 
dominate and become clinically apparent. Therefore, subjects will be allowed to continue study 
therapy after an initial investigator-assessed RECIST 1.1 defined progression as long as they 
meet the following criteria: 
 
1. Site investigator assessed clinical benefit, and 
2. Subject is tolerating treatment. 
 
These criteria aim to ensure the risk/benefit for continuing treatment will continue to favor the 
subjects. The assessment of clinical benefit should take into account whether the subject is 
clinically deteriorating and unlikely to receive further benefit from continued treatment. 
Palliative radiotherapy or surgical resection of isolated lesions is permitted in these subjects and 
will not preclude the continued treatment with pembrolizumab.  
 
All decisions to continue treatment beyond initial progression must be discussed with the 
sponsor-investigator and documented in the study records.  Subjects should discontinue study 
therapy upon further evidence of further progression, defined as an additional 10% or greater 
increase in tumor burden volume from time of initial progression (including all target lesions and 
new measurable lesions). 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 included in the tumor 


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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). 
 
For statistical analyses that include the site investigator-assessed progression date, subjects who 
continue treatment beyond initial site investigator-assessed, RECIST 1.1-defined progression 
will be considered to have site investigator-assessed progressive disease at the time of the initial 
progression event. 
 
5.4 
Discontinuation of Pembrolizumab after CR  
Discontinuation of treatment may be considered for subjects who have attained a confirmed CR 
that have been treated for at least 24 weeks with pembrolizumab and had at least two treatments 
with pembrolizumab beyond the date when the initial CR was declared.  Subjects who then 
experience radiographic disease progression may be eligible for up to one year of additional 
treatment with pembrolizumab at the discretion of the site investigator if no cancer treatment was 
administered since the last dose of pembrolizumab, the subject meets the safety parameters listed 
in the Inclusion/Exclusion criteria, and the trial is open.  Subjects will resume therapy at the 
same dose and schedule at the time of initial discontinuation.   
 
5.5 
Concomitant Medications 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial. If there is a clinical indication for one of these or other medications or 
vaccinations specifically prohibited during the trial, discontinuation from trial therapy or 
vaccination may be required. The site investigator should discuss any questions regarding this 
with the sponsor-investigator. The final decision on any supportive therapy or vaccination rests 
with the site investigator and/or the subject's primary physician. 
 
5.5.1 Allowed Concomitant Medications 
All treatments that the site investigator considers necessary for a subject’s welfare may be 
administered at the discretion of the site investigator in keeping with the community standards of 
medical care.  All concomitant medication will be recorded on the case report form (eCRF) 
including all prescription, over-the-counter (OTC), herbal supplements, and IV medications and 
fluids.  If changes occur during the trial period, documentation of drug dosage, frequency, route, 
and date may also be included on the eCRF. 
 
All concomitant medications received within 28 days before the first dose of trial treatment and 
30 days after the last dose of trial treatment should be recorded.  Concomitant medications 
administered after 30 days after the last dose of trial treatment should be recorded for SAEs and 
ECIs. 
 
 
 


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5.5.2 Prohibited Concomitant Medications 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase (including retreatment for post-complete response relapse) of this trial: 
• Antineoplastic systemic chemotherapy or biological therapy  
• Immunotherapy not specified in this protocol 
• Chemotherapy not specified in this protocol 
• Investigational agents other than pembrolizumab 
• Radiation therapy  
o NOTE:  Radiation therapy to a symptomatic solitary lesion or to the brain may be 
allowed at the site investigator’s discretion.   
• Live vaccines within 30 days prior to the first dose of trial treatment and while 
participating in the trial. Examples of live vaccines include, but are not limited to, the 
following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and 
typhoid vaccine.  
• Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
event of clinical interest of suspected immunologic etiology.  The use of physiologic 
doses of corticosteroids may be approved after consultation with the Sponsor. 
 
Subjects who, in the assessment by the site investigator, require the use of any of the 
aforementioned treatments for clinical management should be removed from the trial.  Subjects 
may receive other medications that the investigator deems to be medically necessary.  The 
Exclusion Criteria describes other medications which are prohibited in this trial.  There are no 
prohibited therapies during the Post-Treatment Follow-up Phase. 
 
5.6 
Supportive Care 
Subjects should receive appropriate supportive care measures as deemed necessary by the site 
investigator. Suggested supportive care measures for the management of adverse events with 
potential immunologic etiology are outlined below. Where appropriate, these guidelines include 
the use of oral or intravenous treatment with corticosteroids as well as additional anti-
inflammatory agents if symptoms do not improve with administration of corticosteroids. Note 
that several courses of steroid tapering may be necessary as symptoms may worsen when the 
steroid dose is decreased. For each disorder, attempts should be made to rule out other causes 
such as metastatic disease or bacterial or viral infection, which might require additional 
supportive care. The treatment guidelines are intended to be applied when the site investigator 
determines the events to be related to pembrolizumab.  
 
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or skin 
photography as part of evaluation of the event.  
 
Pneumonitis  
• For Grade 2 events, treat with systemic corticosteroids. When symptoms improve to 
Grade 1 or less, steroid taper should be started and continued over no less than 4 weeks. 
• For Grade 3-4 events, immediately treat with intravenous steroids.  Administer 
additional anti-inflammatory measures, as needed. 
• Add prophylactic antibiotics for opportunistic infections in the case of prolonged steroid 
administration. 


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Diarrhea/Colitis  
Subjects should be carefully monitored for signs and symptoms of enterocolitis (such as diarrhea, 
abdominal pain, blood or mucus in stool, with or without fever) and of bowel perforation (such 
as peritoneal signs and ileus).   
• All subjects who experience diarrhea/colitis should be advised to drink liberal quantities 
of clear fluids.  If sufficient oral fluid intake is not feasible, fluid and electrolytes should 
be substituted via IV infusion.  For Grade 2 or higher diarrhea, consider GI consultation 
and endoscopy to confirm or rule out colitis. 
• For Grade 2 diarrhea/colitis that persists greater than 3 days, administer oral 
corticosteroids.  
• For Grade 3 or 4 diarrhea/colitis that persists > 1 week, treat with intravenous steroids 
followed by high dose oral steroids.   
• When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks. 
 
Type 1 diabetes mellitus (if new onset, including diabetic ketoacidosis [DKA]) or ≥ Grade 3 
Hyperglycemia, if associated with ketosis (ketonuria) or metabolic acidosis (DKA) 
• For T1DM or Grade 3-4 Hyperglycemia 
o Insulin replacement therapy is recommended for Type I diabetes mellitus and for 
Grade 3-4 hyperglycemia associated with metabolic acidosis or ketonuria.  
o Evaluate patients with serum glucose and a metabolic panel, urine ketones, 
glycosylated hemoglobin, and C-peptide.  
 
Hypophysitis 
• For Grade 2 events, treat with corticosteroids. When symptoms improve to Grade 1 or 
less, steroid taper should be started and continued over no less than 4 weeks. 
Replacement of appropriate hormones may be required as the steroid dose is tapered. 
• For Grade 3-4 events, treat with an initial dose of IV corticosteroids followed by oral 
corticosteroids. When symptoms improve to Grade 1 or less, steroid taper should be 
started and continued over no less than 4 weeks. Replacement of appropriate hormones 
may be required as the steroid dose is tapered. 
 
Hyperthyroidism or Hypothyroidism  
Thyroid disorders can occur at any time during treatment. Monitor patients for changes in 
thyroid function (at the start of treatment, periodically during treatment, and as indicated based 
on clinical evaluation) and for clinical signs and symptoms of thyroid disorders. 
• Grade 2 hyperthyroidism events (and Grade 2-4 hypothyroidism): 
o In hyperthyroidism, non-selective beta-blockers (e.g. propranolol) are suggested 
as initial therapy. 
o In hypothyroidism, thyroid hormone replacement therapy, with levothyroxine or 
liothyronine, is indicated per standard of care. 
• Grade 3-4 hyperthyroidism  
o Treat with an initial dose of IV corticosteroid followed by oral corticosteroids. 
When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks. Replacement of appropriate hormones may 
be required as the steroid dose is tapered. 


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Hepatic 
• For Grade 2 events, monitor liver function tests more frequently until returned to 
baseline values (consider weekly). 
o Treat with IV or oral corticosteroids 
• For Grade 3-4 events, treat with intravenous corticosteroids for 24 to 48 hours.  
• When symptoms improve to Grade 1 or less, a steroid taper should be started and 
continued over no less than 4 weeks. 
 
Renal Failure or Nephritis 
• For Grade 2 events, treat with corticosteroids. 
• For Grade 3-4 events, treat with systemic corticosteroids. 
• When symptoms improve to Grade 1 or less, steroid taper should be started and 
continued over no less than 4 weeks.  
 
Management of Infusion Reactions Signs and symptoms usually develop during or shortly 
after drug infusion and generally resolve completely within 24 hours of completion of infusion. 
Table 2 below shows treatment guidelines for subjects who experience an infusion reaction 
associated with administration of pembrolizumab. 
 
Table 2: Infusion Reaction Treatment Guidelines 
NCI CTCAE Grade 
Treatment 
Premedication at 
subsequent dosing 
Grade 1 
Mild reaction; infusion 
interruption not indicated; 
intervention not indicated 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion 
of the investigator. 
None 
Grade 2 
Requires infusion interruption 
but responds promptly to 
symptomatic treatment (e.g., 
antihistamines, NSAIDS, 
narcotics, IV fluids); 
prophylactic medications 
indicated for < =24 hr 
Stop Infusion and monitor 
symptoms. 
Additional appropriate medical therapy 
may include but is not limited to: 
IV fluids, Antihistamines, NSAIDS 
Acetaminophen, Narcotics 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion 
of the investigator. 
If symptoms resolve within one hour of 
stopping drug infusion, the infusion 
may be restarted at 50% of the original 
infusion rate (e.g., from 100 mL/hr to 
50 mL/hr).  Otherwise dosing will be 
held until symptoms resolve and the 
subject should be premedicated for the 
next scheduled dose. 
Subjects who develop Grade 2 
toxicity despite adequate 
premedication should be 
permanently discontinued from 
further trial treatment 
administration. 
Subject may be 
premedicated 1.5 hr (± 30 
minutes) prior to infusion of 
pembrolizumab (MK-3475) 
with: 
 
Diphenhydramine 50 mg po 
(or equivalent dose of 
antihistamine). 
 
Acetaminophen 500-1000 
mg po (or equivalent dose 
of antipyretic). 


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NCI CTCAE Grade 
Treatment 
Premedication at 
subsequent dosing 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly 
responsive to symptomatic 
medication and/or brief 
interruption of infusion); 
recurrence of symptoms 
following initial improvement; 
hospitalization indicated for 
other clinical sequelae (e.g., 
renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or 
ventilatory support indicated 
Stop Infusion. 
Additional appropriate medical therapy 
may include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion 
of the investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued 
from further trial treatment 
administration. 
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available 
during the period of drug administration. 
 
 
5.7 
Diet and Other Considerations 
 
5.7.1 Diet 
Subjects should maintain a normal diet unless modifications are required to manage an AE such 
as diarrhea, nausea, or vomiting. 
 
5.7.2 Contraception 
Pembrolizumab may have adverse effects on a fetus in utero.  Furthermore, it is not known if 
pembrolizumab has transient adverse effects on the composition of sperm.  Non-pregnant, non-
breast-feeding women may be enrolled if they are willing to use adequate birth control or are 
considered highly unlikely to conceive.  Highly unlikely to conceive is defined as 1) surgically 
sterilized, or 2) postmenopausal (a woman who is ≥45 years of age and has not had menses for 
greater than 1 year will be considered postmenopausal), or 3) not heterosexually active for the 
duration of the study.  Birth control methods can be barrier methods or hormonal method to 
prevent pregnancy. Subjects should start using birth control from study Visit 1 throughout the 
study period up to 120 days after the last dose of study therapy.  
 
The following are considered adequate barrier methods of contraception: diaphragm, condom (by 
the partner), copper intrauterine device, sponge, or spermicide.  Appropriate hormonal 
contraceptives will include any registered and marketed contraceptive agent that contains an 
estrogen and/or a progestational agent (including oral, subcutaneous, intrauterine, or 
intramuscular agents). 
 


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Subjects should be informed that taking the study medication may involve unknown risks to the 
fetus (unborn baby) if pregnancy were to occur during the study.  In order to participate in the 
study they must adhere to the contraception requirement (described above) for the duration of the 
study and during the follow-up period defined above.  If there is any question that a subject will 
not reliably comply with the requirements for contraception, that subject should not be entered 
into the study. 
 
5.7.3 Use in Pregnancy 
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab, the subject 
will immediately be removed from the study.  The site will contact the subject at least monthly 
and document the subject’s status until the pregnancy has been completed or terminated.  The 
outcome of the pregnancy will be reported to the Hoosier Cancer Research Network (HCRN) 
within 1 business day of becoming aware of the event.  HCRN will then report to Merck within 
1 business day if the outcome is a serious adverse experience (e.g., death, abortion, congenital 
anomaly, or other disabling or life-threatening complication to the mother or newborn).   
 
The study investigator will make every effort to obtain permission to follow the outcome of the 
pregnancy and report the condition of the fetus or newborn to HCRN.   If a male subject 
impregnates his female partner the study personnel at the site must be informed immediately and 
the pregnancy reported to HCRN and to Merck and followed as described above. 
 
5.7.4 Use in Nursing Women 
It is unknown whether pembrolizumab is excreted in human milk.  Since many drugs are 
excreted in human milk, and because of the potential for serious adverse reactions in the nursing 
infant, subjects who are breast-feeding are not eligible for enrollment. 
 
6. 
TOXICITIES AND DOSE DELAYS/DOSE MODIFICATIONS 
The NCI Common Terminology Criteria for Adverse Events (CTCAE) v4 will be used to grade 
adverse events.  
 
Subjects enrolled in this study will be evaluated clinically and with standard laboratory tests 
before and at regular intervals during their participation in this study as specified in Study 
Calendar & Evaluations. 
 
Subjects will be evaluated for adverse events (all grades), serious adverse events, and adverse 
events requiring study drug interruption or discontinuation as specified in Study Calendar & 
Evaluations.   
 
6.1 
Dose Delay of Pembrolizumab 
Adverse events (both non-serious and serious) associated with pembrolizumab exposure may 
represent an immunologic etiology. These adverse events may occur shortly after the first dose 
or several months after the last dose of treatment. Pembrolizumab must be withheld for drug-
related toxicities and severe or life-threatening AEs as per Table 3.  
 


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Table 3: Dose Modification and Toxicity Guidelines of pembrolizumab 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 
(CTCAEv4.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies  
Monitor and follow-up  
Pneumonitis  
Grade 2 
Withhold  
• Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
• 
Monitor participants for signs and 
symptoms of pneumonitis 
• 
Evaluate participants with suspected 
pneumonitis with radiographic imaging and 
initiate corticosteroid treatment 
• 
Add prophylactic antibiotics for 
opportunistic infections 
Grade 3 or 4, or 
recurrent Grade 2 
Permanently 
discontinue 
Diarrhea / Colitis  Grade 2 or 3 
Withhold 
• Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
• 
Monitor participants for signs and symptoms 
of enterocolitis (ie, diarrhea, abdominal 
pain, blood or mucus in stool with or 
without fever) and of bowel perforation 
(ie, peritoneal signs and ileus). 
• 
Participants with ≥ Grade 2 diarrhea 
suspecting colitis should consider GI 
consultation and performing endoscopy to 
rule out colitis.  
• 
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 
 
 


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Immune-related 
AEs 
Toxicity grade or 
conditions 
(CTCAEv4.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies  
Monitor and follow-up  
AST / ALT 
elevation or 
Increased 
bilirubin 
Grade 2 
Withhold 
• Administer corticosteroids (initial 
dose of 0.5- 1 mg/kg prednisone or 
equivalent) followed by taper 
• 
Monitor with liver function tests (consider 
weekly or more frequently until liver 
enzyme value returned to baseline or is 
stable 
Grade 3 or 4  
Permanently 
discontinue 
• Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
Type 1 diabetes 
mellitus (T1DM) 
or 
Hyperglycemia 
 
Newly onset 
T1DM or  
Grade 3 or 4 
hyperglycemia 
associated with 
evidence of -cell 
failure 
Withhold 
• Initiate insulin replacement 
therapy for participants with 
T1DM  
• Administer anti-hyperglycemic in 
participants with hyperglycemia  
 
• 
Monitor participants for hyperglycemia or 
other signs and symptoms of diabetes. 
Hypophysitis 
Grade 2 
Withhold 
• Administer corticosteroids and 
initiate hormonal replacements as 
clinically indicated.   
 
• 
Monitor for signs and symptoms of 
hypophysitis (including hypopituitarism and 
adrenal insufficiency)  
Grade 3 or 4  
Withhold or 
permanently 
discontinue1  
Hyperthyroidism  
Grade 2 
Continue  
• Treat with non-selective beta-
blockers (eg, propranolol) or 
thionamides as appropriate  
• 
Monitor for signs and symptoms of thyroid 
disorders.  
 
Grade 3 or 4  
Withhold or  
permanently 
discontinue1 
Hypothyroidism 
Grade 2-4 
Continue  
• Initiate thyroid replacement 
hormones (eg, levothyroxine or 
liothyroinine) per standard of care 
• 
Monitor for signs and symptoms of thyroid 
disorders.  
 
Nephritis and 
Renal 
dysfunction 
Grade 2 
Withhold  
• Administer corticosteroids 
(prednisone 1-2 mg/kg or 
equivalent) followed by taper. 
• 
Monitor changes of renal function 
 
Grade 3 or 4  
Permanently 
discontinue 
 
 


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Immune-related 
AEs 
Toxicity grade or 
conditions 
(CTCAEv4.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies  
Monitor and follow-up  
Myocarditis 
Grade 1 or 2 
Withhold 
• Based on severity of AE 
administer corticosteroids 
• 
Ensure adequate evaluation to confirm 
etiology and/or exclude other causes 
 
Grade 3 or 4 
Permanently 
discontinue 
All other 
immune-related 
AEs 
Intolerable/ 
persistent Grade 2 
Withhold 
• Based on type and severity of AE 
administer corticosteroids  
• 
Ensure adequate evaluation to confirm 
etiology and/or exclude other causes 
 
Grade 3 
Withhold or 
discontinue based 
on the type of 
event.  Events that 
require 
discontinuation 
include and not 
limited to:  
Gullain-Barre 
Syndrome, 
encephalitis 
Grade 4 or 
recurrent Grade 3  
Permanently 
discontinue 
1. Withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating physician.   
NOTE:  
For participants with Grade 3 or 4 immune-related endocrinopathy where withhold of pembrolizumab is required, pembrolizumab may be resumed 
when AE resolves to ≤ Grade 2 and is controlled with hormonal replacement therapy or achieved metabolic control (in case of T1DM).   
 
 


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6.2  
Dose Modification of Sylatron 
 
Table 4: Dose Modification Guidelines of Sylatron for Drug-Related Adverse Events 
Resume treatment at reduced 
dose (see Table 5) 
Withhold treatment 
Permanently discontinue 
treatment 
Absolute Neutrophil Count 
(ANC) ≥ 0.5x109/L 
Absolute Neutrophil Count 
(ANC) < 0.5x109/L 
Persistent or worsening 
severe neuropsychiatric 
disorders toxicity 
Platelet Count (PLT) ≥ 50x109/L 
Platelet Count (PLT) < 50x109/L 
New or worsening 
retinopathy 
Non-hematologic toxicity has 
completely resolved or improved 
to Grade 1 
Non-hematologic toxicity  
Grade ≥ 3 
Grade 4 non-hematologic 
toxicity 
ECOG PS 0-1 
ECOG PS ≥2 
Inability to tolerate a dose of 
60mcg/week 
 
Table 5: Sylatron Dose Modifications 
Dose level -1 
120 mcg weekly 
Dose level -2 
60 mcg weekly 
 
6.3 
Subject Withdrawal/Protocol Therapy Discontinuation 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the 
discretion of the site investigator should any untoward effect occur.  In addition, a subject may 
be withdrawn by the site investigator or the sponsor-investigator if enrollment into the trial is 
inappropriate, the trial plan is violated, or for administrative and/or other safety reasons.   
 
A subject must be discontinued from the trial for any of the following reasons: 
• The subject or legal representative (such as a parent or legal guardian) withdraws 
consent. 
• Confirmed radiographic disease progression 
NOTE: A subject may be granted an exception to continue on treatment with confirmed 
radiographic progression if there is objective clinical benefit, please see Section 5.3 
• Unacceptable adverse experienced 
• Intercurrent illness that prevents further administration of treatment 
• Site investigator’s decision to withdraw the subject 
• The subject has a confirmed positive serum pregnancy test 
• Noncompliance with trial treatment or procedure requirements 
The subject is lost to follow-up  
• Protocol therapy interrupted for > 12 weeks 
• Completed 24 months of uninterrupted treatment with pembrolizumab or 35 
administrations of pembrolizumab, whichever is later.  NOTE: 24 months of 
pembrolizumab is calculated from the date of first dose.  
• Administrative reasons 
 


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The End of Treatment and Follow-up visit procedures are listed in Section 7.  After the end of 
treatment, each subject will have follow up visit (1) at 30 days after last dose of study treatment.   
Serious adverse events will be collected for 90 days after last dose of study treatment (follow up 
visit 2).  Follow up for patients that have not experienced progression will occur every 9 weeks ± 
7 days.  This may be done by phone call or other avenues as appropriate.  Every effort should be 
made to obtain information on radiology scans or other types of disease assessment 
documentation. Once a subject experiences confirmed disease progression or starts a new anti-
cancer therapy, the subject moves into the survival follow-up phase and should be contacted by 
telephone every 12 weeks ± 7 days to assess for survival status until death, withdrawal of 
consent, or the end of the study, whichever occurs first. 
 
6.4 
Subject Replacement Strategy 
If all four sites have more eligible patients than the available slots, the order of enrollment will 
rotate among the four sites. Otherwise the patients will be enrolled according to the order they 
become eligible for enrollment.  
 
6.5 
Clinical Criteria for Early Trial Termination 
Early trial termination will be the result of the criteria specified below: 
1. Quality or quantity of data recording is inaccurate or incomplete 
2. Poor adherence to protocol and regulatory requirements 
3. Incidence or severity of adverse drug reaction in this or other studies indicates a potential 
health hazard to subjects 
4. Plans to modify or discontinue the development of the study drug. In the event of Merck 
decision to no longer supply study drug, ample notification will be provided so that 
appropriate adjustments to subject treatment can be made. 
 
 


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7. 
STUDY CALENDAR & EVALUATIONS 
Study Evaluation 
 
Cycle = 21 days 
Screening 
On Treatment 
Cycle 1-n 
End of 
Treatment Visit11 
Safety Follow 
Up Visit12 
Long Term 
Follow Up 13 
≤ 28 days 
Day 1 
± 5 days 
± 7 days  
30 days after 
EOT/study drug 
± 7 days 
Every 12 
weeks after 
Visit 2 
REQUIRED ASSESSMENTS 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
Medical History1 
X 
 
 
 
 
Diagnosis and Staging1 
X 
 
 
 
 
Physical Exam2 
X 
X10 
X 
X 
 
Vital signs and ECOG Performance Status3 
X 
X 
X 
X 
 
Baseline ophthalmologic assessment4 
X 
 
 
 
 
AEs & concomitant medications 
X 
X 
X 
X 
 
LABORATORY ASSESSMENTS 
 
 
 
 
 
Complete Blood Cell Count with diff (CBC) 
X 
X10 
X 
X 
 
Comprehensive Metabolic Profile (CMP) 
and amylase 
X 
X10 
X 
X 
 
PT/INR and aPTT 
X 
X10 
X 
X 
 
Thyroid Function (TSH, free T4, T3) 
X 
X10 
X 
X 
 
Urinalysis 
X 
X10 
X 
X 
 
Pregnancy test (serum or urine) (WOCBP)5 
X 
 
 
 
 
DISEASE ASSESSMENT 
 
 
 
 
 
CT of chest6 
X 
X 
 
 
X 
CT or MRI of abdomen and pelvis6 
X 
X 
 
 
X 
MRI Brain6 
X 
X 
 
 
X 
TREATMENT EXPOSURE 
 
 
 
 
 
Sylatron7 
 
X 
 
 
 
Pembrolizumab7 
 
X 
 
 
 
SPECIMEN COLLECTION  
 
 
 
 
 
Archival and Newly Obtained Tumor Tissue8 
X 
X8 
 
 
 
Blood Samples9 
X 
X 
X9 
X9 
 
FOLLOW-UP 
 
 
 
 
 
Survival Status, Subsequent Therapy 
 
 
 
 
X 
 


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Key to Footnotes  
1 During the medical history other information to be collected includes smoking history, alcohol history, diagnosis and staging and how the 
healthcare provider and/or subject learned about this study. Diagnosis and staging to include: reviewing pathology report and screening scans. 
Special attention should be given to the assessment of past or current depression or suicidal tendencies. In addition, if a subject has substance 
abuse issues, they are at higher risk of relapse. If concerns are identified during this visit, the appropriate referral to psychiatric services should be 
made to further assess. See SPM for additional information. 
 
2 Patients will be screened for depression, suicidal tendencies and possible relapse of substance abuse at each physical exam. If a concern is noted, 
the patient will be referred for the appropriate mental health evaluation.  In addition, cardiac issues will be assessed per SOC and if concerns are 
identified, appropriate testing should be completed to fully assess the subject. This may include an EKG, ECHO/MUGA or cardiology referral. 
 
3 Vital signs to include blood pressure, weight, and height (screening only) and ECOG performance status 
 
4 A baseline ophthalmologic assessment will be done in subjects with pre-existing retinopathy, or history of retinal vein or artery thrombosis. 
 
5 For women of childbearing potential (WOCBP): urine or serum βhCG, within 28 days of registration and only if clinically appropriate. If a urine 
test is done and it is positive or cannot be confirmed as negative, a serum pregnancy test will be required. 
 
6 Radiology Imaging for disease assessment will be performed at the following timepoints: screening, at the end of Cycle 3 (9 weeks of 
combination therapy) then every 9 weeks (3 Cycles).  Tumor imaging will be performed after the last on-study scan only for patients who do NOT 
have radiographic progression: Radiology Imaging should occur at 30 days, then every 9 weeks thereafter until disease (radiographic) progression.  
MRI of the brain should only be done if the patient is suspected to have a brain lesion. 
 
7 Sylatron will start on C1D1 and continue weekly. During the C1D1 clinic visit, subjects will be trained on how to manage sylatron administration 
at home.  Pembrolizumab will start C2D1 and continue every 3 weeks.  Please see Section 5 for details regarding sylatron and pembrolizumab 
administration.  A window of ± 5 days is allowed to accommodate for schedule conflicts. Laboratory testing should be performed on the day of 
study treatment administration.   
 
8 Archival tissue will be identified during screening and is required if available for all subjects. All subjects will have a biopsy performed of a 
safely accessible tumor before starting treatment (within 42 days of starting treatment on this protocol) and 3 weeks later prior to initiation of 
pembrolizumab (prior to Cycle 2 Day 1).  Subjects for whom newly obtained samples cannot be provided (e.g. inaccessible tumor for biopsy or 
subject safety concerns) may omit both biopsies provided documentation of reason is clear in the medical record.  
 


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9 Serial blood samples will be collected to support biomarker research at the following timepoints: Prior to treatment (1) C1D1, (2) C2D1, (3) 
C5D1 (4) C7D1 and (5) End of Treatment/Safety Follow Up Visit. See CLM for additional details. 
 
10 If screening (baseline) labs and physical exam were performed within 7 days of Cycle 1 Day 1 of treatment, these do not need to be repeated.  
All laboratory assessments should be done prior to treatment. 
 
11 An end of treatment (EOT) visit will be performed for the following situations: (1) if patient has progressed and a discussion of scans/next 
treatment is needed or (2) if a patient has experienced toxicities that necessitates study treatment discontinuation. Special attention should be given 
to the assessment of current depression, suicidal tendencies or relapse of substance abuse. If concerns are identified during this visit, the 
appropriate referral to psychiatric services should be made to further assess. There may be certain situations in which this visit will take place 
locally and discussion regarding next steps would occur via phone call. In this case the research specific blood samples would not be done until the 
safety follow up visit.  
 
12 A safety follow up visit will be performed about 4 weeks after the EOT visit or last dose of study drug. Special attention should be given to the 
assessment of current depression or suicidal tendencies in addition to relapse of substance abuse. If concerns are identified during this visit, the 
appropriate referral to psychiatric services should be made to further assess. After completion of the EOT visit, subjects should be contacted on a 
monthly basis until 180 days after their last dose of study drug to assess for issues with mood or behavior. If a concern is identified the patient will 
be referred to the appropriate mental health resources for evaluation.  If research specific blood samples were not done during the EOT visit, they 
should be drawn during this visit. This visit may take place locally if the patient had an EOT visit at the study facility and study specific blood 
samples were drawn at that time. 
 
13 Long Term Follow up will occur every 12 weeks ± 7 days.  This may be done by phone call or other avenues as appropriate.  Every effort should 
be made to obtain information on radiology scans or other types of disease assessment documentation. Follow up will continue until death, 
withdrawal of consent, or the end of the study, whichever occurs first. 
 
 
 


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Hematology 
Chemistry 
Urinalysis 
Other 
Hematocrit 
Albumin 
Blood 
Serum β-human chorionic gonadotropin† 
Hemoglobin 
Alkaline phosphatase 
Glucose 
  (β-hCG)† 
Platelet count 
Alanine aminotransferase (ALT) 
Protein 
PT (INR) 
WBC (total and differential) 
Aspartate aminotransferase (AST) 
Specific gravity  
aPTT 
Red Blood Cell Count 
Total protein 
Microscopic exam (If abnormal)  
Total triiodothyronine (T3) 
Absolute Neutrophil Count 
Carbon Dioxide ‡ 
results are noted 
Free thyroxine (T4) 
Absolute Lymphocyte Count 
  (CO2 or bicarbonate) 
Urine pregnancy test † 
Thyroid stimulating hormone (TSH) 
 
Sodium 
 
Blood for correlative studies 
 
Calcium 
 
 
 
Chloride 
 
 
 
Glucose 
 
  
 
Phosphorus 
 
  
 
Potassium   
 
  
 
Blood Urea Nitrogen 
 
  
 
creatinine 
 
  
 
Total Bilirubin 
 
  
 
Direct Bilirubin (If total bilirubin is 
elevated above the upper limit of 
normal) 
 
 
 
amylase 
 
 
† Perform on women of childbearing potential only. If urine pregnancy results cannot be confirmed as negative, a serum pregnancy test will be required.   
‡ If considered standard of care in your region. 
 


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8. 
BIOSPECIMEN STUDIES AND PROCEDURES 
Biomarkers in patient tumors that can predict response to anti-PD-1 therapy are being actively 
investigated. One mechanism by which cancer tissues limit the host immune response is via 
upregulation of PD-1 ligand (PD-L1) and its ligation to PD-1 on antigen-specific CD8+ T cells 
[6, 7]. Recent research has reported that tumor regression after therapeutic PD-1 blockade 
requires pre-existing CD8+ T cells that are negatively regulated by PD-1/PD-L1-mediated 
adaptive immune resistance. [8] We propose that Sylatron will increase the response of 
pembrolizumab by increasing the tumor infiltrating CD3 and CD8 cells, and the level of PD-L1 
and PD-1 expression in immune cells and cancer cells. In this study, we will first test the effect 
of Sylatron on tumor infiltrating lymphocytes, the level of PD-1 and PD-L1 expression, and 
clonality of the T-cell repertoire by comparing the tumor biopsies from baseline and three weeks 
of Sylatron treatment. Then we will correlate the change of PD-1, PD-L1 levels, immune score, 
and clonality of the T-cell repertoire from Sylatron treatment with clinical response.  
 
Immunohistochemical (IHC) staining: The level of PD-1 and PD-L1 expression in tumor 
biopsy will be measured by immunohistochemical (IHC) staining at Merck laboratories. 
Immunohistochemical (IHC) staining, Digital image acquisition and analysis: The density of 
intratumoral total (CD3+) and cytotoxic (CD8+) T lymphocytes will be measured in the tumor 
interior (TI) and in the invasive margin (IM) of the three biopsied tumor samples. Immune cell 
densities will be obtained by immunohistochemistry and quantified using a biomarker imaging 
system in tandem with Image J processing software at Lombardi Comprehensive Cancer Center. 
Immune cell density in the TI and IM was converted to a binary score (0 as Low, 1 as High), 
with a cutoff threshold determined by the median density of CD3+ and CD8+ cells. We 
previously carried out a study on the association of intratumoral CD3 and CD8 cell density with 
recurrence free survival in patients with surgically resected Hepatocellular Carcinoma. 
 
Next Generation Sequencing for T-cell receptor clonality: TCR sequencing and clonality 
quantification was performed as previously described [29,30] from tumor samples preserved 
using RNAlater (Qiagen) and stored at −80°C. DNA was isolated by mincing followed by 
extraction utilizing a DNeasy kit (Qiagen). TCRβ CDR3 regions were amplified and sequenced 
using the survey ImmunoSeq assay in a multiplexed PCR method using 45 forward primers 
specific to TCR Vβ gene segments and 13 reverse primers specific to TCR Jβ gene segments. 
The experiments of measuring T-cell receptor clonality will be carried out at Lombardi 
Comprehensive Cancer Center.  
 
PCR template abundance estimation: In order to estimate the average read coverage per input 
template in our multiplex PCR and sequencing approach, we will employ a set of approximately 
850 unique types of synthetic TCR analog, comprising each combination of Vβ and Jβ gene 
segments.[30] These molecules will be included in each PCR reaction at very low concentration 
so that most unique types of synthetic template are not observed in the sequencing output. Using 
the known concentration of the synthetic template pool, we will simulate the relationship 
between the number of observed unique synthetic molecules and the total number of synthetic 
molecules will be added to reaction (this is very nearly one-to-one at the low concentrations we 
employed). These molecules then allowed us to calculate for each PCR reaction the mean 
number of sequencing reads obtained per molecule of PCR template, and thus to estimate the 


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number of rearranged T cell receptors per diploid genome (i.e., level of TIL infiltration) in the 
input material. The PCR analysis will be carried out in Lombardi Comprehensive Cancer Center.  
 
8.1 
Tumor Biopsies 
Archival tissue will be requested for all subjects. All subjects will have a biopsy performed of a 
safely accessible tumor before starting treatment (within 42 days of starting treatment on this 
protocol) and 3 weeks later prior to initiation of pembrolizumab (prior to Cycle 2 Day 1).  
Subjects for whom newly obtained samples cannot be provided (e.g. inaccessible tumor for 
biopsy or subject safety concerns) may omit both biopsies provided documentation of reason is 
clear in the medical record. In these instances, submission of an archived specimen only will 
suffice. 
 
Analysis of molecular characteristics of baseline and on-treatment tumor samples. All patients 
will have biopsies performed of safely accessible tumors before starting treatment (within 42 
days of starting treatment on this protocol) and 3 weeks later. Preferred biopsy is core biopsy; 
five 20-gauge core needle biopsies (diameter about 2 mm) with a throw length of approximately 
2 cm will provide adequate tissue for study. Available paraffin embedded tumor tissue from prior 
biopsies or excisions will also be collected as pre-treatment comparator samples. Preferred 
archival material includes tissue obtained in the same manner as specified in this trial and with 
no systemic anti-tumor treatment received by the patient between the biopsy and their enrollment 
on this protocol. However, other archival tissue may also be collected.    
 
Each set of core biopsies will be divided into 5 portions and processed as below for later 
analysis:   
 
1) FFPE for histology and IHC (20% of the specimen, or 1 core biopsy) 
 
2) Quick-frozen in OCT for immunohistology and protein studies (40% of the specimen, or 
2 core biopsy): embedded in optimum cutting temperature (OCT) solution, frozen in 
liquid nitrogen, and then stored at -80° C.  
 
3) Placed in RNA-later for RNA and RT-PCR (40% of the specimen, or 2 core biopsy).    
 
Of note, patients who are on chronic anticoagulation will be required to hold anticoagulation 
prior to the biopsies being performed.  Patients on warfarin must hold treatment for 5 days, but 
will be on low-molecular weight heparin (LMWH), 1mg/kg subcutaneously twice a day. The 
LMWH will continue until the last biopsy is complete.  Patients may then resume warfarin the 
day after the last biopsy.  Additionally, patients on LMWH will hold (i.e., not receive) the dose 
of LMWH the morning of the procedure, but will resume the LMWH the evening of the day of 
the biopsy. 
 
8.2 
Blood Collections 
Plasma, serum, and peripheral blood for PMBCs will be collected at the five scheduled time 
points: prior to treatment (1) C1D1, (2) C2D1, (3) C5D1 (4) C7D1 and (5) End of Treatment.  
PBMCs will be isolated by Ficoll gradient centrifugation and cryopreserved in 10% DMSO at -
80°C for subsequent evaluation.  


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8.3 
Storage of Biospecimens 
Remaining specimens will be stored for future research once protocol described biospecimen-
based studies are complete.  This option will be presented to subjects in the informed consent. 
 
8.4 
Confidentiality of Biospecimens 
Samples that are collected will be identified by a subject’s sequence ID assigned at the time of 
registration to the trial. Any material issued to collaborating researchers will be anonymized and 
only identified by the subject’s sequence ID. 
 
9. 
CRITERIA FOR DISEASE EVALUATION 
The following sections describe the recommended method to track disease response for solid 
tumor trials as per the Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 (see 
Eisenhauer EA et al. New response evaluation criteria in solid tumours: revised RECIST 
guideline (version 1.1). Eur J Can, 2009.45:p.228-247).  
 
9.1 
Measurable Disease 
Measurable disease is defined as the presence of at least one measurable lesion. 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, as >10 mm with CT scan, or >10 mm with 
calipers by clinical exam. All tumor measurements must be recorded in millimeters (or decimal 
fractions of centimeters). 
 
9.1.1 Malignant Lymph Nodes 
To be considered pathologically enlarged and measurable, a lymph node must be >15 mm in 
short axis when assessed by CT scan (CT scan slice thickness recommended to be no greater 
than 5 mm). At baseline and in follow-up, only the short axis will be measured and followed. 
 
9.2 
Non-measurable Lesions 
All other lesions (or sites of disease), including small lesions (longest diameter <10 mm or 
pathological lymph nodes with ≥ 10 to <15 mm short axis), are considered non-measurable 
disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis 
cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not followed by CT or 
MRI), are considered as non-measurable. 
 
NOTE:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. ‘Cystic lesions’ thought to represent cystic metastases can be considered 
as measurable lesions, if they meet the definition of measurability described above. However, if 
non-cystic lesions are present in the same subject, these are preferred for selection as target 
lesions. 
 
9.3 
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 


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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. 
 
9.4 
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. 
 
9.5 
Evaluation of Target Lesions 
NOTE: In addition to the information below, also see section 4.3.2 in the international criteria 
proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) Committee, version 
1.1 (Eur J Cancer 45;2009:228-247) for special notes on the assessment of target lesions.  
 
Complete 
Response (CR) 
Disappearance of all target lesions. Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to 
<10 mm. 
Partial Response 
(PR) 
At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum diameters 
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 
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). 
 
9.6 
Evaluation of Non-Target Lesions 
Complete Response (CR) 
Disappearance of all non-target lesions and normalization 
of tumor marker level. All lymph nodes must be non-
pathological in size (<10 mm short axis) 
 
NOTE:  If tumor markers are initially above the upper 
normal limit, they must normalize for a subject to be 
considered in complete clinical response. 
Non-CR/ Non-PD 
Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal 
limits 
Progressive Disease (PD) 
Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions. 


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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 site 
investigator should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the sponsor investigator. 
 
9.7 
Evaluation of Best Overall Response 
NOTE: Revise table if response rate is primary objective of the study, and confirmation of 
response is required. See Eur J Cancer 45;2009:228-247 for complete details. 
 
Target Lesions 
Non-Target Lesions 
New Lesions 
Overall 
Response 
CR 
CR 
No 
CR 
CR 
Non-CR/ Non-PD 
No 
PR 
CR 
Not evaluated 
No 
PR 
PR 
Non-PD/ or not all 
evaluated 
No 
PR 
SD 
Non-PD or not all evaluated 
No 
SD 
Not all evaluated 
Non-PD 
No 
Non-evaluable 
PD 
Any 
Yes or No 
PD 
Any 
PD* 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
*In exceptional circumstances, unequivocal progression in non-target lesions may be 
accepted as disease progression. 
 
Subjects with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be classified as having 
“symptomatic deterioration.” Every effort should be made to document the objective progression 
even after discontinuation of treatment. 
 
In some circumstances, it may be difficult to distinguish residual disease from normal tissue. 
When the evaluation of complete response depends on this determination, it is recommended that 
the residual lesion be investigated (fine needle aspirate/biopsy) to confirm the complete response 
status. 
 
9.8 
Definitions for Response Evaluation – RECIST 1.1 
 
9.8.1 First Documentation of Response 
The time between initiation of therapy and first documentation of PR or CR. 
 
9.8.2 Confirmation of Response 
To be assigned a status of complete or partial response, changes in tumor measurements must be 
confirmed by repeat assessments performed no less than four weeks after the criteria for response 
are first met. 


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9.8.3 Objective Response Rate  
The objective response rate is the proportion of all subjects with confirmed PR or CR according 
to RECIST 1.1, from the start of treatment until disease progression/recurrence (taking as 
reference for progressive disease the smallest measurements recorded since the start of 
treatment). 
 
9.8.4 Time to Progression 
A measurement from the date of registration until the criteria for disease progression is met as 
defined by RECIST 1.1. Subjects who have not progressed or have died due to any cause will be 
right-censored at the date of the last disease evaluation or date of death. 
 
9.8.5 Progression Free Survival 
A measurement from the date of registration until the criteria for disease progression is met as 
defined by RECIST 1.1 or death occurs. Subjects who have not progressed will be right-censored 
at the date of the last disease evaluation. 
 
9.8.6 Overall Survival 
Overall survival is defined by the date of registration to date of death from any cause. 
 
9.9 
Immune-Related RECIST (irRECIST) 
 
9.9.1 Measurable Lesion Definitions and Target Lesion Selection 
Follow the definitions from RECIST 1.1. Measurable lesions must be accurately  measured in at 
least one dimension with a minimum size of: 
• 10 mm in the longest diameter by CT or MRI scan (or no less than double the slice 
thickness) for non-nodal lesions and ≥15 mm in short axis for nodal lesions 
• 10 mm caliper measurement by clinical exam 
• 20 mm by chest X-ray 
• At the baseline tumor assessment, the sum of the products of the two largest 
perpendicular diameters (SPD) of all index lesions (five lesions per organ, up to 10 
visceral lesions and five cutaneous index lesions) is calculated. 
• Baseline: Target and Non-Target Lymph Node Lesion Definitions - Follow the 
definitions from RECIST 1. 
• Baseline: Bone Lesions- Follow the definitions from RECIST 1.1. Regardless of the 
imaging modality blastic bone lesions will not be selected as target lesions. Lytic or 
mixed lytic-blastic lesions with a measurable soft tissue component ≥10 mm can be 
selected as target lesions. 
• Baseline: Cystic and necrotic lesions as target lesions that are partially cystic or necrotic 
can be selected as target lesions. The longest diameter of such a lesion will be added to 
the Total Measured Tumor Burden (TMTB) of all target lesions at baseline. If other 
lesions with a non-liquid/non-necrotic component are present, those should be preferred. 
• Baseline: Lesions with prior local treatment during target lesion selection the radiologist 
will consider information on the anatomical sites of previous intervention (e.g. previous 
irradiation, RF-ablation, TACE, surgery, etc.). Lesions undergoing prior intervention will 


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not be selected as target lesions unless there has been a demonstration of progress in the 
lesion 
 
9.9.2 Non-measurable Lesion Definitions 
Follow definitions from RECIST 1.1 
9.9.3 Non-target lesions will include 
▪ Measurable lesions not selected as target lesions 
▪ All sites of non-measurable disease, such as neoplastic masses that are too small to 
measure because their longest uninterrupted diameter is < 10 mm (or < two times the 
axial slice thickness), ie. the longest per-pendicular diameter is ≥10 and < 15 mm. 
▪ Other types of lesions that are confidently felt to represent neoplastic tissue, but are 
difficult to measure in a reproducible manner.  These include bone metastases, 
leptomeningeal metastases, malignant ascites, pleural or pericardial effusions, ascites,  
inflammatory breast disease, lymphangitis cutis/pulmonis, cystic lesions, ill-defined 
abdominal masses, skin lesions, etc. 
 
9.9.4 Target and Non-Target Lymph Node Lesion Definitions 
Follow definitions from RECIST 1.1 
 
9.9.5 Non-Target Lesion Selection 
All lesions or sites of disease not recorded as target lesions should be recorded as non-target 
lesions at baseline. There is no limit to the number of non-target lesions that can be recorded at 
baseline. 
 
9.9.6 Bone Lesions 
Follow definitions from RECIST 1.1 
 
Regardless of the imaging modality blastic bone lesions will not be selected as target lesions. 
Lytic or mixed lytic-blastic lesions with a measurable soft tissue component ≥10 mm can be 
selected as target lesions. 
 
9.9.7 Cystic and Necrotic Lesions as Target Lesions 
Lesions that are partially cystic or necrotic can be selected as target lesions. The longest diameter 
of such a lesion will be added to the Total Measured Tumor Burden (TMTB) of all target lesions 
at baseline. If other lesions with a non-liquid/non-necrotic component are present, those should 
be preferred. 
 
9.9.8 Lesions with Prior Local Treatment 
During target lesion selection the radiologist will consider information on the anatomical sites of 
previous intervention (e.g. previous irradiation, RF-ablation, TACE, surgery, etc.). Lesions 
undergoing prior intervention will not be selected as target lesions unless there has been a 
demonstration of progress in the lesion. 
 
9.9.9 Follow-up 
• Only index and measurable new lesions are taken into account. The longest diameters of 
non-nodal target and new non-nodal measurable lesions, and short axes of nodal target 


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and new nodal measurable lesions will be recorded. Together they determine the Total 
Measured Tumor Burden (TMTB) at follow-up. 
• Definition of Measurable New Lesions: In order to be selected as new measurable lesions 
(≤ 2 lesions per organ, ≤ 5 lesions total, per timepoint), new lesions must meet criteria as 
defined for baseline target lesion selection and meet the same minimum size requirements 
of 10 mm in long diameter and minimum 15 mm in short axis for new measurable lymph 
nodes. New measurable lesions shall be prioritized according to size, and the largest 
lesions shall be selected as new measured lesions. 
• Non-Target Lesion Assessment- The RECIST 1.1 definitions for the assessment of non-
target lesions apply. The response of non-target lesions primarily contributes to the 
overall response assessments of irCR and irNon-CR/Non-PD (irNN). Non-target lesions 
do not affect irPR and irSD assessments. Only a massive and unequivocal worsening of 
non-target lesions alone, even without progress in the TMTB is indicative of irPD. 
• New Non-Measurable Lesions Definition and Assessment: All new lesions not selected 
as new measurable lesions are considered new non-measurable lesions and are followed 
qualitatively. Only a massive and unequivocal progression of new non-measurable 
lesions leads to an overall assessment of irPD for the timepoint. Persisting new non-
measurable lesions prevent irCR 
 
9.9.10 Evaluation of Best Overall Response per irRECIST 
% Change in 
Sum of the 
Diameters 
Target 
Lesion 
Definition 
Non-Target 
Lesion 
Definition 
New 
Measurable 
Lesions 
New 
Unmeasurable 
Lesions 
Overall 
Modified 
RECIST 
Timepoint 
Response 
-100% a 
CR 
CR 
No 
No 
CR 
-100% a 
CR 
Non-CR 
or not all 
evaluated 
No 
No 
PR 
≤ - 30% 
PR 
Any 
Yes or no 
Yes or no 
PR 
> -30% to  
< +20% 
SD 
Any 
Yes or no 
Yes or no 
SD 
Not all 
evaluated 
Not 
evaluated 
Any 
Yes or no 
Yes or no  
NE  
≥ ± 20% 
PD 
Any 
Yes or no 
Yes or no 
PD 
 
CR =complete response; NE= not evaluable; PD=progressive disease; PR =partial response; 
RECIST =Response Evaluation Criteria in Solid Tumors; SD= stable disease. 
 
a When lymph nodes are included as target lesions, the % change in the sum of the diameters 
may not be 100% even if complete response criteria are met since a normal lymph node is 
defined as having a short axis of < 10 mm. Any pathological lymph nodes (whether target or 


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non-target) must have reduction in short axis to < 10 mm in order to meet the definition of CR. 
Including Measurable New Lesions When Present. 
 
10. 
DRUG INFORMATION 
 
10.1 
Pembrolizumab (Keytruda®) 
Pembrolizumab is a potent and highly selective humanized mAb of the IgG4/kappa isotype 
designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2.  
KeytrudaTM (pembrolizumab) has recently been approved in the United Stated for the treatment 
of subjects with unresectable or metastatic melanoma and disease progression following 
ipilumumab and, if BRAF V600 mutation positive, a BRAF inhibitor. It is also approved for the 
treatment of subjects with PD-L1 positive metastatic NSCLC who have disease progression on 
or after platinum chemotherapy. Please refer to the current version of the Keytruda® prescribing 
information and the pembrolizumab Investigator’s Brochure (IB) for additional information 
regarding this drug. 
 
10.1.1 Supplier/How Supplied 
Merck will supply pembrolizumab at no charge to subjects participating in this clinical trial, as 
summarized in the table below. 
 
Product Name & Potency 
Dosage Form 
Pembrolizumab 100 mg/ 4mL 
Solution for Injection 
10.1.2 Preparation 
Please refer to the Pharmacy Manual for a comprehensive description of pembrolizumab 
preparation. 
 
10.1.3 Storage and Stability 
Clinical supplies must be stored in a secure, limited-access location under the storage conditions 
specified on the label.   
 
Clinical supplies may not be used for any purpose other than that stated in the protocol. 
 
10.1.4 Handling and Disposal 
Upon completion or termination of the study, all unused and/or partially used investigational 
product will be destroyed at the site per institutional policy. It is the Investigator’s responsibility 
to arrange for disposal of all empty containers, provided that procedures for proper disposal 
have been established according to applicable federal, state, local and institutional guidelines and 
procedures, and provided that appropriate records of disposal are kept. 
 
10.1.5 Dispensing, Returns and Reconciliation 
The investigator is responsible for keeping accurate records of the clinical supplies received from 
Merck or designee, the amount dispensed to and returned by the subjects and the amount 
remaining at the conclusion of the trial.  
 


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10.1.6 Use in Pregnancy and Nursing Women 
Based on its mechanism of action, pembrolizumab can cause fetal harm when administered to a 
pregnant woman. Subjects who are pregnant or planning to become pregnant are not eligible for 
enrollment. It is unknown whether pembrolizumab is excreted in human milk.  Since many drugs 
are excreted in human milk, and because of the potential for serious adverse reactions in the 
nursing infant, subjects who are breast-feeding are not eligible for enrollment. 
 
10.1.7 Adverse Events 
Please refer to the current Investigator’s Brochure for a complete list of adverse events.  
 
Pembrolizumab is generally well tolerated and demonstrates a favorable safety profile in 
comparison to chemotherapy. Pembrolizumab is an immunomodulatory agent, and based on this 
mechanism of action, immune mediated adverse events are of primary concern. Important 
identified risks for pembrolizumab are of an immune mediate nature, including: pneumonitis, 
colitis, hypophysitis (including hypothryoidism/hyperthyroidism), hepatitis, Type I diabetes 
mellitis, uveitis, and nephritis, myositis, Guillain-Barre syndrome, pancreatitis, and severe skin 
reaction toxic epidermal necrolysis (TEN), some with fatal outcome). A new important risk of 
myocarditis has been identified; cases with fatal outcome have been reported.   
 
The majority of immune-mediated adverse events were mild to moderate in severity, were 
manageable with appropriate care, and rarely required discontinuation of therapy.  
 
In addition to the previously noted identified risks, infusion-related reactions are a risk but are 
not considered immune mediated; these are also further described in the current IB. 
10.2 
Sylatron 
SYLATRON, peginterferon alfa-2b, is a covalent conjugate of recombinant alfa-2b interferon 
with monomethoxy polyethylene glycol (PEG). The average molecular weight of the PEG 
portion of the molecule is 12,000 daltons. The average molecular weight of the SYLATRON 
molecule is approximately 31,000 daltons. The specific activity of pegylated interferon alfa-2b is 
approximately 0.7 x 108 international units/mg protein. 
 
Interferon alfa-2b is a protein with a molecular weight of 19,271 daltons produced by 
recombinant DNA techniques. It is obtained from the bacterial fermentation of a strain of 
Escherichia coli bearing a genetically engineered plasmid containing an interferon gene from 
human leukocytes. 
 
Each vial contains200 mcg of peginterferon alfa-2b as a sterile, white to off-white lyophilized 
powder, and dibasic sodium phosphate anhydrous (1.11 mg), monobasic sodium phosphate 
dihydrate (1.11 mg), polysorbate 80 (0.074 mg), and sucrose (59.2 mg). 
 
 
 


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10.2.1 Supplier/How Supplied 
Merck will supply sylatron at no charge to subjects participating in this clinical trial, as 
summarized in the table below. 
 
Product Name & Potency 
Dosage Form 
Sylatron 
Lyophilized Powder for Injection 
 
10.2.2 Preparation 
Reconstitute SYLATRON with 0.7 mL of Sterile Water for Injection, USP.  
 
 
Swirl gently to dissolve the lyophilized powder. DO NOT SHAKE.  
• Visually inspect the solution for particulate matter and discoloration prior to 
administration. Discard if solution is discolored, cloudy, or if particulates are present.  
• Do not withdraw more than 0.5 mL of reconstituted solution from each vial.  
• Administer SYLATRON subcutaneously. Rotate injection sites.  
• If reconstituted solution is not used immediately, store at 2°-8°C (36°-46°F) for no more 
than 24 hours. Discard reconstituted solution after 24 hours. DO NOT FREEZE.  
• For single-use only. DISCARD ANY UNUSED PORTION.  
 
10.2.3 Storage and Stability 
SYLATRON should be stored at 25°C (77°F); excursions permitted to 15°-30°C (59-86°F) [see 
USP Controlled Room Temperature]. DO NOT FREEZE. 
 
10.2.4 Handling and Disposal 
Upon completion or termination of the study, all unused and/or partially used investigational 
product will be destroyed at the site per institutional policy. It is the Investigator’s responsibility 
to arrange for disposal of all empty containers, provided that procedures for proper disposal 
have been established according to applicable federal, state, local and institutional guidelines and 
procedures, and provided that appropriate records of disposal are kept. 
 
10.2.5 Dispensing, Returns and Reconciliation 
The investigator is responsible for keeping accurate records of the clinical supplies received from 
Merck or designee, the amount dispensed to and returned by the subjects and the amount 
remaining at the conclusion of the trial.  
 
10.2.6 Use in Pregnancy and Nursing Women 
There are no adequate and well-controlled studies of SYLATRON in pregnant women. 
Nonpegylated interferon alfa-2b was an abortifacient in Macaca mulatta (rhesus monkeys) at 15 
and 30 million international units (IU)/kg (estimated human equivalent of 5 and 10 million 
IU/kg, based on body surface area adjustment for a 60-kg adult). The estimated Intron A human 
SYLATRON 
Single-Use 
Vial 
 
Diluent (Sterile 
Water for 
Injection, USP) 
 
Deliverable 
Product and 
Volume 
Final 
Concentration 
200 mcg* 
add 
0.7 mL 
= 
200 mcg in 0.5 mL 
40 mcg/0.1 mL 


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equivalent dose of 5 to 10 million IU/kg daily is approximately equal to a human equivalent dose 
of 79 to 158 mcg/kg/week of SYLATRON. Use SYLATRON during pregnancy only if the 
potential benefit justifies the potential risk to the fetus. 
 
It is not known whether the components of SYLATRON are excreted in human milk. Studies in 
mice have shown that mouse interferons are excreted in breast milk. Because of the potential for 
adverse reactions from the drug in nursing infants, a decision must be made whether to 
discontinue nursing or discontinue the SYLATRON treatment, taking into account the 
importance of the therapy to the mother. 
 
10.2.7 Adverse Events 
Please refer to the current prescribing information for sylatron for additional details.  Most 
common adverse reactions (>60%) are: fatigue, increased ALT, increased AST, pyrexia, 
headache, anorexia, myalgia, nausea, chills, and injection site reaction. (6.1) 
 
11 
ADVERSE EVENTS 
The descriptions and grading scales found in the NCI CTCAE v4 will be utilized for AE 
assessment. A copy of the CTCAE v4 can be downloaded from the CTEP website at 
http://ctep.cancer.gov. All forms for AE/SAE recording and reporting can be found in the Study 
Procedure Manual or in the EDC system (Documents and Information Tab). 
 
11.1 Definitions 
 
11.1.1 Adverse Event (AE) 
An AE is any untoward medical occurrence whether or not considered related to the study drug 
that appears to change in intensity during the course of the study. The following are examples of 
AEs:  
• Unintended or unfavorable sign or symptom 
• A disease temporally associated with participation in the protocol 
• An intercurrent illness or injury that impairs the well-being of the subject 
 
Abnormal laboratory values or diagnostic test results constitute AEs only if they induce clinical 
signs or symptoms or require treatment or further diagnostic tests   
 
Hospitalization for elective surgery or routine clinical procedures that are not the result of an AE 
(e.g., surgical insertion of central line) should not be recorded as an AE.  
 
Disease progression should not be recorded as an AE, unless it is attributable to the study 
regimen by the site investigator. 
 
 
 


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11.1.2 Serious Adverse Event (SAE) 
A SAE is an adverse event that: 
• Results in death. NOTE: Death due to disease progression should not be reported as a 
SAE, unless it is attributable by the site investigator to the study drug(s) 
• Is life-threatening (defined as an event in which the subject was at risk of death at the 
time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe) 
• Requires inpatient hospitalization for > 24 hours or prolongation of existing 
hospitalization. NOTE: Hospitalization for anticipated or protocol specified procedures 
such as administration of chemotherapy, central line insertion, metastasis interventional 
therapy, resection of primary tumor, or elective surgery, will not be considered serious 
adverse events. 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly or birth defect 
• Is an important medical event (defined as a medical event(s) that may not be immediately 
life-threatening or result in death or hospitalization but, based upon appropriate medical 
and scientific judgment, may jeopardize the subject or may require intervention (e.g., 
medical, surgical) to prevent one of the other serious outcomes listed in the definition 
above). Examples of such events include, but are not limited to, intensive treatment in an 
emergency room or at home for allergic bronchospasm; blood dyscrasias or convulsions 
not resulting in hospitalization; or the development of drug dependency or drug abuse. 
 
11.1.3 Unexpected Adverse Event 
For this study, an AE is considered unexpected when it varies in nature, intensity or frequency 
from information provided in the current IB, prescribing information or when it is not included in 
the informed consent document as a potential risk. Unexpected also refers to AEs that are 
mentioned in the IB as occurring with a class of drugs or are anticipated from the 
pharmacological properties of the drug, but are not specifically mentioned as occurring with the 
particular drug under investigation.   
 
11.1.4 Relatedness 
AEs will be categorized according to the likelihood that they are related to the study drug(s). 
Specifically, they will be categorized using the following terms:  
 
Unrelated 
Adverse Event is not related to the study drug(s)  
Unlikely 
Adverse Event is doubtfully related to the study drug(s)  
Possible 
Adverse Event may be related to the study drug(s)  
Probable 
Adverse Event is likely related to the study drug(s)  
Definite 
Adverse Event is clearly related to the study drug(s)  
 
 
 


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11.2 
Reporting 
 
11.2.1 Adverse Events  
• AEs will be recorded from time of signed informed consent until 30 days after 
discontinuation of study drug(s).  
• AEs will be recorded regardless of whether or not they are considered related to the study 
drug(s).   
• All AEs will be recorded in the subject’s medical record and on the appropriate study 
specific eCRF form within the EDC system. 
• AEs considered related to study drug(s) will be followed until resolution to        
 ≤ Grade 1 or baseline, deemed clinically insignificant, and/or until a new anti-cancer 
treatment starts, whichever occurs first. 
 
11.2.2 Serious Adverse Events (SAEs) 
 
11.2.2.1 
Site Requirements for Reporting SAEs to HCRN 
• SAEs will be reported from time of signed informed consent until 90 days after 
discontinuation of study drug(s).  
• SAEs will be reported on the SAE Submission Form within 1 business day of discovery 
of the event.   
• SAEs include events related and unrelated to the study drug(s).  
• All SAEs will be recorded in the subject’s medical record and on the appropriate study 
specific eCRF form within the EDC system.   
• All SAEs regardless of relation to study drug will be followed until resolution to ≤ Grade 
1 or baseline and/or deemed clinically insignificant and/or until a new anti-cancer 
treatment starts, whichever occurs first. 
 
The site will submit the completed SAE Submission Form to HCRN within 1 business day of 
discovery of the event. The form may be submitted to HCRN electronically to 
safety@hoosiercancer.org. The site investigator is responsible for informing the IRB and/or other 
local regulatory bodies as per local requirements.   
 
The original copy of the SAE Submission Form and the email correspondence must be kept 
within the study file at the study site. 
 
Once the SAE has resolved (see resolution guidelines listed in 11.2.2.1), sites must submit a 
follow-up SAE Submission Form within a reasonable timeframe to HCRN electronically to 
safety@hoosiercancer.org.   
 
11.2.2.2 
HCRN Requirements for Reporting SAEs to Merck 
Hoosier Cancer Research Network will report any possibly related and unexpected SAE to 
Merck within one business day of receipt of the SAE/ECI Submission Form and to regulatory 
authorities (FDA) per federal guidelines.  Follow-up information will be provided to Merck as it 
is received from site.  Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215 993-
1220).  
 


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11.2.2.3 
Sponsor-Investigator Responsibilities  
HCRN will send a SAE summary to the sponsor-investigator within 1 business day of receipt of 
SAE Submission Form from a site.  The sponsor-investigator will promptly review the SAE 
summary and assess for expectedness and relatedness.   
 
11.3 
HCRN Responsibilities to FDA 
HCRN will manage the Investigational New Drug Application (IND) associated with this 
protocol on behalf of the sponsor-investigator. HCRN will cross-reference this submission to the 
Merck’s parent IND at the time of submission. Additionally, HCRN will submit a copy of these 
documents to Merck at the time of submission to FDA. 
 
For protocols conducted under an IND, HCRN will be responsible for all communication with 
the FDA in accordance with 21CFR312 including but not limited to the 7 and 15 Day Reports, as 
well as an Annual Progress Report. Additionally, HCRN will submit a copy of these reports to 
Merck at the time of submission to FDA. 
 
11.4 
IND Safety Reports Unrelated to this Trial 
Merck will provide to HCRN IND safety reports from external studies that involve the study 
drug(s) per their guidelines.  HCRN will forward safety reports to the sponsor-investigator who 
will review these reports and determine if revisions are needed to the protocol or consent. HCRN 
will forward these reports to participating sites within 1 business day of receiving the sponsor-
investigator’s review.  Based on the sponsor-investigator’s review, applicable changes will be 
made to the protocol and informed consent document (if required).  All IND safety reports will 
also be made available to sites via the EDC system.    
 
Upon receipt from HCRN, site investigators (or designees) are responsible for submitting these 
safety reports to their respective IRBs, as per their IRB policies. 
 
11.5 
Reporting of Pregnancy and Lactation to the Sponsor-Investigator and to Merck 
Although pregnancy and lactation are not considered adverse events, it is the responsibility of 
site investigators or their designees to report any pregnancy or lactation in a subject 
(spontaneously reported to them), including the pregnancy of a male subject's female partner that 
occurs during the trial or within 120 days of completing the trial.  All subjects and female 
partners of male subjects who become pregnant 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 adverse 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 HCRN. HCRN will report such events to the 
sponsor-investigator and Merck Global Safety within 1 business day of receiving notification of 
the event. (Attn: Worldwide Product Safety; FAX 215-993-1220) 
 
 
 


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11.6 
Events of Clinical Interest 
Events of Clinical Interest (ECI) described below must be recorded as such on the SAE/ECI 
Submission Form and reported within 24 hours to safety@hoosiercancer.org at HCRN. HCRN 
will report these events within one business day of receipt to Merck Global Safety. (Attn: 
Worldwide Product Safety; FAX 215 993-1220). 
 
Events of clinical interest for this trial include: 
1.  an overdose of Funder's product that is not associated with clinical symptoms or 
abnormal laboratory results. For purposes of this trial, an overdose will be defined as any 
dose exceeding the prescribed dose for pembrolizumab greater than 10mg/kg over the 
prescribed dose. No specific information is available on the treatment of overdose of 
pembrolizumab. In the event of overdose, pembrolizumab should be discontinued and the 
subject should be observed closely for signs of toxicity.  Appropriate supportive 
treatment should be provided if clinically indicated.  If an adverse event(s) is associated 
with (“results from”) the overdose of a Merck product, the adverse event(s) is reported as 
a serious adverse event, even if no other seriousness criteria are met. 
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. The purpose of the 
criteria is to specify a threshold of abnormal hepatic tests that may require an additional 
evaluation for an underlying etiology.   
 
12 
STATISTICAL METHODS 
 
12.1 
Study Design 
This is an open-label, single-arm, multicenter Phase II safety and efficacy study of combination 
therapy with pembrolizumab and Sylatron (Peginterferon alpha-2b) in patients with advanced 
cholangiocarcinoma who have progressed on or cannot tolerate frontline chemotherapy.  
 
12.2 
Endpoints 
 
12.2.1 Definition of Primary Endpoint 
• Efficacy endpoint: objective response rate: defined as the proportion of subjects who 
achieve the best response (CR and PR) determined by RECIST1.1.  
 
12.2.2 Definition of Secondary Endpoints 
• PFS: defined as time from registration till the patient’s disease progression or death from 
any cause whichever occurs first (those for whom event of progression or death not 
observed will be censored). 
• OS: defined as time from registration till the patient’s death from any cause (patient who 
are still alive at the end of the study will be censored). 


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• Objective response rate: defined as the proportion of subjects who achieve the best 
response (CR and PR) determined by irRECIST. 
• Safety and tolerability of the combination of Sylatron and pembrolizumab as assessed by 
CTCAE v4. Will include patients’ toxicity profile, adverse event, serious adverse event, 
serious adverse even leading to discontinuation of the treatment, death. 
 
12.2.3 Definition of Exploratory Endpoints 
• The density of CD3 and CD8 in the tumor interior and invasive margin of the tumor, and 
the clonality of the T-cell repertoire. 
• Proliferation of CD8+ T cells, Granzyme B+ cells and proliferation of tumor cells. 
 
12.3 
Sample Size and Accrual 
The primary objective of the study is to test that addition of Sylatron will improved the response 
rate of pembrolizumab from 17% to 35% in patients with advanced cholangiocarcinoma. The 
sample size is based on the number of patients that are anticipated to complete the primary 
objective. 
 
We propose that the addition of Sylatron to a pembrolizumab regimen will improve the response 
rate of pembrolizumab from 17% to 35%. Simon’s two-stage optimum design will be used to test 
the null hypothesis of P <= 0.17 versus the alternative hypothesis of P >= 0.350. At the first 
stage, 16 patients will be treated with the combination of Sylatron and pembrolizumab. The trial 
will be terminated if 3 or fewer respond. If there are at least 4 responders, the trial will go on to 
the second stage and 28 patients will be enrolled to a total of 44 patients. If the total number 
responding among the 44 patients is less than or equal to 11, the null hypothesis will not be 
rejected and the combination of Sylatron plus pembrolizumab will not be investigated further. 
Using this statistical method, there is a 0.046 (4.6%) probability of erroneously concluding that 
this drug combination is effective when it actually is not (targeted value of 0.05). If the drug is 
actually effective, there is a 0.191 (19.1%) probability of concluding that it is not (targeted value 
of 0.2). The power of the design is 80% with a one-sided significance level of 0.05. 
 
We anticipate that 2 patients will be recruited per month and total time for study recruitment will 
be 24 months, with each patient followed for a minimum of 6 months, the anticipated time to 
complete the study will be 24 – 30 months.  Allowing for a 4% drop out rate, a total of 46 
patients will be enrolled for this trial. 
 
12.4 
Analysis Datasets 
 
Population 
Definition 
Enrolled 
This will comprise all subjects who meet the 
eligibility criteria and are registered onto the study. 
  


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Population 
Definition 
Evaluable for Efficacy 
This will comprise all subjects who receive at least 
one dose of sylatron and pembrolizumab and either 
undergo at least one post-baseline assessment or die 
before any evaluation.  Non evaluable patients will 
be replaced. 
   
Intention-to-treat (ITT) 
This will comprise all subjects who meet the 
eligibility criteria and are registered onto the study 
irrespective of their compliance to the planned 
course of treatment.  
 
 
Per Protocol Set (Valid 
Cases, Efficacy 
Sample, Evaluable 
Subjects Sample) 
 
This will comprise all subjects who complied with 
the protocol sufficiently to ensure that these data 
would be likely to exhibit the effects of treatment, 
according to the underlying scientific model. 
Compliance covers such considerations as exposure 
to treatment, availability of measurements and 
absence of major protocol violations. This 
population should be specifically defined in the 
protocol. 
 
Safety 
This will comprise all subjects who receive at least 
one dose of sylatron and pembrolizumab  
 
Treated 
This will comprise all subjects who have been 
exposed to the planned course of treatment to any 
extent. 
 
12.4.1 Analysis Plans for Primary Objective 
The overall response rate will be estimated with its 95% exact confidence interval.  
 
12.4.2 Analysis Plans for Secondary Objectives 
Progression free survival (PFS) and overall survival (OS) will be evaluated using the methods of 
Kaplan and Meier (1958). 95% confidence interval will be constructed for the estimated median 
PFS and OS. The exploratory objective response rate will be estimated with its 95% exact 
confidence interval. Safety summaries will be presented by the severity of the adverse event and 
by relationship to study drug. Descriptive statistics (minimum, maximum, mean median, 
standard deviation for continuous variables; counts, percentages for categorical variables) will be 
used in summarizing of all laboratory and safety parameters (adverse events, serious adverse 
events, adverse events leading to discontinuation, deaths) for all treated subjects. 
 
12.4.3 Analysis Plans for Exploratory Objectives 
Density of CD3+ T cells and CD8+ T cells, proliferation of CD8+ T cells, Granzyme B+ cells 
and proliferation of tumor cells will be listed and summarized using the descriptive statistics 
(minimum, maximum, mean median, standard deviation).  The CD8 + Tcells, Granzyme B+ 


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cells, and proliferation of tumor cells will be correlated with the response by comparing the 
means of different groups using either 2-sample t-tests or non-parametric Wilcoxon rank-sum 
test, or the Chi-square test based on the distribution and structure of the data. 
 
13 
TRIAL MANAGEMENT 
 
13.1 
Data and Safety Monitoring Plan (DSMP) 
The study will be conducted with guidance from the Georgetown Lombardi Comprehensive 
Cancer Center Cancer Center’s DSMP.  
 
HCRN oversight activities include: 
• Review all adverse events requiring expedited reporting as defined in the protocol 
• Provide trial accrual progress, safety information and data summary reports to the 
sponsor-investigator  
• Submit data summary reports to the lead institution Data Safety Monitoring Committee 
according to Georgetown Lombardi Comprehensive Cancer Center DSMP. 
 
13.2 
Georgetown Lombardi Comprehensive Cancer Center Data Safety Monitoring 
Committee 
HCRN will provide the following for the Georgetown Lombardi Comprehensive Cancer Center 
DSMC to review: 
• Adverse event summary report 
• Audit results if applicable 
• Data related to stopping/decision rules described in study design 
• Study accrual patterns  
• Protocol deviations 
 
The Georgetown Lombardi Comprehensive Cancer Center DSMC will review study data every 
quarter.  Documentation of DSMC reviews will be provided to sponsor-investigator and HCRN.  
Issues of immediate concern by the DSMC will be brought to the attention of the sponsor-
investigator and other regulatory bodies as appropriate.  The sponsor-investigator will work with 
HCRN to address the DSMC’s concerns.   
 
13.3 
Data Quality Oversight Activities 
Remote validation of the EDC system data will be completed on a continual basis throughout the 
life cycle of the study.  Automated edit check listings will be used to generate queries in the EDC 
system and transmitted to the site to address in a timely fashion. Corrections will be made by the 
study site personnel.  
 
The trial site may also be subject to quality assurance audit by Merck or its designee as well as 
inspection by appropriate regulatory agencies. 
 
13.3.1 Onsite Monitoring 
There will be at least one routine visit per site per year for sites that have accrued.  Additional for 
cause visits may occur as necessary. Selected source documents will be reviewed for verification 
of agreement with data entered into the EDC system.  It is important for the site investigator and 


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their relevant personnel to be available for a sufficient amount of time during the monitoring 
visits or audit, if applicable. The site investigator and institution guarantee access to source 
documents by HCRN or its designee. 
 
The trial site may also be subject to quality assurance audit by Merck or its designee as well as 
inspection by appropriate regulatory agencies. 
 
13.4 
Compliance with Trial Registration and Results Posting Requirements 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and the 
Food and Drug Administration Amendments Act (FDAAA), the sponsor-investigator of the trial 
is solely responsible for determining whether the trial and its results are subject to the 
requirements for submission to the Clinical Trials Data Bank, http://www.clinicaltrials.gov. All 
results of primary and secondary objectives must be posted to CT.gov within a year of 
completion.  The sponsor-investigator has delegated responsibility to HCRN for registering the 
trial and posting the results on clinicaltrials.gov. Information posted will allow subjects to 
identify potentially appropriate trials for their disease conditions and pursue participation by 
calling a central contact number for further information on appropriate trial locations and study 
site contact information.   
 
14 
DATA HANDLING AND RECORD KEEPING 
 
14.1 
Data Management 
HCRN will serve as the Clinical Research Organization for this trial. Data will be collected 
through a web based clinical research platform, the EDC system, a system compliant with Good 
Clinical Practices and Federal Rules and Regulations.  HCRN personnel will coordinate and 
manage data for quality control assurance and integrity. All data will be collected and entered 
into the EDC system by study site personnel from participating institutions.   
 
14.2 
Case Report Forms and Submission 
Generally, clinical data will be electronically captured in the EDC system and correlative results 
will be captured in the EDC system or other secure database(s). If procedures on the study 
calendar are performed for standard of care, at minimum, that data will be captured in the source 
document. Select standard of care data will also be captured in the EDC system, according to 
study-specific objectives.  
 
The completed dataset is the sole property of the sponsor-investigator’s institution and should 
not be exported to third parties, except for authorized representatives of appropriate 
Health/Regulatory Authorities, without permission from the sponsor-investigator and HCRN. 
 
14.3 
Record Retention 
To enable evaluations and/or audits from Health Authorities/HCRN, the site investigator agrees 
to keep records, including the identity of all subjects (sufficient information to link records; e.g., 
hospital records), all original signed informed consent forms, copies of all source documents, and 
detailed records of drug disposition. All source documents are to remain in the subject’s file and 
retained by the site investigator in compliance with the site contract with HCRN.  No records 
will be destroyed until HCRN confirms destruction is permitted. 


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14.4 
Confidentiality 
There is a slight risk of loss of confidentiality of subject information. All records identifying the 
subjects will be kept confidential and, to the extent permitted by the applicable laws and/or 
regulations, will not be made publicly available. Information collected will be maintained on 
secure, password protected electronic systems. Paper files that contain personal information will 
be kept in locked and secure locations only accessible to the study site personnel.  
 
Subjects will be informed in writing that some organizations including the sponsor-investigator 
and his/her research associates, HCRN, Merck, IRB, or government agencies, like the FDA, may 
inspect their medical records to verify the information collected, and that all personal 
information made available for inspection will be handled in strictest confidence and in 
accordance with local data protection laws. 
 
If the results of the study are published, the subject’s identity will remain confidential. 
 
15 
ETHICS 
 
15.1 
Institutional Review Board (IRB) Approval 
The final study protocol and the final version of the informed consent form must be approved in 
writing by an IRB. The site investigator must submit written approval by the IRB to HCRN 
before he or she can enroll subjects into the study.   
 
The site investigator is responsible for informing the IRB of any amendment to the protocol in 
accordance with local requirements. In addition, the IRB must approve all advertising used to 
recruit subjects for the study. The protocol must be re-approved by the IRB, as local regulations 
require.  
 
Progress reports and notifications of serious and unexpected adverse events will be provided to 
the IRB according to local regulations and guidelines. 
 
15.2 
Ethical Conduct of the Study 
The study will be performed in accordance with ethical principles originating from the 
Declaration of Helsinki.  Conduct of the study will be in compliance with ICH Good Clinical 
Practice, and with all applicable federal (including 21 CFR parts 56 & 50), state, or local laws. 
 
15.3 
Informed Consent Process 
The site investigator will ensure the subject is given full and adequate oral and written 
information about the nature, purpose, possible risks and benefits of the study. Subjects must 
also be notified they are free to discontinue from the study at any time. The subject should be 
given the opportunity to ask questions and allowed time to consider the information provided. 
 
The subject’s signed and dated informed consent must be obtained before conducting any 
procedure specifically for the study. The site investigator must store the original, signed 
informed consent form. A copy of the signed informed consent form must be given to the 
subject.  
 


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