Conditions: Melanoma
Keywords: peptide vaccine Montanide ISA-51 pembrolizumab PD-1 KEYTRUDA
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 22
Healthy volunteers: no

Brief summary:
This study evaluates whether it is safe to administer a peptide vaccine in combination with pembrolizumab. This study will also evaluate the effects of the combination of the peptide vaccine and pembrolizumab on the immune system. The investigators will monitor these effects by performing tests in the laboratory on participants' blood, a lymph node, and tumor samples.

Detailed description:

Arms:
arm 1: 6MHP (200 mcg each peptide) will be administered intradermally and subcutaneously on days 1, 8, 15, 43, 64, and 85. Pembrolizumab (200 mg) will be administered intravenously every 3 weeks for up to 2 years, beginning on day 1.

Interventions: intervention 1: 6MHP intervention 2: Pembrolizumab
Intervention descriptions: intervention 1: 6 melanoma helper vaccine comprised of 6 class II MHC-restricted helper peptides intervention 2: Humanized monoclonal antibody (mAb) specific for PD-1.

Protocol document:
Prot_SAP_ICF_000.pdf: 
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UNIVERSITY OF VIRGINIA 
HUMAN IMMUNE THERAPY CENTER 
 
 
MEL 64 
 
 
A TRIAL TO EVALUATE THE SAFETY, IMMUNOGENICITY, AND CLINICAL ACTIVITY 
OF A HELPER PEPTIDE VACCINE PLUS PD-1 BLOCKADE 
 
Abbreviated title:  PATHVACS (PD-1 Antibody and T-Helper Vaccine And Correlative 
Studies) 
 
 
 
 
 
 
 
 
 
 
 
 
Confidentiality Statement 
The information contained in this document is the property of the University of Virginia Human 
Immune Therapy Center.  Distributing, copying, or disclosing information contained in this 
document requires prior authorization from the Human Immune Therapy Center, except that 
this document may be disclosed to the appropriate institutional review boards and 
representatives of the U.S. Food and Drug Administration.   


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TITLE:  A trial to evaluate the safety, immunogenicity, and clinical activity of a helper peptide vaccine 
plus PD-1 blockade 
Sponsor 
University of Virginia Human Immune Therapy Center 
Principal Investigator 
Director, Human Immune 
Therapy Center 
Craig L. Slingluff, Jr. 
University of Virginia 
434-924-1730 
cls8h@virginia.edu 
Co-Investigators 
William Grosh, MD 
434-924-1904 
wwg9u@virginia.edu 
 
Elizabeth Gaughan, MD 
434-924-7678 
emg5x@virginia.edu 
 
Lynn Dengel, MD 
434-284-1978 
ltd5b@hscmail.mcc.virginia.edu 
 
Varinder Kaur, MD 
434-394-5226 
vk4q@hscmail.mcc.virginia.edu  
Carmel Nail, FNP-C 
434-982-4042 
cjn2r@virginia.edu 
 
Kathleen Haden, ANP-C 
434-924-1730 
km3s@virginia.edu 
 
Jennifer Eccles, MPAS, PA-C  
434-243-0066  
jme5j@virginia.edu  
 
Kimberly Bullock, PhD 
434-924-0180 
kb9d@virginia.edu 
 
Biostatisticians: 
Gina R. Petroni, PhD 
434-924-8363 
grp4c@virginia.edu 
 
Mark Smolkin, MS 
434-982-1032 
mes6r@virginia.edu 
 
Clinical Research 
Coordinators and Data 
Management 
 
Emily Allred, PhD 
434-982-1902 
eh4m@virginia.edu 
 
Sarah Lewis, BA 
434-924-8709 
set5v@virginia.edu 
 
Meagan Darling 
434-982-6584 
mtd6wa@virginia.edu 
Jessica Zareno, MS 
434-982-1901 
jhz4f@virginia.edu 
 
Adela Mahmutovic 
434-982-6714 
am6bd@hscmail.mcc.virginia.edu 
 
Authors: 
 
Craig L. Slingluff, Jr., MD 
Kimberly Bullock, PhD 
Gina R. Petroni, PhD 
 
 
 
 
 
 
 


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SIGNATURE PAGE 
 
 
 
INVESTIGATOR’S AGREEMENT 
I confirm that I have read this protocol and I agree to conduct the study as outlined herein.  I agree to 
conduct the study in accordance with the ethical principles that have their origin in the Declaration of 
Helsinki and that are consistent with Good Clinical Practices, as outlined in ICH E6, and the 
applicable laws and regulations.  
 
 
Sponsor-Investigator 
 
______________________ 
 
_________________________              ___________ 
Name  
 
 
 
Signature 
 
 
 
Date 


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IND NUMBER: 10825 
 
 
TABLE OF CONTENTS 
1.0 
TRIAL SUMMARY ....................................................................................................................... 6 
2.0 
TRIAL DESIGN ........................................................................................................................... 6 
2.1 
Trial Design ................................................................................................................................ 6 
2.2 
Trial Diagram .............................................................................................................................. 7 
3.0 
OBJECTIVES .............................................................................................................................. 7 
3.1 
Primary Objectives .................................................................................................................... 7 
3.2 
Secondary Objectives ............................................................................................................... 7 
3.3 
Exploratory Objectives .............................................................................................................. 7 
4.0 
BACKGROUND & RATIONALE ................................................................................................. 8 
4.1 
Background ................................................................................................................................ 8 
4.2 
Study Rationale .......................................................................................................................... 8 
4.2.1 
Pharmaceutical and Therapeutic Background ..................................................................... 9 
4.2.2 
Preclinical and Clinical Trial Data ....................................................................................... 10 
4.3 
Rationale ................................................................................................................................... 10 
4.3.1 
Rationale for the Trial and Selected Subject Population .................................................... 10 
4.3.2 
Rationale for Dose Selection/Regimen/Modification .......................................................... 12 
4.3.3 
Rationale for Endpoints ...................................................................................................... 13 
5.0 
METHODOLOGY ...................................................................................................................... 16 
5.1 
Entry Criteria ............................................................................................................................ 16 
5.1.1 
Diagnosis/Condition for Entry into the Trial ........................................................................ 16 
5.1.2 
Subject Inclusion Criteria .................................................................................................... 16 
5.1.3 
Subject Exclusion Criteria .................................................................................................. 18 
5.2 
Trial Treatments ....................................................................................................................... 20 
5.2.1 
Dose Selection/Modification ............................................................................................... 20 
5.2.2 
Timing of Dose Administration ........................................................................................... 25 
5.2.3 
Trial Blinding/Masking ........................................................................................................ 26 
5.3 
Randomization or Treatment Allocation ............................................................................... 26 
5.4 
Stratification ............................................................................................................................. 26 
5.5 
Concomitant Medications/Vaccinations (allowed & prohibited) ......................................... 26 
5.5.1 
Acceptable Concomitant Medications ................................................................................ 26 
5.5.2 
Prohibited Concomitant Medications .................................................................................. 27 
5.6 
Rescue Medications & Supportive Care ................................................................................ 27 
5.7 
Diet/Activity/Other Considerations ........................................................................................ 30 
5.7.1 
Diet ..................................................................................................................................... 30 
5.7.2 
Contraception ..................................................................................................................... 30 
5.7.3 
Use in Pregnancy ............................................................................................................... 32 
5.7.4 
Use in Nursing Women....................................................................................................... 32 
5.8 
Subject Withdrawal/Discontinuation Criteria........................................................................ 32 
5.9 
Subject Replacement Strategy ............................................................................................... 34 
5.10 Clinical Criteria for Early Trial Termination .......................................................................... 34 
6.0 
TRIAL FLOW CHART ............................................................................................................... 35 
6.1 
Study Flow Chart ..................................................................................................................... 35 
7.0 
TRIAL PROCEDURES .............................................................................................................. 40 
7.1 
Trial Procedures ...................................................................................................................... 40 
7.1.1 
Administrative Procedures ................................................................................................. 40 
7.1.2 
Clinical Procedures/Assessments ...................................................................................... 42 
7.1.3 
Laboratory Procedures/Assessments ................................................................................ 46 
7.1.4 
Other Procedures ............................................................................................................... 47 


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7.1.5 
Visit Requirements ............................................................................................................. 48 
7.2 
Assessing, Recording, and Reporting Adverse Events ...................................................... 49 
7.2.1 
Definitions ........................................................................................................................... 49 
7.2.2 
Attribution Assessment ....................................................................................................... 51 
7.2.3 
Evaluating Adverse Events ................................................................................................ 52 
7.2.4 
Adverse Event Classifications ............................................................................................ 55 
7.2.5 
Agent-Specific Expected Adverse Events List ................................................................... 56 
7.2.6 
Dose-Limiting Toxicities...................................................................................................... 56 
7.2.7 
Recording and Reporting Adverse Events ......................................................................... 57 
7.2.8 
Sponsor Responsibility for Reporting Adverse Events ....................................................... 63 
8.0 
STATISTICAL CONSIDERATIONS .......................................................................................... 63 
8.1 
Design ....................................................................................................................................... 63 
8.2 
Evaluation of Sample Populations and Criteria.................................................................... 63 
8.2.1 
Safety.................................................................................................................................. 63 
8.2.2 
Immunogenicity .................................................................................................................. 63 
8.2.3 
Clinical efficacy ................................................................................................................... 64 
8.3 
Sample Size and Accrual ........................................................................................................ 64 
8.4 
Stratification ............................................................................................................................. 65 
8.5 
Safety Monitoring .................................................................................................................... 65 
8.6 
Analyses ................................................................................................................................... 65 
9.0 
LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL SUPPLIES ................. 66 
9.1 
Investigational Product ........................................................................................................... 66 
9.2 
Packaging and Labeling Information ..................................................................................... 67 
9.3 
Clinical Supplies Disclosure................................................................................................... 67 
9.4 
Storage and Handling Requirements .................................................................................... 67 
9.5 
Returns and Reconciliation .................................................................................................... 67 
10.0 ADMINISTRATIVE AND REGULATORY DETAILS................................................................. 67 
10.1 Study Conduct and Ethical Considerations .......................................................................... 67 
10.2 UVA Institutional Review Board for Health Sciences Research ......................................... 68 
10.3 Consent Forms and the Consenting Process....................................................................... 68 
10.4 Compliance with Trial Registration and Results Posting Requirements .......................... 68 
10.5 Maintenance of Study Documents ......................................................................................... 68 
10.6 Data Collection ......................................................................................................................... 68 
10.6.1 
Endpoint Data ..................................................................................................................... 68 
10.7 Monitoring Plan ........................................................................................................................ 69 
10.7.1 
Monitoring Schedule ........................................................................................................... 69 
11.0 LIST OF REFERENCES ........................................................................................................... 70 
12.0 APPENDICES ........................................................................................................................... 75 
12.1 ECOG Performance Status ..................................................................................................... 75 
12.2 Common Terminology Criteria for Adverse Events V4.0 (CTCAE)..................................... 76 
12.3 Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 Criteria for Evaluating 
Response in Solid Tumors ................................................................................................................ 77 
12.4 AJCC Staging System ............................................................................................................. 78 
12.5 New York Heart Association Disease Classification ........................................................... 80 
12.6 Vaccine Lot Release and Stability Testing ............................................................................ 81 
12.7 Summary of Changes .............................................................................................................. 83 
 
 
 


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1.0 TRIAL SUMMARY 
Abbreviated Title 
6MHP Vaccine Plus Pembrolizumab 
Trial Phase 
Phase I/II 
Clinical Indication 
advanced melanoma (stage IIIB-IV at initial presentation or on 
recurrence), 
Trial Type 
Open-label 
Type of control 
N/A 
Route of administration 
IV (pembrolizumab); SQ and ID (6MHP) 
Trial Blinding 
N/A 
Treatment Groups  
Single Group:  6MHP + pembrolizumab 
Number of trial subjects 
A maximum of 25 to obtain 22 evaluable subjects 
Estimated duration of trial 
Approximately 47 months. 
Duration of Participation 
Approximately 71 months 
Estimated average length of 
treatment per patient 
Approximately 2 years  
 
 
 
 
2.0 
TRIAL DESIGN 
2.1 
Trial Design 
This study is an open-label, phase I/II study of a vaccine comprised of a mixture of 6 synthetic 
melanoma helper peptides (6MHP) administered in Montanide ISA-51 (incomplete Freund’s 
adjuvant) combined with pembrolizumab (Figure 1).  The study will accrue up to 25 subjects to 
obtain evaluable data on 22 subjects. 
All subjects will receive the same treatment regimen consisting of 6MHP administered 
intradermally (ID) and subcutaneously (SQ) on days 1, 8, 15, 43, 64, and 85. Pembrolizumab 
will be administered intravenously (IV) every 3 weeks, beginning on day 1. Duration of 
pembrolizumab will be up to 2 years. 
Biopsy specimens will be collected from the tumor (days 1 and 22) and a sentinel immunized 
node (SIN; day 22). The SIN biopsy will no longer be required after protocol modification 
approval to remove the SIN biopsy component. Biopsy and peripheral blood specimens will be 
used in the immunologic analyses. 
Follow-up after last dose of pembrolizumab will occur 30 days post last infusion.  Subjects will 
be followed annually for disease status and survival. Tumor assessments will be completed at 
screening and again at days 57, 127, and as indicated per standard care.  The expectation is 
that there will be additional follow-up as part of standard of care, either by the study physician 
or by a local referring physician. Every effort will be made to obtain data on disease status and 
survival at all such visits, in addition to the mandated study visits. 
 


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2.2 
Trial Diagram 
Figure 1. Clinical Trial Schema 
 
3.0 
OBJECTIVES 
3.1 
Primary Objectives 
(1) Safety:  To determine whether the administration of pembrolizumab plus a vaccine consisting of 6 
melanoma-derived class II MHC-restricted helper peptides (6MHP) is safe. 
(2) Immunogenicity:  To estimate the immunogenicity of 6MHP in the blood when co-administered 
with pembrolizumab, with or without removal of a sentinel immunized node. 
3.2 
Secondary Objectives 
To determine whether combined treatment with 6MHP vaccine plus pembrolizumab: 
(1) Modifies the tumor microenvironment, including estimation of whether combined treatment: 
(a) Increases infiltration of CD4+ and CD8+ T cells into tumor metastases, especially CD4+ T 
cells reactive to the vaccine peptides. 
(b) Increases Th1-dominant immune signatures in the tumor microenvironment.  
(2) Induces CD8+ responses to defined melanoma defined antigens (epitope-spreading) and IgG 
antibody responses to 6MHP in the blood and SIN, when SIN biopsy specimen available.  
3.3 
Exploratory Objectives 
(1) To obtain preliminary data on whether 6MHP vaccine plus pembrolizumab induces CD4+ or 
CD8+ T cell responses to mutated neoantigens  
 


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(2) To obtain preliminary data on whether 6MHP vaccine plus pembrolizumab induces clinical 
responses (as measured by RECIST 1.1) in patients with or without prior PD-1/PD-L1 blockade 
therapy. 
 
4.0 
BACKGROUND & RATIONALE 
4.1 
Background 
Cancer immunotherapy for solid tumors is coming of age, with FDA-approved immuno-
therapeutics in prostate cancer, melanoma, and renal cell cancer.  Interleukin-2 (IL-2) and the 
anti-CTLA-4 antibody ipilimumab are approved for melanoma; both induce durable clinical 
regressions. Recent data also show that blockade of PD-1/PD-L1 induces durable clinical 
regressions of melanoma, renal cell cancer and non-small cell lung cancer (NSCLC) (1), and 
the PD-1 antibody pembrolizumab has been approved for treatment of advanced melanoma in 
patients who have progressed after ipilimumab therapy. Furthermore, antigen-specific adoptive 
T cell therapy induces clinical regressions that are durable in about 20% of treated patients (2). 
There is excitement about this growing armamentarium of systemic immunotherapeutics, 
whose effects are mediated predominantly by T lymphocytes.  However, despite the 
effectiveness of available immunotherapeutic approaches, current therapies still fail in about 
70-80% of patients. Thus, there is a need for new combination approaches that build on the 
demonstrated clinical value of immune therapy. 
Cancer vaccines inducing antigen-specific T cell responses are emerging as a component of 
combination immunotherapy.  In the past few years, a cancer vaccine has been approved for 
prostate cancer, based on improved survival outcomes from two randomized trials (3), and a 
randomized prospective trial in melanoma patients showed that adding a peptide vaccine to 
high-dose IL-2 significantly prolonged progression-free survival (PFS) when compared to IL-2 
alone (4).  Thus, after several decades of development and optimization, there is now evidence 
that some cancer vaccines may improve clinical outcomes, in particular in combination with 
other active therapy.  
We have developed a vaccine incorporating 6 intermediate-length peptides that induces CD4+ 
helper T cell (TH) responses (6 helper peptides, 6MHP), and  has clinical activity in patients with 
advanced melanoma (5).  The 6MHP vaccine has also been shown to induce Th1 dominant T 
cell responses (6)  and cross-priming of CD8+ T cells (7). The current protocol is to obtain 
preliminary data on whether the combination of the 6MHP vaccine with immune checkpoint 
blockade of PD-1 is safe and improves immunologic and clinical outcomes compared to prior 
experience with each single agent alone. This trial will incorporate correlative studies of 
immune responses in blood, lymph nodes, and tumor to obtain a more complete understanding 
of the host: tumor relationship in the context of these combination therapies. These studies hold 
promise: 
 
To modulate T cell infiltration into metastases 
 
To increase helper T cell responses to vaccine, and  
 
To increase clinical response rates and to extend the life of patients with melanoma. 
 
4.2 
Study Rationale 
Evidence for the Role of the Immune System in Protecting Against the Development of Solid 
Tumors 


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There has long been evidence of immune responses to cancer, but evidence of impact on 
tumor progression has not been well demonstrated until recently.  The most convincing 
experimental evidence of the importance of immune surveillance in preventing the development 
of solid tumors is provided by work in murine models, in which 50-100% of knockout mice 
lacking STAT1 and/or IFNγ receptor function developed spontaneous solid tumors of various 
histologies within 12-15 months, whereas normal mice never developed malignancies during 
the same time period (8).  These studies strongly support the role of cellular immune function in 
the control of cancer progression.  These findings are supported in humans by the fact that 
blockade of immune checkpoints (CTLA-4 and/or PD-1) induces durable clinical responses in 
patients with melanoma and other cancers (9-11). 
The Role of CD4+ Helper T Lymphocytes in Anti-tumor Immune Responses.   
 
Initially, the majority of cancer vaccines were designed to activate the CD8+ cytotoxic T cell arm 
of the host immune system. However, more recent approaches target the activation of CD4+ Th 
cells.  This is based in part on results from earlier studies which demonstrated that depletion of 
CD4+ T-cells abrogates all or part of protective immune response to vaccines (12).  
Furthermore, adoptive therapy with CD4+ T-cells has been shown to induce tumor protection in 
some model systems (13,14).   
 
There are several mechanisms by which Th cells mediate anti-tumor responses.  Th cells can 
activate dendritic cells (DC) for heightened antigen presentation, causing the DC to secrete IL-2 
and other cytokines and co-stimulatory molecules that support the induction of CD8+ T cell 
immune responses (15-18). In addition, Th responses support the establishment of CD8+ T cell 
memory responses (19-22). Furthermore, strong Th1 help produces a cytokine milieu which is 
critical to the induction of immune-mediated tumor destruction (23,24).   
 
4.2.1 Pharmaceutical and Therapeutic Background 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades (25).  Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in 
various malignancies  (26-30).  In particular, the presence of CD8+ T-cells and the ratio of CD8+ 
effector T-cells / FoxP3+ regulatory T-cells seems to correlate with improved prognosis and 
long-term survival in many solid tumors. 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress 
immune control.  The normal function of PD-1, expressed on the cell surface of activated T-
cells under healthy conditions, is to down-modulate unwanted or excessive immune responses, 
including autoimmune reactions.  PD-1 (encoded by the gene Pdcd1) is an Ig superfamily 
member related to CD28 and CTLA-4 which has been shown to negatively regulate antigen 
receptor signaling upon engagement of its ligands (PD-L1 and/or PD-L2) (31-34).  The 
structure of murine PD-1 has been resolved (35).  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 (31,36).  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 (37,38).  PD-1 was shown to be expressed on activated lymphocytes including 


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peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer cells (39,40).  Expression 
has also been shown during thymic development on CD4-CD8- (double negative) T-cells as well 
as subsets of macrophages and dendritic cells (41).  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 (37,42-44).  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 (37).  Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor.  PD-1 
has been suggested to regulate tumor-specific T-cell expansion in subjects with melanoma 
(MEL) (45).  This suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune 
evasion and should be considered as an attractive target for therapeutic intervention. 
Pembrolizumab (previously known as SCH 900475 and 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.   
4.2.2 Preclinical and Clinical Trial Data 
Refer to the Investigator’s Brochure for Preclinical and Clinical data. 
4.3 
Rationale 
4.3.1 Rationale for the Trial and Selected Subject Population 
Melanoma is the fifth most common cancer in the United States, and over 70,000 new cases 
will be diagnosed this year (46).  Worldwide, approximately 50,000 people die each year from 
melanoma.  When diagnosed and treated for localized disease, a patient’s prognosis is often 
favorable; however, approximately 12% of patients with localized disease eventually recur with 
metastatic disease.  Factors associated with an increased risk of recurrence include the 
presence of ulceration, microsatellitosis, intransit disease and lymph node involvement.  Prior to 
the current era of checkpoint blockade therapy, the median survival time for patients with stage 
IV metastatic melanoma was only about 6-10 months (47).  
 
CD4+ T-helper cells have been shown to play an important role in anti-tumor immunity.  Anti-
tumor responses can occur via direct interactions between CD4+ T cells and tumor cells or 
alternatively, through indirect mechanisms including the licensing and activation of antigen 
presenting cells (15,16,48). The 6MHP vaccine incorporates known MHC class II-restricted 
peptides derived from melanoma-associated tumor antigens and administration of the vaccine 
in an emulsion with Montanide ISA-51 induces Th1-dominant CD4+ T cell responses to the 
peptides (5,7).   T cell responses against the vaccine have been induced in 40-80% of patients, 
and RECIST-defined clinical response rates and disease control rates have been observed in 
8% and 30%, respectively. In prior melanoma studies, Mel41 and E1602, durations of SD and 
clinical responses have been durable, ranging from 1 to 7 years (5,49) (Table 1). Also, there 
has been a strong and significant association between immune response to the 6MHP and 
survival, in patients with advanced melanoma in the ECOG trial E1602 (univariate, p = 0.005, 
multivariate p =0.038, HR 0.50) (49)(Reed 2015 3)(Figure 2). 
 


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The programmed cell death receptor-1 (PD-1) is found on activated T cells, and binding of this 
receptor with its ligands results in the down-regulation of T cell responses (50).  Pembrolizumab 
blocks the interaction between PD-1 and its ligands, preventing down-regulation of the T cell 
response. Clinical responses with pembrolizumab in the melanoma setting have been observed 
in approximately 26% of patients who have progressed after ipilimumab therapy 
(51).  Combining pembrolizumab with the 6MHP vaccine may lead to enhanced targeted T cell 
responses against defined tumor antigens and result in the induction of improved clinical 
response rates in patients with metastatic disease.  The goals of this phase I study are to 
evaluate the safety of the combination of 6MHP and pembrolizumab and also to evaluate the T 
cell response against the 6MHP vaccine in the context of pembrolizumab administration.  
Clinical responses will also be measured. 
 
 
Figure 2:  Overall Survival on E1602 
Overall survival by helper T cell response to 6MHP 
in analyzable patients on arms C and D of E1602 
trial (n = 64). 
 
To improve the clinical benefit of this and other vaccines, it is critical to support T cell infiltration 
and function in the tumor microenvironment. We have reported that melanoma metastases can 
be categorized into 3 Immunotypes based on immune cell infiltrates, where Immunotype A 
melanomas (29%) lack infiltrates, Immunotype B (63%) have immune cell infiltrates cuffing 
intratumoral vessels but not infiltrating tumor nests, and only Immunotype C melanomas (8%) 
have diffuse immune infiltrates (52). Blockade of PD-1/PD-L1 can increase T cell infiltration and 
combination with a vaccine should improve tumor targeting. Also, recent data have revealed 
Table 1.  Clinical Response Rates to 6MHP Vaccines in Subjects 
with Advanced Melanoma in Mel41 and E1602 Trials (RECIST) 
Study 
N 
CR+PR 
CR+PR+SD 
RR 
DCR 
Mel41 
17 
2 
4 
12% 
24% 
E1602 Arm D (6MHP) 
42 
3 
15 
7.1% 
36% 
E1602 Arm C 
32 
2 
8 
6.3% 
25% 
All studies 
91 
7 
27 
7.7% 
30% 


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increased PD1 expression on exhausted CD4+ T cells (53); thus, blocking PD1/PDL1 is 
expected to support CD4+ T cell function.  
The current proposal is for a clinical trial combining this active 6MHP vaccine with 
pembrolizumab. Primary endpoints include safety and immune response. Secondary endpoints 
will include assessment of changes in the tumor microenvironment. Exploratory objectives will 
include assessment of objective response rate, overall clinical outcome and association 
between immune response and survival.   There is great interest in obtaining preliminary data 
on whether the combination of 6MHP vaccine and pembrolizumab may increase objective 
clinical response rates, PFS, or overall survival. However, patterns of care for patients are 
changing rapidly as new immunotherapy agents are becoming available.  On one hand, the 
overall response rate for patients pretreated with ipilimumab is about 23%, but for patients 
treated with pembrolizumab as first-line therapy is 33%.  Thus, powering the study for response 
rate would depend on limiting enrollment to only one of these approaches. In addition, 
combination immunotherapy with PD-1 blockade plus CTLA-4 blockade is being employed, with 
response rates of about 50%, but with much higher toxicity than with pembrolizumab alone.  
Patients may be selected for one of these 3 regimens (pembrolizumab first, CTLA-4 blockade 
first, or combination therapy) for reasons that may affect the patient populations, including 
patient frailty, age, or biomarker assessment of metastases.  Thus, the present study is 
designed to obtain pilot data on clinical outcome but to power the study for safety, detection of 
effects on the immune responses (in all patients), and for detection of changes in the tumor 
microenvironment (in a subset of patients). 
4.3.2 Rationale for Dose Selection/Regimen/Modification  
Pembrolizumab:   
The rationale for further exploration of 2 mg/kg and comparable doses of pembrolizumab in 
solid tumors is based on: 1) similar efficacy and safety of pembrolizumab when dosed at either 
2 mg/kg or 10 mg/kg Q3W in melanoma patients, 2) the flat exposure-response relationships of 
pembrolizumab for both efficacy and safety in the dose ranges of 2 mg/kg Q3W to 10 mg/kg 
Q3W, 3) the lack of effect of tumor burden or indication on distribution behavior of 
pembrolizumab (as assessed by the population PK model) and 4) the assumption that the 
dynamics of pembrolizumab target engagement will not vary meaningfully with tumor type. 
The choice of the 200 mg Q3W as an appropriate dose for the switch to fixed dosing is based 
on simulations performed using the population PK model of pembrolizumab showing that the 
fixed dose of 200 mg every 3 weeks will provide exposures that 1) are optimally consistent with 
those obtained with the 2 mg/kg dose every 3 weeks, 2) will maintain individual patient 
exposures in the exposure range established in melanoma as associated with maximal efficacy 
response and 3) will maintain individual patients exposure in the exposure range established in 
melanoma that are well tolerated and safe.  
A fixed dose regimen will simplify the dosing regimen to be more convenient for physicians and 
to reduce potential for dosing errors.  A fixed dosing scheme will also reduce complexity in the 
logistical chain at treatment facilities and reduce wastage. 
Standard of care in the metastatic/unresectable setting is administration of pembrolizumab for 
up to two years. Regulatory approval does not limit the time on therapy. In this study, we will 
continue pembrolizumab for 2 years of therapy in the setting of stable disease or response 
without limiting toxicity.  


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6MHP vaccine:   
The 6MHP vaccine was tested at 3 dose levels (200, 400, 800 mcg per vaccine) and no 
differences were observed in immunogenicity, Th1 profiles or in toxicity (6).  Thus the lowest 
dose of 200 mcg will be used in this protocol. 
4.3.3 Rationale for Endpoints 
The 6MHP vaccine has been administered to over 200 subjects and overall has been well-
tolerated.  A summary of toxicities related to 6MHP administration may be found in Table 2.   
Table 2.  Reported Toxicities for 6MHP Vaccines in Humans (n=207) 
Toxicity (based on max grade) 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
 
 
 
 
 
LOCAL, INJECTION SITE 
 
 
 
 
Injection site reaction 
18% 
56% 
2.4% 
 
Ulceration 
 
5% 
1.4% 
 
 
 
 
 
 
CONSTITUTIONAL 
 
 
 
 
Fatigue  
43% 
8% 
3.4% 
 
Headache 
27% 
1.4% 
0.5% 
 
Rigors, Chills 
24% 
1.4% 
-- 
 
Nausea 
23% 
2% 
0.5% 
 
Sweating 
19% 
1% 
 
 
Myalgias 
18% 
0.5% 
 
 
Arthralgias 
17% 
0.5% 
 
 
Fever 
16% 
2% 
 
 
Dizziness 
13% 
 
 
 
Anorexia 
13% 
3% 
 
 
Diarrhea 
12% 
2% 
 
 
Cough 
13% 
 
 
 
Allergic rhinitis 
11% 
 
 
 
Nasal/paranasal reactions 
11% 
 
 
 
Pain larynx/throat 
10% 
 
 
 
Flushing 
10% 
 
 
 
Pruritis 
9% 
0.5% 
 
 
Rash 
6% 
3.4% 
 
 
Dyspnea 
5% 
1% 
0.5% 
 
Vomiting 
5% 
1% 
0.5% 
 
Flu-like syndrome 
6% 
 
 
 
Mucositis 
6% 
 
 
 
Constipation 
5% 
 
 
 
Autoimmune reaction 
4% 
0.5% 
 
 
Wound, non-infectious 
4% 
 
 
 
Pain, other 
2% 
1% 
0.5% 
 
Abdominal pain 
1.4% 
 
0.5% 
 
Tinnitus 
 
0.5% 
0.5% 
 
Tumor pain 
0.5% 
 
0.5% 
 
Hearing (without monitoring program) 
 
 
0.5% 
 
 
 
 
 
 
CLINICAL LABORATORY 
 
 
 
 
Hyperglycemia (not fasting) 
22% 
1% 
 
 
Hemoglobin, low 
17% 
1% 
0.5% 
 
Hyperkalemia 
13% 
 
 
 
Lymphopenia 
9% 
2.9% 
1% 
 


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Toxicity (based on max grade) 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Leukocytes 
8% 
1% 
 
 
Hyponatremia 
7% 
 
 
 
Increased creatinine 
6% 
0.5% 
 
 
Hypoglycemia 
6% 
 
 
 
AST, SGOT 
5% 
 
 
0.5% 
ALT, SGPT 
4% 
 
1% 
 
Neutrophils 
3% 
2% 
 
 
Metabolic, Other 
3% 
0.5% 
0.5% 
 
Alk phos 
4% 
0.5% 
 
 
Bilirubin 
3% 
 
0.5% 
 
 
Pembrolizumab has been evaluated in multiple studies with doses ranging from 1 mg/kg to 10 
mg/kg Q2W to Q3W.  Safety data from the prior PN001 phase I clinical trial study (479 
subjects) suggest that pembrolizumab is well-tolerated, with 4.2% of study subjects 
discontinuing study treatment due to a treatment-related AE (Investigator’s Brochure).   
The described trial is the first evaluation of pembrolizumab combined with a peptide-based 
vaccine (6MHP) and the first evaluation of any PD-1/PD-L1 antibody in combination with a 
helper-peptide vaccine.  Thus, safety is included as a primary endpoint for this trial.   Additional 
endpoints include measures of immunogenicity and clinical efficacy.   
4.3.3.1 Efficacy Endpoints 
From prior clinical trials with the 6MHP vaccine, we determined that we can induce T cell 
responses to the peptides following vaccination (5,49,54). In addition, vaccination with 6MHP 
led to clinical responses in a modest number of subjects (5,49).  Administration of 
pembrolizumab with 6MHP may enhance CD4+ T cell responses directed against tumor-derived 
peptides within the vaccine and lead to improved disease control by preventing down-regulation 
of the T cell response following vaccination. Accordingly, we have included endpoints to obtain 
preliminary data on whether combination of 6MHP with immune checkpoint blockade improves 
immunologic and clinical outcomes compared with historical data for each single agent alone.   
Biomarker Research 
In order to optimize combinatorial immunotherapy approaches for the treatment of cancer, we 
must obtain a more complete understanding of the host: tumor relationship in the context of 
these combination therapies. The following analyses are included as part of this study to 
evaluate the biology of host immune responses in the peripheral blood, within a lymph node 
immediately draining a vaccine site (sentinel immunized node (SIN)), and within sites of tumor.  
Blood and tumor tissue samples will be taken pre- and post- study drug administration to 
evaluate changes over time.  A SIN biopsy will be taken one week following the third vaccine 
for a subset of patients. 
Measuring T cell responses to Melanoma Antigens in the Vaccine:  To estimate whether the 
immunogenicity of 6MHP, and induction of epitope-spreading, will be increased by co-
administration with pembrolizumab.   
We anticipate that co-administration of pembrolizumab with a helper peptide vaccine may 
increase the CD4+ T cell response to the vaccines.  We have also observed induction of CD8+ 
T cells following vaccination with 6MHP, presumably due to epitope spreading (7).  Thus, we 
hypothesize that CD4 and CD8 T cell responses will increase in frequency, magnitude, and 
duration with pembrolizumab. 


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Immune responses in PBMC and SIN will be measured by ELIspot assay, proliferation assay, 
and/or flow cytometry.  Increases in immune response rate, magnitude, and duration will all be 
of interest.  Of greatest interest will be the induction of durable helper T cell responses, defined 
as responses in PBMC at 2 or more of the blood draws after day 85.  Also, we will test for T cell 
responses to multiple antigens, using overlapping 15-mers from NY-ESO-1, MelanA, MAGE-
A1, MAGE-A3, tyrosinase, and gp100, as well as for CD8+ T cell responses to a panel of at 
least 14 defined epitopes from these proteins. This will also include analysis of immune 
responses in the tumor microenvironment, as detailed below, with the expectation of tumor 
biopsies in at least 14 of the patients enrolled on this trial. 
Since we have observed induction of epitope spreading to peptide antigens not in the vaccine, 
we hypothesize that vaccination with helper peptides will also induce epitope spreading to 
mutated neoantigens, and that the activity of T cells reactive to them in the tumor may be 
supported by co-administration with pembrolizumab.  Thus, we propose exploratory studies to 
identify putative neoantigens in these patients and to test whether patients with immune 
responses to the vaccine also have epitope spreading to recognition of those mutated 
neoantigens, and whether T cells reactive to those antigens may be identified among tumor 
infiltrating lymphocytes. 
Impact of sentinel immunized node biopsy, and presence of tumor, on circulating immune 
response.  The induction of immune responses to vaccines are presumed to be mediated by 
interactions of T cells and antigen presenting cells in the vaccine-draining node (sentinel 
immunized node, SIN).  Measurement of circulating T cell responses thus may be affected by 
removal of the SIN at week 3 in the first set of patients enrolled on this trial.  They may also be 
affected by homing to metastatic tumor.  For those tumors that permit infiltration by vaccine-
reactive T cells, it would be ideal if T cells induced by vaccination primarily home to tumor and 
are relatively depleted from circulation.  Thus, we are interested in obtaining preliminary data on 
whether circulating immune responses differ, after the SIN is harvested, for the first patients 
enrolled, who undergo SIN biopsy, compared to those who do not undergo SIN biopsy.  To 
address this, the protocol is revised for the latter group of patients not to have SIN biopsy.   
Tumor microenvironment.  To determine whether Th1 CD4+ T cells induced by vaccination 
infiltrate the tumor microenvironment and whether they are associated with a favorable immune 
signature.      
Induction of T cells reactive to melanoma antigens in the circulation is necessary but not 
sufficient for tumor control.  We will test whether CD4+ T cells induced by the 6MHP vaccine 
infiltrate melanoma metastases, for the subset of patients (at least 12 patients) who have tumor 
accessible for biopsy (typically skin metastases, superficial nodes, and soft tissue masses). 
Tumor tissue can be limiting; so isolation of viable cells in adequate number from metastatic 
tumor biopsies can be challenging.  An alternate approach is to identify T cell receptors of the T 
cells induced by the vaccines.  We hypothesize that there will be increased infiltration of T cells 
induced by 6MHP vaccine when co-administered with pembrolizumab, compared to pre-
treatment biopsies.  We also hypothesize that expansion of Th1 CD4+ cells will support 
expansion of tumor-reactive CD8+ T cells in the tumor microenvironment, which will be 
evaluated simultaneously. 
We will determine if there is evidence of a T cell response in PBMC. Immune responses are 
anticipated in more than 50% of patients.  The PBMC samples with responses and 
corresponding pretreatment PBMC samples will be prepared as isolated CD4+ T cell 
populations by negative selection using Miltenyi beads. Those cells will be submitted for T-cell 
receptor (TCR) sequence profiling by ImmunoSeq (Adaptive Biotechnologies, Seattle, WA), 
which will identify TCRs enriched in the PBMC and SIN as T cells responding to the vaccines.   


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We will also send frozen (or FFPE) tumor tissue for the same analysis, as a measure of 
whether T cells induced by vaccination are then found infiltrating the tumors.   In cases where 
tumor-infiltrating lymphocytes can be isolated in adequate quantity to perform functional 
analyses, this will be done as well, as validation of the TCR sequencing studies, but we expect 
that to be an uncommon event.  The TCR molecular analysis will be feasible in a larger 
proportion of patients. Associations with clinical outcome will be noted as pilot data.  
To understand whether the combination therapy induces Th1-biased immune signatures in the 
tumor microenvironment, we will perform gene expression analysis on pretreatment tumors day 
1 and treated tumors day 22. Tumor specimens placed in RNA-Later at the patient bedside, 
typically within 5 min of excision and stored at -80oC, provide source material. RNA will be 
isolated by our laboratory staff from those specimens. RNA amplification, array application 
using HUMAN GENE 2.0 ST chips from Affymetrix Inc, RNA-seq, or comparable analysis, and 
data analyses will be performed using Partek Genomic Suite & Ingenuity Pathway Analysis 
(IPA) software to provide principal component analysis, identification of genes differentially 
expressed on day 22 (vs. day 1) to mark effects of the combination therapy.  Changes will be 
evaluated in canonical pathways, gene network, and transcription factor expression. Gene 
expression of pretreatment samples will be correlated with clinical responses.   
The histology evaluations will be compared to the TCR expression data, to assess whether 
infiltration with vaccine-reactive CD4+ T cells is associated with increased infiltration of CD4+ 
cells or lymphocytes overall, or with Immunotype C infiltration patterns (55) in particular.  
Immunohistochemical stains to clarify these observations may be performed on tumors. 
5.0 
METHODOLOGY 
5.1 
Entry Criteria 
5.1.1 Diagnosis/Condition for Entry into the Trial 
Subjects with unresectable stage IIIB or IIIC melanoma, or stage IV metastatic melanoma that 
have clinical or radiological evidence of disease. Stage definition may occur at original 
diagnosis or after recurrence. These subjects may have had cutaneous, uveal, mucosal primary 
melanoma, or an unknown primary melanoma.  Staging must be confirmed by cytological or 
histological examination. Staging of cutaneous melanoma will be based on the AJCC v7 
staging system (Appendix 12.4) (56). Subjects must be eligible to be treated with 
pembrolizumab based on clinician judgement. 
5.1.2 Subject Inclusion Criteria 
In order to be eligible for participation in this trial: 
1. A subject must be willing and able to provide written informed consent/assent for the trial. 
2. A subject must be  18 years of age on day of signing informed consent. 
3. A subject may be naïve for immunotherapy agents or have received interferon-alpha, 
ipilimumab or other CTLA-4 antibody, PD-1 antibody (or anti-PD-L1 antibody), interleukin-2, 
or prior cancer vaccines other than the 6MHP vaccine. Patients who have received a PD-
1/PD-L1 antibody may be enrolled in either of the following settings: 
a) A patient who has experienced progression of melanoma during that therapy or 
after having completed that therapy,  


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b) A patient who fails to experience an objective clinical response  (partial response or 
complete response by RECIST 1.1 criteria) after either 12 weeks of continuous 
anti-PD1 antibody or anti-CTLA4/anti-PD1 combination therapy, and is a candidate 
to receive pembrolizumab therapy 
4. A subject must have measurable disease based on RECIST 1.1.   
Subjects will be required to have radiological studies to define radiologically evident 
disease.  Required studies include: 
 
Chest CT scan, 
 
Abdominal and pelvic CT scan, and 
 
Head CT scan or MRI 
PET/CT fusion scan may replace scans of the chest, abdomen, and pelvis. 
5. Subjects who have metastatic melanoma available for biopsy pretreatment and on day 22 
must consent to having those biopsies.  These melanoma lesions may be in nodes, skin, 
soft tissue, liver, or other sites that can be accessed safely by needle biopsy, incisional or 
excisional biopsy, with or without image guidance.  The lesions to be biopsied must be 
specified at study enrollment and not included as target lesions for RECIST calculations.  In 
instances where disease that is accessible to biopsy is limited, archival tissue specimens 
collected after a subject’s last systemic therapy may be used for baseline measures. 
Subjects must have measurable disease in addition to the lesion(s) to be biopsied. 
6. Subjects who have had brain metastases will be eligible if all of the following are true: 
 
Each brain metastasis must have been completely removed by surgery or each 
unresected brain metastasis must have been treated with stereotactic radiosurgery.   
 
There has been no evident growth of any brain metastasis since the most recent 
treatment 
 
No brain metastasis is > 2 cm in diameter at the time of registration. 
 
Neurologic symptoms have returned to baseline,  
 
There is no evidence of new or enlarging brain metastases,  
 
Subjects are not using steroids for at least 7 days prior to registration.   
7. The most recent surgical resections or gamma-knife therapy for malignant melanoma must 
have been completed ≥ 1 week prior to registration. 
8. A subject must have a performance status of 0 or 1 on the ECOG Performance Scale. 
9. A subject must demonstrate adequate organ function as defined in Table 3, all screening 
labs should be performed within 28 days of treatment initiation.           
Table 3.  Adequate Organ Function Laboratory Values 
System 
Laboratory Value 
Hematological 
 
Absolute neutrophil count (ANC) 
≥1,500 /mcL 
Platelets 
≥100,000 / mcL 
Hemoglobin 
≥9 g/dL or ≥5.6 mmol/L  
Renal 
 
Serum creatinine OR 
Measured or calculateda creatinine 
clearance 
≤1.5 X upper limit of normal (ULN) OR 
 
≥60 mL/min for subject with creatinine levels > 1.5 X 


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System 
Laboratory Value 
(GFR can also be used in place of 
creatinine or creatinine clearance) 
institutional ULN 
Hepatic 
 
Serum total bilirubin 
≤ 1.5 X ULN OR 
 
Direct bilirubin ≤ ULN for subjects with total bilirubin levels 
> 1.5 ULN 
AST (SGOT) and ALT (SGPT) 
≤ 2.5 X ULN  OR 
≤ 5 X ULN for subjects with liver metastases 
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. 
 
10. Female subjects of childbearing potential should have a negative urine or serum pregnancy 
test 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 (Section 5.7.2) must be willing to use an 
adequate method of contraception as outlined in Section 5.7.2 – Contraception, for the 
course of the study through 120 days after the last dose of study medication.   
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for 
the subject. 
12. Male subjects of childbearing potential (Section 5.7.2) must agree to use an adequate 
method of contraception as outlined in Section 5.7.2 – Contraception, starting with the first 
dose of study therapy through 120 days after the last dose of study therapy. 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for 
the subject. 
13. Blood is to be collected for HLA typing (Class I and Class II), which will be analyzed as part 
of the immunologic endpoints, but HLA type will not be an inclusion/exclusion criterion. 
14. A subject must have at least two intact (undissected) axillary and/or inguinal lymph node 
basins. 
5.1.3 Subject Exclusion Criteria 
    The subject must be excluded from participating in the trial if the subject: 
1. Is currently participating in or has participated in a study of an investigational agent or using 
an investigational device within 4 weeks of the first dose of treatment. 
2. Is currently receiving Interferon (e.g. Intron-A®), growth factors (e.g. Procrit®, Aranesp®, 
Neulasta®), or interleukins (e.g. Proleukin®), or has received these agents within 4 weeks of 
the first dose of treatment. 
3. Is currently receiving nitrosureas or has received this therapy within the preceding 6 weeks 
of first dose of treatment. 


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4. Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other 
form of immunosuppressive therapy within 7 days prior to registration with the following 
exceptions (which are permitted): 
 
replacement steroid doses in patients with adrenal or pituitary insufficiency  
 
Intra-articular steroid injections 
 
Inhaled steroids (e.g.: Advair®, Flovent®, Azmacort®) at low doses (less than 500 
mcg fluticasone per day, or equivalent) 
 
Topical and nasal corticosteroids  
 
Non-steroidal anti-inflammatory drugs 
5. Has had a prior monoclonal antibody within 3 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.   
6. Has had prior chemotherapy, targeted small molecule therapy, or external beam 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.   
7. Has a known additional malignancy that is progressing or requires active treatment.  
Exceptions include carcinoma in situ of the breast (DCIS or LCIS), basal cell carcinoma of 
the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone 
potentially curative therapy.   
8. Has known active central nervous system (CNS) metastases and/or carcinomatous 
meningitis.   
9. Has an active autoimmune disease requiring systemic treatment within the past 3 months 
or a documented history of clinically severe autoimmune disease, or a syndrome that 
requires systemic steroids or immunosuppressive agents.  Exceptions to this criterion 
include: 
 
Subjects with vitiligo or other depigmenting illness. 
 
Resolved childhood asthma/atopy  
 
Intermittent use of bronchodilators or local steroid injections  
 
Hypothyroidism stable on hormone replacement or Sjogren’s syndrome  
 
The presence of laboratory evidence of autoimmune disease (e.g. positive ANA 
titer) without symptoms 
 
Mild arthritis requiring NSAID medications 
10. Has a history of (non-infectious) pneumonitis that required steroids or current evidence of 
interstitial lung disease or pneumonitis.  
11. Has an active infection requiring systemic therapy. 
12. 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 treating investigator.   
13. Has known psychiatric or substance abuse disorders that would interfere with cooperation 
with the requirements of the trial. 
14. 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. 
15. Is HIV positive or has evidence of active Hepatitis C virus (testing to be done within 6 
months of study entry) or active Hepatitis B virus. 
16. Has received a live vaccine or allergy desensitization injections within 30 days prior to the 
first dose of trial treatment.   
17. Has known or suspected allergies to any component of the vaccine. 
18. Has been vaccinated previously with any of the synthetic peptides included in this protocol.  
19. Is classified according to the New York Heart Association classification as having Class III 
or IV heart disease (Appendix 12.5). 
20. Has uncontrolled diabetes, defined as having a HGBA1C  8.5%. 
21. Has a body weight < 110 pounds (without clothes) at enrollment, due to the amount and 
frequency with which blood will be drawn. 
5.2 
Trial Treatments 
The treatment to be used in this trial is outlined below in Table 4. 
Table 4.  Trial Treatment 
 
Drug 
Dose/Potency 
Dose 
Frequency 
Route of 
Administration 
Regimen/Treatment 
Period 
Use 
Pembrolizumab1 
200 mg 
Q3W 
starting at 
Day 1 
IV infusion 
Up to 2 years 
Experimental 
6MHP 
200 mcg each 
peptide 
Days 1, 8, 
15, 43, 64, 
85 
SQ and ID 
Injection 
Through Day 85 
Experimental 
1The pembrolizumab dosing interval may be increased as described in Section 5.2.1.3. 
Trial treatment should begin within 14 days of registration. 
5.2.1 Dose Selection/Modification 
5.2.1.1 Dose Selection 
The rationale for selection of doses to be used in this trial is provided in Section 4.0 – 
Background and Rationale.   
5.2.1.2 Study Drug Preparation and Administration 
Pembrolizumab 
Details on the preparation and administration of pembrolizumab are provided in the Pharmacy 
Manual for MK-3475 (pembrolizumab). 


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6MHP 
Details on the preparation of 6MHP will be provided on vaccine mixing forms.  The prepared 
peptide vaccines will be stored in a plastic syringe and delivered to the clinicians in a plastic 
bag.  This bag with the syringe will be stored at room temperature until the vaccine is 
administered.  Ideally, the vaccine should be administered within 1-2 hours after mixing.  If the 
vaccine is not administered within 4 hours after mixing, it should be discarded. 
Designation of Vaccine Sites 
Evidence suggests nodes proximal to a tumor site may be relatively immunosuppressed; 
therefore, the vaccination sites will be selected to be distant from the sites of tumor whenever 
possible.  In general, subjects will be vaccinated in upper arm or thigh sites with intact draining 
nodes.  Vaccines will be administered at the designated site(s).  Chronic inflammatory reactions 
are expected to occur in patients at their vaccine sites. Induration may persist for months, but is 
not expected to require additional therapy.  Sterile abscesses may occur in some patients.  
These are not a basis for discontinuation of the vaccines unless they lead to ulceration of 
greater than 2 cm diameter, require antibiotics, or require surgical debridement.   
Administration of 6MHP 
The vaccine regimen will be the same for all subjects.  Days 1, 8, 15, 43, 64, 85:  200 mcg each 
of the 6 peptides (Table 5), emulsified in Montanide ISA-51 adjuvant (2 ml total will be 
administered).  Each of vaccines 1-6 will be administered subcutaneously (50%) and 
intradermally (50%).  Vaccines 1-3 will be administered at one skin site. Vaccines 4-6 will also 
be administered at one skin site, but in a separate location than vaccines 1-3.  If either vaccine 
site has severe inflammation or ulceration after 1-2 vaccines, the next vaccine(s) may be 
placed near the original site. 
 
Table 5.  Class II-Restricted Melanoma Peptides 
Allele 
Sequence 
Epitope 
HLA-DR4 
AQNILLSNAPLGPQFP 
Tyrosinase 56-70#  
HLA-DR15 
FLLHHAFVDSIFEQWLQRHRP 
Tyrosinase 386-406 
HLA-DR4 
RNGYRALMDKSLHVGTQCALTRR 
Melan-A/MART-151-73 
HLA-DR11 
TSYVKVLHHMVKISG 
MAGE-3 281-295 
HLA-DR13 
LLKYRAREPVTKAE 
MAGE-1,2,3,6 121-134 
HLA-DR4 & -DR1 
WNRQLYPEWTEAQRLD 
gp100 44-59 
# An alanine residue was added to the N-terminus to prevent cyclization. 
 
Pre-medications 
None required. 
Post-Vaccination Observation 
All subjects will be closely observed for adverse events for at least 20 minutes following each 
vaccination.  Any time thereafter, subjects should report any adverse events to the research 
coordinator or research clinician. 


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5.2.1.3 Dose Modification  
6MHP vaccines:  There will be no dose modifications of the vaccine components.   
In circumstances where assessment of an AE is limited, such as by intercurrent illness, or when 
laboratory studies are required to assess for other causes of toxicity, the vaccine schedule may 
be interrupted for up to 21 days.  Delay of one vaccine administration by up to 21 days will not 
be considered a protocol violation if due to an AE, regardless of attribution.  If more than one 
vaccine is delayed by 21 days due to an AE, regardless of attribution, vaccine treatment should 
be discontinued, though the other systemic therapy may be continued. 
Pembrolizumab:  Pembrolizumab will be withheld for drug-related AEs as detailed below and in 
Table 6.  In the event that the dose of pembrolizumab is held, subjects may continue receiving 
the 6MHP vaccine if the investigators do not believe the toxicities are attributable to the 
vaccines.   
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 6, below. See Section 5.6 and 
Table 8 for supportive care guidelines, including use of corticosteroids. 
Table 6. Dose Modification and Toxicity Management Guidelines for Immune-related AEs Associated 
with Pembrolizumab 
General instructions: 
1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 
weeks. 
2. For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to 
Grade 0-1 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 


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Grade 4 
Permanently 
discontinue 
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. 
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  
Hyper-
thyroidism  
Grade 2 
Continue  
 Treat with non-selective beta-
blockers (eg, propranolol) or 
thionamides as appropriate  
 
Monitor for signs and symptoms of 
thyroid disorders.  
 
Grade 3 or 4  
Withhold or  
permanently 
discontinue1 
Hypothyroidism 
Grade 2-4 
Continue  
 
Initiate thyroid replacement 
hormones (eg, levothyroxine or 
liothyroinine) per standard of 
care 
 
Monitor for signs and symptoms of 
thyroid disorders.  
 
Nephritis and 
Renal 
dysfunction 
Grade 2 
Withhold  
 
Administer corticosteroids 
(prednisone 1-2 mg/kg or 
equivalent) followed by taper. 
 
Monitor changes of renal function 
 
Grade 3 or 4  
Permanently 
discontinue 
Myocarditis 
Grade 1 or 2 
Withhold 
 
Based on severity of AE 
administer corticosteroids 
 
Ensure adequate evaluation to 
confirm etiology and/or exclude 
other causes 
 
Grade 3 or 4 
Permanently 
discontinue 
All other 
immune-related 
Intolerable/ 
persistent Grade 2 
Withhold 
 
Based on type and severity of 
AE administer corticosteroids  
 
Ensure adequate evaluation to 
confirm etiology and/or exclude 


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AEs 
Grade 3 
Withhold or 
discontinue based 
on the type of 
event.  Events 
that require 
discontinuation 
include and not 
limited to:  
Gullain-Barre 
Syndrome, 
encephalitis 
other causes 
 
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).   
 
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 patient's study record. 
5.2.1.4 Delayed Visit for Reasons Other Than Toxicity 
A schedule for return visits should be established at the first visit.  If a subject misses a 
treatment, the missed treatment will be administered as soon as possible, and treatment will be 
continued for an additional time period so that the subsequent vaccinations are given in the 
appropriate intervals.  Subjects who are vaccinated outside of the established schedule should 
return to the original schedule as soon as possible. 
The table below (Table 7) defines what constitutes a delayed visit, whether the subject should 
continue to be treated, and whether a protocol violation should be reported and recorded.  The 
range of days is counted from the original scheduled date.   
Table 7.  Delayed Visit for Reasons other than Toxicity 
Treatment Period 
Range of Days 
Subject Treatment 
Protocol 
Deviation 
Biopsy/Vaccine 
1*/Pembrolizumab 
 
 
 
Day 1 
 2 days 
Vaccine, Labs, Pembrolizumab 
No 
        
 3 to 7 days 
Vaccine, Labs, Pembrolizumab 
Yes 
 
 8 or more days 
Labs 
Yes 
Vaccines 2-3* 
 
 
 
Days 8, 15 
 2 days 
Vaccine/Labs 
No 
        
 3 to 7 days 
Vaccine/Labs 
Yes 
 
 8 or more days 
Labs 
Yes 
Biopsy/Pembrolizumab 
 
 
 
Day 22 
 2 days 
Labs, Biopsies, Pembrolizumab 
No 


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 3 to 7 days 
Labs, Biopsies, Pembrolizumab 
Yes 
 
 8 or more days 
Labs 
Yes 
Vaccine 4*/Pembrolizumab 
 
 
 
Days 43 
 2 days 
Vaccine, Labs, Pembrolizumab 
No 
 
 3 to 7 days 
Vaccine, Labs, Pembrolizumab 
Yes 
 
 8 or more days 
Labs 
Yes 
Assessment 
 
 
 
Day 57 
 7 days 
Scans** 
No 
 
 8 to 14 days 
Scans 
No 
 
 15 or more days 
Scans 
Yes 
Vaccine 5*/Pembrolizumab 
 
 
 
Day 64 
 7 days 
Vaccine, Labs, Pembrolizumab 
No 
 
 8 to 14 days 
Vaccine, Labs, Pembrolizumab 
Yes 
 
 15 or more days 
Labs 
Yes 
Vaccine 6*/Pembrolizumab 
 
 
 
Day 85 
 7 days 
Vaccine, Labs, Pembrolizumab 
No 
 
 8 to 14 days 
Yes 
 
 15 or more days 
Labs 
Yes 
Assessment 
 
 
 
Day 92 
 7 days 
Labs 
No 
 
 8 to 14 days 
Labs 
Yes 
 
 15 or more days 
Labs 
Yes 
Pembrolizumab 
 
 
 
Day 106+ 
 7 days 
Labs/Pembrolizumab 
No 
 
 8 to 14 days 
Labs/Pembrolizumab 
Yes 
 
 15 or more days 
Labs, Pembrolizumab/Scans** 
Yes 
 
 
 
 
Safety Follow-up 
 
 
 
30-days after last dose of 
pembrolizumab  
 14 days 
Labs 
No 
 
 15 or more days 
Labs 
Yes 
* A subject will be taken off protocol treatment if more than one vaccination is delayed [ 3 to 7 days] 
during the treatment period. 
** CT scans on days 57 and 127 (weeks 8 and 18) should also be completed within these time limits.  
Subsequent scans should be completed per clinical care.  The scan at week 8 is to measure 
response, with confirmatory scans if needed.  Scans beyond week 18 may be performed earlier or 
more frequently than specified in the protocol if indicated as part of clinical care.   
5.2.2 Timing of Dose Administration 
Trial treatment should be administered after all procedures/assessments have been completed 
as detailed on the Trial Flow Chart (Section 6.0).  All trial treatments will be administered on an 
outpatient basis. 
Pembrolizumab will be administered as a 30 minute IV infusion (treatment cycle intervals may 
be increased due to toxicity as described in Section 5.2.1.3.  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). 


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The Pharmacy Manual for MK-3475 contains specific instructions for pembrolizumab dose 
calculation, reconstitution, preparation of the infusion fluid, and administration. 
6MHP will be administered as a subcutaneous and intradermal injection. 
On days when both pembrolizumab and vaccine are administered, the vaccine may be 
administered before or after pembrolizumab, but preferably before.   
5.2.3 Trial Blinding/Masking 
This is an open-label trial; therefore, the Sponsor-Investigator and subject will know the 
treatment administered. 
5.3 
Randomization or Treatment Allocation 
All subjects will receive 6MHP plus pembrolizumab following the same treatment regimen. 
5.4 
Stratification 
Patients will be monitored for post entry stratification by whether or not biopsies are obtained at 
baseline and day 22. 
5.5 
Concomitant Medications/Vaccinations (allowed & prohibited) 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial.  If there is a clinical indication for one of these or other medications or 
vaccinations specifically prohibited during the trial, discontinuation from trial therapy or 
vaccination may be required.  The investigator should discuss any questions regarding this with 
the Sponsor-Investigator.  The final decision on any supportive therapy or vaccination rests with 
the investigator and/or the subject's primary physician.  However, the decision to continue the 
subject on trial therapy or vaccination schedule requires the mutual agreement of the 
Investigator, the Sponsor-Investigator, and the subject.  
5.5.1 Acceptable Concomitant Medications 
All treatments that the investigator considers necessary for a subject’s welfare may be 
administered at the discretion of the investigator in keeping with the community standards of 
medical care including the following: 
 
Nonsteroidal anti-inflammatory agents 
 
Anti-histamines (e.g. Claritin®, Allegra®) 
 
Topical and nasal corticosteroids or steroids for the reasons cited in sections 5.5.2. 
 
Short-term therapy for acute conditions not specifically related to melanoma 
 
Chronic medications except those listed in section 5.5.2 
 
Influenza vaccines (excluding the live version of the vaccine) are permitted, but 
should be administered at least 2 weeks prior to or at least 2 weeks after 
administration of study drug. 
 
All concomitant medication will be recorded on the case report form (CRF) including all 
prescription, over-the-counter (OTC), herbal supplements, and IV medications and fluids.  If 


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changes occur during the trial period, documentation of drug dosage, frequency, route, and 
date may also be included on the CRF. 
All concomitant medications received within 28 days before the first dose of trial treatment and 
30 days after the last dose of trial treatment should be recorded.  Concomitant medications 
administered after 30 days after the last dose of trial treatment should be recorded for SAEs 
and ECIs as defined in Section 7.2. 
5.5.2 Prohibited Concomitant Medications 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase of this trial: 
 
Anti-cancer systemic chemotherapy or biological therapy  
 
Immunotherapy not specified in this protocol 
 
Chemotherapy not specified in this protocol 
 
Investigational agents; Note: pembrolizumab and 6MHP are permitted during the 
treatment phase, per the protocol. 
 
Radiation therapy; Note: Radiation therapy to a symptomatic solitary lesion or to the 
brain may be allowed after consultation with Sponsor-Investigator.   
 
Allergy desensitization injections 
 
Systemic steroid therapy or any other form of immunosuppressive therapy with the 
following exceptions (which are permitted): 
o 
replacement steroid doses in patients with adrenal or pituitary 
insufficiency  
o 
Inhaled steroids (e.g.: Advair®, Flovent®, Azmacort®) at low doses (less 
than 500 mcg fluticasone per day, or equivalent) 
 
Street drugs 
 
Live vaccines within 30 days prior to the first dose of trial treatment, while participating 
in the trial and for at least 2 weeks after the last dose of study drug. Examples of live 
vaccines include, but are not limited to, the following: measles, mumps, rubella, chicken 
pox, yellow fever, rabies, BCG, Flu-Mist ®, and typhoid (oral) vaccine.  
Subjects who, in the assessment by the investigator, require the use of any of the 
aforementioned treatments for clinical management should be removed from the trial.  
Subjects may receive other medications that the investigator deems to be medically 
necessary. 
The Exclusion Criteria describes other medications which are prohibited in this trial. 
There are no prohibited therapies during the Post-Treatment Follow-up Phase. 
5.6 
Rescue Medications & Supportive Care 
Subjects should receive appropriate supportive care measures as deemed necessary by the treating 
investigator.  Suggested supportive care measures for the management of adverse events with 
potential immunologic etiology are outlined below. 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 


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are intended to be applied when the investigator determines the events to be related to 
pembrolizumab.  
Note: if after the evaluation the event is determined not to be related, the investigator does not need 
to follow the treatment guidance (as outlined below). Refer to Section 5.2.1 for dose modification.  
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or skin 
photography as part of evaluation of the event.  
 
Pneumonitis:  
o 
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. 
o 
For Grade 3-4 events, immediately treat with intravenous steroids.  Administer 
additional anti-inflammatory measures, as needed. 
o 
Add prophylactic antibiotics for opportunistic infections in the case of prolonged 
steroid administration. 
 
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).   
 
o 
All subjects who experience diarrhea/colitis should be advised to drink liberal 
quantities of clear fluids.  If sufficient oral fluid intake is not feasible, fluid and 
electrolytes should be substituted via IV infusion.  For Grade 2 or higher diarrhea, 
consider GI consultation and endoscopy to confirm or rule out colitis. 
o 
For Grade 2 diarrhea/colitis that persists greater than 3 days, administer oral 
corticosteroids.  
o 
For Grade 3 or 4 diarrhea/colitis (or Grade 2 diarrhea that persists > 1 week), treat 
with intravenous steroids followed by high dose oral steroids.   
o 
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) 
 
o 
For T1DM or Grade 3-4 Hyperglycemia 
 
Insulin replacement therapy is recommended for Type I diabetes mellitus and 
for Grade 3-4 hyperglycemia associated with metabolic acidosis or ketonuria.  
 
Evaluate patients with serum glucose and a metabolic panel, urine ketones, 
glycosylated hemoglobin, and C-peptide.  
 
 
Hypophysitis: 
 
o 
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. 
o 
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 


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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. 
 
o 
Grade 2 hyperthyroidism events (and Grade 3-4 hypothyroidism): 
 
In hyperthyroidism, non-selective beta-blockers (e.g. propranolol) are 
suggested as initial therapy. 
 
In hypothyroidism, thyroid hormone replacement therapy, with levothyroxine 
or liothyronine, is indicated per standard of care. 
o 
Grade 3-4 hyperthyroidism  
 
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. 
 
 
Hepatic: 
o 
For Grade 2 events, monitor liver function tests more frequently until returned to 
baseline values (consider weekly). 
 
Treat with IV or oral corticosteroids 
o 
For Grade 3-4 events, treat with intravenous corticosteroids for 24 to 48 hours.  
o 
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: 
o 
For Grade 2 events, treat with corticosteroids. 
o 
For Grade 3-4 events, treat with systemic corticosteroids. 
o 
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 8 shows treatment guidelines for subjects who experience an infusion reaction 
associated with administration of pembrolizumab (MK-3475). 
Table 8. 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 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may 
include but is not limited to: 
Subject may be premedicated 
1.5h (± 30 minutes) prior to 
infusion of pembrolizumab (MK-


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NCI CTCAE Grade 
Treatment 
Premedication at subsequent 
dosing 
treatment (e.g., antihistamines, 
NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated 
for < =24 hrs 
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. 
3475) with: 
 
Diphenhydramine 50 mg po (or 
equivalent dose of 
antihistamine). 
 
Acetaminophen 500-1000 mg 
po (or equivalent dose of 
antipyretic). 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not rapidly 
responsive to symptomatic 
medication and/or brief interruption 
of infusion); recurrence of 
symptoms following initial 
improvement; hospitalization 
indicated for other clinical sequelae 
(e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor or 
ventilatory support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDS 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Epinephrine 
 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of the 
investigator. 
Hospitalization may be indicated. 
Subject is permanently discontinued from 
further trial treatment administration. 
No subsequent dosing 
Appropriate resuscitation equipment should be available in the room and a physician readily available during the period 
of drug administration. 
 
 
5.7 
Diet/Activity/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.   


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For this trial, male subjects will be considered to be of non-reproductive potential if they have 
azoospermia (whether due to having had a vasectomy or due to an underlying medical 
condition).   
Female subjects will be considered of non-reproductive potential if they are either:  
(1) postmenopausal (defined as at least 12 months with no menses without an alternative medical 
cause; in women < 45 years of age a high follicle stimulating hormone (FSH) level in the 
postmenopausal range may be used to confirm a post-menopausal state in women not using 
hormonal contraception or hormonal replacement therapy. In the absence of 12 months of 
amenorrhea, a single FSH measurement is insufficient.);  
OR  
(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy or bilateral 
tubal ligation/occlusion, at least 6 weeks prior to screening;  
OR  
(3) has a congenital or acquired condition that prevents childbearing. 
Female and male subjects of reproductive potential must agree to avoid becoming pregnant or 
impregnating a partner, respectively, while receiving study drug and for 120 days after the last 
dose of study drug by complying with one of the following:   
(1) practice abstinence† from heterosexual activity;  
OR  
(2) use (or have their partner use) acceptable contraception during heterosexual activity.   
Acceptable methods of contraception are‡: 
Single method (one of the following is acceptable): 
 
intrauterine device (IUD) 
 
vasectomy of a female subject’s male partner  
 
contraceptive rod implanted into the skin 
  
Combination method (requires use of two of the following): 
 
diaphragm with spermicide (cannot be used in conjunction with cervical cap/spermicide) 
 
cervical cap with spermicide (nulliparous women only)   
 
contraceptive sponge (nulliparous women only)  
 
male condom or female condom (cannot be used together) 
 
hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin-only 
pill), contraceptive skin patch, vaginal contraceptive ring, or subcutaneous contraceptive 
injection 
  
†Abstinence (relative to heterosexual activity) can be used as the sole method of 
contraception if it is consistently employed as the subject’s preferred and usual lifestyle and if 


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considered acceptable by local regulatory agencies and ERCs/IRBs.  Periodic abstinence 
(e.g., calendar, ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are 
not acceptable methods of contraception.  
 ‡If a contraceptive method listed above is restricted by local regulations/guidelines, then it 
does not qualify as an acceptable method of contraception for subjects participating at sites 
in this country/region. 
Subjects should be informed that taking the study medication may involve unknown risks to the 
fetus (unborn baby) if pregnancy were to occur during the study.  In order to participate in the 
study, subjects of childbearing potential must adhere to the contraception requirement 
(described above) from the day of study medication initiation (or 14 days prior to the initiation of 
study medication for oral contraception) throughout the study period up to 120 days after the 
last dose of trial therapy.  If there is any question that a subject of childbearing potential will not 
reliably comply with the requirements for contraception, that subject should not be entered into 
the study. 
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 Sponsor-Investigator and to 
Merck without delay and within 24 hours 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 the Sponsor-
Investigator.  If a male subject impregnates his female partner the study personnel at the site 
must be informed immediately and the pregnancy reported to the Sponsor-Investigator and to 
Merck and followed as described in Section 7.2.8. 
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. 
5.8 
Subject Withdrawal/Discontinuation Criteria 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the 
discretion of the investigator should any untoward effect occur.  In addition, a subject may be 
withdrawn by the investigator or the Sponsor-Investigator if enrollment into the trial is 
inappropriate, the trial plan is violated, or for administrative and/or other safety reasons.  
Specific details regarding discontinuation or withdrawal are provided in Section 7.1.4 – Other 
Procedures. 
Protocol treatment includes both the 6MHP vaccine and pembrolizumab.  Either or both may be 
discontinued for any of the following reasons.   
 
The subject or legal representative (such as a parent or legal guardian) withdraws 
consent. 
 
Confirmed radiographic disease progression 


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Note: A subject may be granted an exception to continue on treatment with confirmed 
radiographic progression if clinically stable or clinically improved.  Patients with 
progressive disease should undergo a second scan at least 4 weeks later to confirm 
progression and exclude the possibility of a tumor flare reaction, according to immune-
related response criteria (irRC) guidelines. 
 
Any dose-limiting toxicity (DLT), as defined in Section 7.2.7, warrants discontinuation of 
the agent to which the DLT is attributed. If a DLT attributed to one intervention is not 
believed to be related to the other treatment, only the one to which the DLT is attributed 
must be discontinued, and other protocol interventions may be continued as close to the 
original schedule as possible. However, management of toxicities attributed to PD-1 
antibody should follow current standard practice guidelines, including use of steroids 
when indicated.   Also, if a patient is discontinued from PD-1 antibody but not from 
vaccine, the visits every 3 weeks for PD-1 antibody, and the associated safety studies 
(e.g.: CBC, chemistries) do not need to be performed. 
 
Disease progression requiring other therapy (e.g. surgery under general anesthesia, 
radiation, chemotherapy, or steroid therapy).  The appearance of small metastases or 
recurrent tumor deposits will not be a basis for discontinuing the vaccinations.  Biopsy to 
determine the nature of new lesions, or minor surgical procedures to excise a new lesion, 
will not be a basis for discontinuing vaccinations.  Also, surgery to perform a biopsy of 
tumor at day 22, in accord with the protocol, will not be a basis for discontinuing therapy, 
whether done under local anesthesia or general anesthesia.  
 
Intercurrent illness that prevents further administration of treatment 
 
Initiation of cytotoxic chemotherapy, radiation therapy, or targeted therapy for melanoma 
or other cancer. 
 
Initiation of systemic steroid therapy, or other systemic immunosuppressive therapy, 
except that steroid or immunosuppressive therapy for management of toxicities of 
pembrolizumab is allowed without discontinuation of vaccines.    
 
Any other potential adverse reaction deemed sufficiently serious to warrant 
discontinuation of therapy by the Principal Investigator or one of the Associate 
Investigators. 
 
Investigator’s decision to withdraw the subject 
 
The subject has a confirmed positive serum pregnancy test 
 
Noncompliance with trial treatment or procedure requirements 
 
The subject is lost to follow-up 
 
Completed 24 months of uninterrupted treatment with pembrolizumab or 35 
administrations of study medication, whichever is later. 
Note: 24 months of study medication is calculated from the date of first dose. Subjects 
who stop pembrolizumab after 24 months may be eligible for additional pembrolizumab 
treatment as part of their clinical care if they progress after stopping study treatment.  
 
Administrative reasons 
 
The End of Treatment and Follow-up visit procedures are listed in Section 6 (Protocol Flow 
Chart) and Section 7.1.5 (Visit Requirements).  After the end of treatment, each subject will be 
followed for 30 days for adverse event monitoring (serious adverse events will be collected for 
90 days after the end of treatment as described in section 7.1.5.3.1 and 7.2.7.8).  Subjects who 
discontinue for reasons other than progressive disease will have post-treatment follow-up for 
disease status until disease progression, initiating a non-study cancer treatment, withdrawing 


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consent or becoming lost to follow-up (every 8 weeks post discontinuation up to 2 years or until 
the toxicity resolves).  After documented disease progression each subject will be followed by 
telephone annually for overall survival until death, withdrawal of consent, or until study closure, 
whichever occurs first. 
5.9 
Subject Replacement Strategy 
A subject who is enrolled but does not receive any pembrolizumab or 6MHP, or any of the 
study-related procedures may be replaced.  Every attempt will be made to evaluate data for 
endpoint assessment from subjects who withdrawal from the study.    
5.10 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 as determined by the 
Sponsor-Investigator. 
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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6.0 
TRIAL FLOW CHART 
 
6.1 
Study Flow Chart 
Trial Period: 
Active Treatment 
Day 
Main Study 
Screening  
1 
8 
15 
22 
43 
57 
64 
85 
92 
106 
127 
148 
169 
190 
365 
730 
Week 
 
0 
1 
2 
3 
6 
8 
9 
12 
13 
15 
18 
21 
24 
27 
52 
104 
Scheduling Window (Days): 
 
 
± 2 
± 2 
± 2 
± 2 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
Administrative Procedures 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent 
Xa 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pathology Review at UVA 
Xa 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laboratory Procedures 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC with Differential m 
Xb 
Xf 
 
 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
Comprehensive Serum Chemistry Panel m,v 
Xb,e 
Xf 
 
 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
HGBA1C 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urinalysis 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test: Serum or urine -HCG in 
women 
Xc 
Xu 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
T3, FT4 and TSH 
 
X 
 
 
 
X 
 
 
X 
 
 
X 
 
X 
 
X 
X 
PT/INR and aPTT 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HIV/HCV/HBV 
Xd 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ANA/RF 
 
X 
 
 
 
X 
 
 
X 
 
 
 
 
 
 
X 
X 
Clinical Assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics and Medical History 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam 
Xb 
Xf 
X 
X 
X 
X 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 


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Trial Period: 
Active Treatment 
Day 
Main Study 
Screening  
1 
8 
15 
22 
43 
57 
64 
85 
92 
106 
127 
148 
169 
190 
365 
730 
Week 
 
0 
1 
2 
3 
6 
8 
9 
12 
13 
15 
18 
21 
24 
27 
52 
104 
Scheduling Window (Days): 
 
 
± 2 
± 2 
± 2 
± 2 
± 14 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
± 7 
Prior and Concomitant Medication Review 
Xb 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Record Baseline Symptoms 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review Adverse Events 
 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Designation of potential vaccination sites 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of skin and nodal basins for 
evidence of disease 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of skin for vitiligo 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
Assessment of hair and eye color 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 
X 
X 
X 
X 
Visual acuity exam/color vision 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient diary reviewed and/or distributed 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
 
 
 
 
 
Efficacy Measures/Tumor Imaging 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT chest/abdomen/pelvis or PET-CTr 
X 
 
 
 
 
 
Xh 
 
 
 
 
Xh 
 
 
Xj 
Xj 
Xj 
Head MRI/CTr 
X 
 
 
 
 
 
Xi 
 
 
 
 
Xi 
 
 
Xi 
Xi 
Xi 
Digital images of cutaneous lesionsr 
X 
 
 
 
 
 
Xh 
 
 
 
 
Xh 
 
 
Xj 
Xj 
Xj 
Research Specimen Collection and 
Procedures 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
120 cc blood- green top tube 
 
Xk 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
80 cc blood- green top tube 
 
 
X 
X 
X 
X 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
20 cc blood- red top tube 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
Tumor Biopsy 
 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
SIN biopsy (thru protocol v04-04-17 only) 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Study Drug Administration 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
6MHP 
 
X 
X 
X 
 
X 
 
X 
X 
 
 
 
 
 
 
 
 
Pembrolizumab every 3 weeks 
 
X 
 
 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
Xt 


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End of Treatment 
Post-Treatment 
 
Discontinuation of 
pembrolizumab or of 
both drugsl 
Safety Follow-up 
Discontinuation of 
pembrolizumab or of 
both drugsl  
Follow Up Visits o 
After discontinuation 
for reasons other than 
disease progression 
Survival Follow-Upq  
After discontinuation of 
therapy for disease 
progression and/or 
initiation of new 
antineoplastic therapy 
Scheduling Window (days) 
 
± 14 Days 
± 15 Days 
± 28 Days 
 
At time of 
discontinuation of 
pembrolizumab  
30 days post 
discontinuation of 
pembrolizumab  
Every 8 weeks post 
discontinuation up to 2 
years or until resolution 
of toxicitys 
Annually 
Laboratory Procedures 
 
 
 
 
CBC with Differential 
X 
X 
 
 
Comprehensive Serum Chemistry Panelv 
X 
X 
 
 
Urinalysis 
X 
 
 
 
T3, FT4 and TSH 
X 
X 
 
 
Clinical Assessments 
 
 
 
 
Physical Exam 
X 
X 
X 
 
Prior and Concomitant Medication Review 
X 
X 
 
 
Review Adverse Events 
X 
X 
X 
 
Efficacy Measures/Tumor Imaging 
 
 
 
 
CT chest/abdomen/pelvis or PET-CT 
Xj 
 
Xj 
 
Head MRI/CT 
Xi 
 
 
 
Digital images of cutaneous lesions 
Xj 
 
Xj 
 
Research Specimen Collection and 
Procedures 
 
 
 
 
80 cc blood- green top tube 
X 
X 
Xs 
 
20 cc blood- red top tube 
X 
X 
Xs 
 


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End of Treatment 
Post-Treatment 
 
Discontinuation of 
pembrolizumab or of 
both drugsl 
Safety Follow-up 
Discontinuation of 
pembrolizumab or of 
both drugsl  
Follow Up Visits o 
After discontinuation 
for reasons other than 
disease progression 
Survival Follow-Upq  
After discontinuation of 
therapy for disease 
progression and/or 
initiation of new 
antineoplastic therapy 
Scheduling Window (days) 
 
± 14 Days 
± 15 Days 
± 28 Days 
 
At time of 
discontinuation of 
pembrolizumab  
30 days post 
discontinuation of 
pembrolizumab  
Every 8 weeks post 
discontinuation up to 2 
years or until resolution 
of toxicitys 
Annually 
Tumor Biopsy 
Xn 
 
 
Xn 
Survival Status 
 
 
 
 
Survival Status  
X 
X 
X 
X 
Start of Antineoplastic therapy 
 
 
 
X 
 
 
 
 
 
a  Any point prior to registration 
 
 
b Pre-study within 6 weeks of registration 
 
c  Within 2 weeks of registration (for childbearing women) 
 
d  Within 6 months of registration 
 
 
e To include fasting glucose 
f History & physical, comprehensive chemistry, and CBC with differential, for Day 1 are not required if the pre-study assessment was completed within 10 
calendar days of day 1. 
g For patients who have tumor accessible to biopsy, biopsies will be completed 1) at screening or up until day 1, and 2) at day 22.  Additional biopsies 
may be performed during the study or during follow-up if subjects are removed from the study or experience progression. 
h Tumor imaging (window of ± 14 Days) should be performed when clinically needed to verify objective clinical responses (per RECIST v1.1) and every 8-
12 weeks as indicated per standard care. 
 
i  Head imaging should be completed when clinically indicated. 
 
j Tumor imaging should be completed as indicated per standard care. 
 
k Blood for HLA typing is included in the research bloods 
l If a subject is discontinued and the assessments have been completed as part of a regularly scheduled visit, the assessments do not need to be 
repeated.  If a subject is discontinued from 6MHP but continues with pembrolizumab, the safety follow-up visit for 6 MHP will occur at the time of their 
next infusion of pembrolizumab. 
m Repeat CBC and chemistries every 3 weeks, just prior to the next dose of pembrolizumab. If there is a delay in pembrolizumab treatment for toxicity or 
other reasons, the CBC and chemistries should be delayed comparably, to enable those blood studies on the same day (before) each dose of 
pembrolizumab. 


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n If subjects develop superficial metastatic deposits accessible to biopsy/excision with minimal morbidity, an optional biopsy may be collected for research 
purposes.  If surgical resection or biopsies are completed for clinical care, the tumor tissue may be collected for study related analyses. 
o Follow-up visits every 8 weeks will not be required beyond 2 years from study entry. If a subject is managed locally and is not able to return to UVA 
every 8 weeks after discontinuation for reasons other than disease progression, because of toxicity or intercurrent health problems, every effort will be 
made to obtain records that supply data comparable to what is specified in the table. 
p Head MRI/CT may be performed every 6 months or as clinically indicated. 
q At the time of disease progression or if a subject begins receiving a new antineoplastic therapy, the subject will move into survival follow-up.  Subjects 
may be contacted by telephone for survival follow-up status. The expectation is that there will be additional follow-up as part of standard of care, either by 
the study physician or by a local referring physician. Every effort will be made to obtain data on disease status and survival at all such visits, in addition to 
the mandated study visits. 
r Patients with progressive disease should undergo a second scan at least 4 weeks later to confirm progression and exclude the possibility of a tumor 
flare reaction, according to irRC guidelines. 
S If a subject discontinues pembrolizumab for toxicity, that patient should be followed every 8 weeks until resolution of the toxicity or until 2 years from 
study entry, whichever is longer. If the toxicity resolves before 2 years, then the patient should continue with visits requiring research blood draws and 
tumor biopsies. 
t Week 52 is last planned clinical trial intervention other than continued dosing of pembrolizumab every 3 weeks; pembrolizumab is to be continued every 
3 weeks between week 26 and week 52, and beyond that to 2 years, along with safety labs as needed in routine clinical care.   
u Must be completed within 72 hours prior to receiving the first dose of study drug.  If the screening test is completed within 72 hours prior to Day 1, this 
test does not need to be repeated. 
v Refer to Table 9 for a complete list of analyses to be completed as part of the comprehensive chemistry panel. 
 
 
 


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7.0 
TRIAL PROCEDURES 
7.1 
Trial Procedures 
The Trial Flow Chart - Section 6.0 summarizes the trial procedures to be performed at each 
visit.  Individual trial procedures are described in detail below.  It may be necessary to perform 
these procedures at unscheduled time points if deemed clinically necessary by the investigator. 
Furthermore, additional evaluations/testing may be deemed necessary by the Sponsor-
Investigator and/or Merck for reasons related to subject safety. In some cases, such 
evaluation/testing may be potentially sensitive in nature (e.g., HIV, Hepatitis C, etc.), and thus 
local regulations may require that additional informed consent be obtained from the subject.  In 
these cases, such evaluations/testing will be performed in accordance with those regulations. 
7.1.1 Administrative Procedures 
7.1.1.1 
Informed Consent 
The Investigator must obtain documented consent from each potential subject prior to 
participating in a clinical trial. 
7.1.1.1.1  General Informed Consent 
Consent must be documented by the subject’s dated signature or by the subject’s legally 
acceptable representative’s dated signature on a consent form along with the dated signature 
of the person conducting the consent discussion.  
A copy of the signed and dated consent form should be given to the subject before participation 
in the trial. 
The initial informed consent form, any subsequent revised written informed consent form and 
any written information provided to the subject must receive the IRB/ERC’s approval/favorable 
opinion in advance of use.  The subject or his/her legally acceptable representative will be 
informed in a timely manner if new information becomes available that may be relevant to the 
subject’s willingness to continue participation in the trial.  The communication of this information 
will be provided and documented via a revised consent form or addendum to the original 
consent form that captures the subject’s dated signature or by the subject’s legally acceptable 
representative’s dated signature. 
Specifics about a trial and the trial population will be added to the consent form template at the 
protocol level.   
The informed consent will adhere to IRB/ERC requirements, applicable laws and regulations 
and Sponsor-Investigator requirements. 
7.1.1.2 
Inclusion/Exclusion Criteria 
All inclusion and exclusion criteria will be reviewed by the investigator or qualified designee to 
ensure that the subject qualifies for the trial.  


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7.1.1.3 
Registration 
All subjects must sign the consent form prior to determination of eligibility for this study.  
Registration will occur following verification of eligibility by the treating physician.  Subjects will 
be registered in the OnCore database and should receive their first study treatment within 2 
weeks of registration.  
7.1.1.4 
Medical History 
A medical history will be obtained by the investigator or qualified designee.  Medical history will 
include all active conditions, and any condition diagnosed within the prior 10 years that are 
considered to be clinically significant by the Investigator.  Details regarding the disease for 
which the subject has enrolled in this study will be recorded separately and not listed as 
medical history.   
7.1.1.5 
Prior and Concomitant Medications Review 
7.1.1.5.1 
Prior Medications 
The investigator or qualified designee will review prior medication use, including any protocol-
specified washout requirement, and record prior medication taken by the subject within 42 days 
before starting the trial.  Treatment for the disease for which the subject has enrolled in this 
study will be recorded separately and not listed as a prior medication.  
7.1.1.5.2 
Concomitant Medications 
The investigator or qualified designee will record medication, if any, taken by the subject during 
the trial.  All medications related to reportable SAEs and ECIs should be recorded as defined in 
Section 7.2. 
7.1.1.6 
Disease Details and Treatments 
7.1.1.6.1 
Disease Details 
The investigator or qualified designee will obtain prior and current details regarding disease 
status.  
7.1.1.6.2 
Prior Treatment Details 
The investigator or qualified designee will review all prior cancer treatments including systemic 
treatments, radiation and surgeries. 
7.1.1.6.3 
Subsequent Anti-Cancer Therapy Status 
The investigator or qualified designee will review all new anti-neoplastic therapy initiated after 
the last dose of trial treatment.  If a subject initiates a new anti-cancer therapy within 30 days 
after the last dose of trial treatment, the 30 day Safety Follow-up visit must occur before the first 
dose of the new therapy.  Once new anti-cancer therapy has been initiated the subject will 
move into survival follow-up.  


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7.1.1.7 
Trial Compliance (Medication/Diet/Activity/Other) 
Treatment compliance may be evaluated through drug accountability assessments and through 
the evaluation of subject medical records and CRF documents. 
7.1.2 Clinical Procedures/Assessments 
The following evaluations will be performed on an outpatient basis.   
7.1.2.1 Adverse Event (AE) Monitoring 
The investigator or qualified designee will assess each subject to evaluate for potential new or 
worsening AEs as specified in the Trial Flow Chart and more frequently if clinically indicated.  
Toxicity diaries will also be distributed to subjects and reviewed by study personnel.  Adverse 
experiences will be graded and recorded throughout the study and during the follow-up period 
according to NCI CTCAE Version 4.0 (see Section 12.2).  Toxicities will be characterized in 
terms regarding seriousness, causality, toxicity grading, and action taken with regard to trial 
treatment.  
All AEs of unknown etiology associated with pembrolizumab exposure should be evaluated to 
determine if it is possibly an event of clinical interest (ECI) of a potentially immunologic etiology 
(irAE).  See Section 5.6.1 regarding the identification, evaluation and management of AEs of a 
potential immunological etiology.   
Please refer to section 7.2 for detailed information regarding the assessment and recording of 
AEs.   
7.1.2.2 Physical Exams 
The investigator or qualified designee will perform a complete physical exam during the 
screening period.  Clinically significant abnormal findings should be recorded as medical 
history.   
Physical exams will include the following: 
 
vital signs (temperature, pulse, respiratory rate, blood pressure) 
 
weight,  
 
ECOG performance status,  
 
medication review,  
 
neurologic function-general 
 
 Height will be measured at screening only 
7.1.2.3 Vital Signs 
The investigator or qualified designee will take vital signs at screening, prior to the 
administration of each dose of trial treatment and at treatment discontinuation as specified in 
the Trial Flow Chart (Section 6.0).  Vital signs should include temperature, pulse, respiratory 
rate, weight and blood pressure.  Height will be measured at screening only. 
 


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7.1.2.4 Eastern Cooperative Oncology Group (ECOG) Performance Scale 
The investigator or qualified designee will assess ECOG status (see Section 12.1) as specified 
in the Trial Flow Chart.  
7.1.2.5 
Designation of Vaccine Sites 
Evidence suggests nodes proximal to a tumor site may be relatively immunosuppressed; 
therefore, the vaccination sites will be selected to be distant from the sites of tumor whenever 
possible.  In general, subjects will be vaccinated in upper arm or thigh sites with intact draining 
nodes.  Vaccines will be administered at the designated site(s).   
7.1.2.6 
Visual Assessments 
Visual acuity will be assessed using the Snellen chart. 
Color vision will be assessed using an Ishihara eye chart. 
 
7.1.2.7 
Tumor Imaging and Assessment of Disease 
Tumor Imaging 
Tumor imaging may include CT/PET-CT scans and/or MRI.  These will complement physical 
exam and other imaging as required, but the primary measures of clinical response will be 
based on CT/PET-CT and/or MRI and will use RECIST v1.1 criteria. For each subject, the 
same method of assessment will be used to evaluate tumor burden at baseline and throughout 
the course of the study. 
Tumor Measurements 
RECIST 1.1 Criteria will be used to evaluate tumor burden (Section 12.3). 
7.1.2.8 
Tumor Tissue Collection and Correlative Studies Blood Sampling 
7.1.2.8.1 
 Tumor Biopsies  
Tumor biopsies will be completed in subjects who have adequate and accessible metastatic 
tumor in addition to at least one site of measurable disease.  Biopsy sites may be in nodes, 
skin, soft tissue, liver, or other sites that can be accessed by needle biopsy, incisional or 
excisional biopsy.  Biopsies may be completed with or without image guidance.   
Size Requirements 
A critical component of this protocol is the histologic and cytologic evaluation of changes in 
immune effectors and the tumor microenvironment after vaccination and systemic therapy.  A 
minimum of 0.16 cm3 but ideally 0.3 cm3 or more of tumor tissue will be needed for each biopsy 
time point as described in the inclusion criteria. Biopsies may be taken from a single lesion or 
multiple lesions at each of the time points depending on the size of each lesion.  If taken from 
multiple lesions, those lesions should be similar.  For example, three non-ulcerated skin 
metastases would be considered similar; one bleeding small bowel metastasis would not be 
considered similar to a subcutaneous nodule). 
Sampling 


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The biopsies will vary based on the clinical scenario and may include six core biopsies, an 
incisional biopsy or an excisional biopsy as outlined in the inclusion criteria. 
Procedure 
When appropriate (and we anticipate the majority of cases) the biopsies will be performed 
under local anesthesia (typically lidocaine HCl 1% and epinephrine 1:100,000 injection + or - 
8.4% sodium bicarbonate), in the outpatient clinic or comparable procedure room, using sterile 
technique.  In cases when clinical standard of care requires a larger procedure the biopsies 
may be performed in the operating room under standard technique. 
To minimize errors in analysis due to sampling error and specimen heterogeneity, each study 
biopsy specimen will be divided into several components and randomly allocated into various 
preservation conditions. Ideally, tissue will be divided into the following preservation conditions, 
using core needle biopsies (19 mm long and 2 mm diameter; about 80 mm3), or incisional or 
excisional biopsies with at least the same minimum tissue volume: 
It is most critical to obtain the following: 
 
Formalin: 1 core biopsy or similar tissue volume (about 80 mm3 or greater) will be fixed 
in formalin, then paraffin-embedded (for histology/immunohistology) 
 
 
Quick-frozen: 2 core biopsies or similar tissue volume (each about 80 mm3 or greater) 
quick-frozen processed for protein studies, histology, or nucleic acid studies. If only one 
core can be obtained, this portion should be provided as two specimens (eg cut the 
core biopsy specimen in half). 
 
When sufficient tissue is available, the following should also be obtained: 
 
RNA-later: 1 core biopsy or similar tissue volume (about 80 mm3 or greater) will be 
placed in RNA-later (for RNA/RT PCR) 
 
Viable cell suspension:  2 core biopsies or similar tissue volume (total about 160 mm3 
or greater) will be processed for single-cell suspension by mechanical disaggregation, 
then enzymatic digestion (collagenase, hyaluronidase, DNAase).  The resulting 
suspensions will be cryopreserved in FBS serum and DMSO (for cellular immune 
function and flow cytometry). 
 
If there is additional tissue, it may be processed for additional immunologic studies. 
 
The incisions will be sutured closed.  Toxicities related to the biopsies will be recorded.   
Based on our experience in prior clinical trials (Mel48 (NCT00705640), Mel51 (NCT00977145 ), 
and Mel53 (NCT01264731)), it is adequate, for each specimen, to have at least the equivalent 
of a core biopsy specimen that is 19 mm long and 2 mm in diameter (about 80 mm3), or a cubic 
specimen 5 mm in width. Thus, for 1 FFPE and 1-2 QF specimens, we need about 160-240 
mm3 (2-3 cores, or 1 lesion about 7-10 mm in diameter).  For those with larger specimens (>1 
cm diameter), some will also be saved as viably cryopreserved single cell suspensions.  
A 5 micron section of each tumor specimen will be stained by H&E and reviewed to assess the 
extent and quality of viable tumor. For FFPE specimens, only those with at least 4 mm2 viable 
tumor (on cross-section) will be considered evaluable for histologic and immunohistologic 
studies. FFPE tissue will be evaluated for immunotype and for immune cell infiltrates. For QF 
specimens, those with at least 70% tumor will be considered evaluable.  
Evaluations 


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Tissue samples may be screened for antigen expression or protein profiles using tests such as 
Western blots, immunohistochemistry, PCR, flow cytometry or gene chip analysis.   
Tumor escape mechanisms may also be evaluated.   
Specimens will be used in immunological assays to assess T cell function or antibody 
response.  Assays generally used for this type of testing include, but are not limited to, ELIspot 
assays, ELISAs, chromium-release assays, proliferation assays, intracellular cytokine staining, 
and T cell receptor sequencing.   
Specimens may be used to study the immunologic aspects of the tumor microenvironment or 
as targets or controls in laboratory assays.  
Specimens may be used to establish cell lines for long-term studies. 
This tissue may also be compared to lesions resected prior to enrollment, which will be 
requested from the pathology department of each institution as paraffin-embedded tissue 
samples, and these tissues may be banked for use in future studies.   
HLA typing (Class I and Class II) will be analyzed as part of the immunologic endpoints. (8 ml) 
7.1.2.8.2 
Optional Tumor Biopsies (at the time of progression, after study completion 
and withdrawal) 
If during the study, participants develop superficial metastatic deposits accessible to 
biopsy/excision with minimal morbidity, an optional biopsy may be collected for research 
purposes. 
If tumor samples are collected when a Mel 64 participant is no longer participating in the Mel 64 
study and the participant consents to allow their tissue to be collected under the IRB #10598 
tissue banking study to be analyzed for Mel 64, the tissue may be analyzed as part of the Mel 
64 analysis. 
Optional biopsy samples may be evaluated as described in section 7.1.2.8.1. 
7.1.2.8.3 
Tumor Collected for Clinical Care 
If during the study, participants develop metastases or recurrences, or progress, these may be 
removed as part of their clinical care, and following receipt by pathology, may be evaluated by 
the study research team.   
7.1.2.8.4 
Blood Collection for Research Analyses 
Blood should be obtained prior to the vaccine injection if a vaccine is scheduled to be 
administered.  Results of research blood tests are not required prior to administering the 
vaccine on that date.   
The following blood samples for research will be collected and processed by the UVA 
Biorepository and Tissue Research Facility (BTRF). 
 
80 cc -120 cc blood collected in heparinized green top tubes for lymphocytes.  
 
20 cc blood collected in red top tubes for serum 
 


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Samples will be analyzed for analyses that may include the following (and leftover sample will 
be banked and stored for future biomedical research): 
 
Functional assays for T cell responses to melanoma antigens (the 6 melanoma helper 
peptides of the vaccine, and other melanoma antigens, and control antigens), including 
ELIspot assays, and multiparameter flow cytometry for cytokine release. 
 
Multimer assays for T cell receptor specificity  
 
High throughput T cell receptor sequencing. 
 
Genetic polymorphisms of immune-related genes 
 
Gene expression profiling of blood cells  
 
Production of chemokines, cytokines from circulating lymphocytes and other immune 
cells. 
 
Multiparameter flow cytometry for cellular markers, including markers of regulatory T 
cells, myeloid cells, and T cell maturation. 
 
Serum antibodies 
 
Serum cytokines, chemokines or other serum proteins 
 
7.1.3 
Laboratory Procedures/Assessments 
Laboratory tests for hematology, chemistry, urinalysis, and others are specified in Table 9.   
 
Table 9.  Laboratory Tests 
Hematology 
Chemistry 
Urinalysis 
Other 
Hematocrit 
Albumin 
Blood 
Urine pregnancy or serum 
β-human chorionic 
gonadotropin (β-hCG)† 
Hemoglobin 
Alkaline phosphatase 
Glucose 
HgB-A1C  
Platelet count 
Alanine aminotransferase (ALT) 
Protein 
PT (INR) 
WBC (total and 
differential) 
Aspartate aminotransferase 
(AST) 
Specific gravity  
aPTT 
Red Blood Cell Count 
Lactate dehydrogenase (LDH) 
(every 6 weeks) 
Microscopic exam (If abnormal)  
Total triiodothyronine (T3) 
Absolute Neutrophil 
Count 
Carbon Dioxide  
    (CO2 or bicarbonate) 
results are noted 
Free thyroxine (T4) 
 
Creatinine 
 
Thyroid stimulating 
hormone (TSH) 
 
Uric Acid 
 
HIV testing 
 
Calcium 
 
HCV testing 
 
Chloride 
 
HBV testing 
 
Glucose 
 
 ANA/RF  
 
Phosphorus 
 
  
 
Potassium   
 
  
 
Sodium 
 
  
 
Magnesium 
 
  
 
Total Bilirubin 
 
  
 
Direct Bilirubin (If total bilirubin is 
elevated above the upper limit of 
normal) 
 
 


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Hematology 
Chemistry 
Urinalysis 
Other 
 
Total protein 
 
 
 
Blood Urea Nitrogen 
 
 
† Perform on women of childbearing potential only. If urine pregnancy results cannot be confirmed as negative, a serum 
pregnancy test will be required.   
 
7.1.4 
Other Procedures 
7.1.4.1 
Sentinel Immunized Node (SIN) Biopsy 
The SIN biopsy will be performed until the approval of the protocol modification where the 
requirement for SIN biopsy was removed (through protocol v04-04-17).  Thereafter, SIN 
biopsies will not be performed.  
Procedure 
The node (sentinel immunized node, SIN) will be identified by radiocolloid (usually technetium 
99 sulfur colloid) injection, with or without lymphoscintigraphy imaging, and with use of a 
handheld gamma probe during the procedure. This will be performed under local anesthesia in 
the clinic, in conjunction with the vaccine site biopsy, by a qualified surgeon.   
Lymphatic mapping will be initiated, usually in the nuclear medicine suite, after intradermal 
injection with radiocolloid (typically technetium 99-sulfur colloid).  The node excision will be 
performed under local anesthesia (usually lidocaine HCl 1-2%, with or without epinephrine 
1:100,000 injection, with or without 8.4% sodium bicarbonate), in the outpatient clinic or 
comparable procedure room, using sterile technique.  A handheld gamma probe will be used. 
When possible, the node will be sectioned into 5 sections:  a central section (10-20% of the 
node), leaving two adjacent sections of about 40% each.  These latter two sections will be 
bisected.  They will be allocated into various preservation conditions: 
 
1 central section will be fixed in formalin, then paraffin-embedded  
 
(for histology/immunohistology) 
 
1 section will be placed in RNA-later. (for RNA/RT PCR) 
 
1 section will be quick-frozen (for immunohistology/protein studies) 
 
2 sections (40%) will be processed for single cell suspension by mechanical 
disaggregation, then enzymatic digestion (collagenase, hyaluronidase, DNAase).  The 
resulting suspensions will be cryopreserved in FBS and DMSO (for cellular immune 
function and flow cytometry).   
If there is additional tissue, it may be processed for additional immunologic or angiogenic 
studies. 
The incisions will be sutured closed. 
Toxicities related to the biopsies will be recorded. 
7.1.4.2 
Withdrawal/Discontinuation 
When a subject discontinues/withdraws prior to trial completion, all applicable activities 
scheduled for the final trial visit should be performed at the time of discontinuation.  Any 
adverse events which are present at the time of discontinuation/withdrawal should be followed 
in accordance with the safety requirements outlined in Section 7.2 - Assessing and Recording 


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Adverse Events.  Subjects who a) attain a CR or b) complete 24 months of treatment with 
pembrolizumab may discontinue treatment with the option of restarting treatment upon 
progression.  Restarting treatment will be completed as part of a subject’s standard clinical 
care, at the discretion of their treating physician.  After discontinuing treatment following 
assessment of CR, these subjects should return to the site for a Safety Follow-up Visit 
(described in Section 7.1.5.3.1) and then proceed to the Follow-Up Period of the study 
(described in Section 7.1.5.4). 
7.1.5 
Visit Requirements 
Visit requirements are outlined in Section 6.0 - Trial Flow Chart.   Specific procedure-related 
details are provided above in Section 7.1 - Trial Procedures. 
7.1.5.1 
Screening 
A member of the study team will explain the purpose of the study and the study-related 
procedures to potential subjects.  Subjects will be asked to provide written informed consent 
prior to the initiation of any study-related procedures.  The results from assessments performed 
as part of a subject’s clinical care prior to receipt of informed consent may be utilized to fulfill a 
screening requirement, if the assessments were completed within the required window for 
screening.  
7.1.5.2 
Treatment Period 
The treatment period will begin on Day 1 and will continue until the subject completes the 
treatment regimen or discontinues treatment. 
7.1.5.2.1 End of Treatment Visit 
This visit will occur at the time that a subject is discontinued from the study. 
7.1.5.2.2 Second Course (Retreatment Period for Post-Complete Remission Relapse 
Only) 
Subjects who stop pembrolizumab with SD or better and who experience disease progression 
may receive additional doses of pembrolizumab as part of their clinical care following evaluation 
by their treating physician. 
 
7.1.5.3 
Post-Treatment Visits 
7.1.5.3.1 Safety Follow-Up Visit 
The mandatory Safety Follow-Up Visit should be conducted approximately 30 days after the 
last dose of trial treatment (pembrolizumab or 6MHP) or before the initiation of a new anti-
cancer treatment, whichever comes first.  All AEs that occur prior to the Safety Follow-Up Visit 
should be recorded.  Subjects with an AE of Grade > 1 will be followed until the resolution of 
the AE to Grade 0-1 or until the beginning of a new anti-neoplastic therapy, whichever occurs 
first.  SAEs that occur within 90 days of the end of treatment or before initiation of a new anti-
cancer treatment should also be followed and recorded.   


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7.1.5.4 
Follow-up Visits 
Subjects who discontinue treatment pembrolizumab or both drugs for a reason other than 
disease progression will move into the Follow-Up Phase and should be assessed every 8 
weeks (56 ± 7 days) by radiologic imaging to monitor disease status.  Every effort should be 
made to collect information regarding disease status until the start of new anti-neoplastic 
therapy, disease progression, death, end of the study or if the subject begins retreatment with 
pembrolizumab as detailed in Section 7.1.5.2.2. Information regarding post-study anti-
neoplastic treatment will be collected if new treatment is initiated. 
Follow-up visits every 8 weeks will not be required beyond 2 years from study entry. If a subject 
is managed locally and is not able to return to UVA every 8 weeks after discontinuation for 
reasons other than disease progression, because of toxicity or intercurrent health problems, 
every effort will be made to obtain records that supply data comparable to what is specified in 
the study calendar. 
 
If a subject discontinues pembrolizumab for toxicity, that subject should be followed every 8 
weeks until resolution of the toxicity or until 2 years from study entry, whichever is longer. If the 
toxicity resolves before 2 years, then the subject should continue with visits requiring research 
blood draws and tumor biopsies. 
 
Subjects with progressive disease should undergo a second scan at least 4 weeks later to 
confirm progression and exclude the possibility of a tumor flare reaction, according to irRC 
guidelines. 
 
7.1.5.4.1 Survival Follow-up 
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 annually for survival status until death, withdrawal of consent, or the end of the 
study, whichever occurs first.  
 
7.2 
Assessing, Recording, and Reporting Adverse Events 
7.2.1 Definitions 
Adverse Event (AE): An adverse event is defined as any untoward medical occurrence in a 
patient or clinical investigation subject administered a pharmaceutical product and which does 
not necessarily have to have a causal relationship with this treatment. An adverse event can 
therefore be any unfavorable and unintended sign (including an abnormal laboratory finding, for 
example), symptom, or disease temporally associated with the use of a medicinal product or 
protocol-specified procedure, whether or not considered related to the medicinal product or 
protocol-specified procedure.  Any worsening (i.e., any clinically significant adverse change in 
frequency and/or intensity) of a preexisting condition that is temporally associated with the use 
of the study drugs or protocol-specified procedure is also an adverse event. 
Changes resulting from normal growth and development that do not vary significantly in 
frequency or severity from expected levels are not to be considered adverse events.   
Merck product includes any pharmaceutical product, biological product, device, diagnostic 
agent or protocol-specified procedure, whether investigational (including placebo or active 


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comparator medication) or marketed, manufactured by, licensed by, provided by or distributed 
by Merck for human use. 
6MHP includes the 6 melanoma helper peptide vaccine. 
Adverse events may occur during the course of the use of Merck product and 6MHP in clinical 
trials or as prescribed in clinical practice, from overdose (whether accidental or intentional), 
from abuse and from withdrawal. 
Progression of the cancer under study is not considered an adverse event. 
Unexpected AE – Any adverse event not described in section 7.2.5. 
Serious AE:  A serious adverse event is any adverse event occurring at any dose during the 
study that: 
 Results in death; 
 Is life threatening; 
 Results in persistent or significant disability/incapacity; 
 Results in or prolongs an existing inpatient hospitalization; 
 Is a congenital anomaly/birth defect; 
 Is a new cancer (that is not a condition of the study); 
 Is associated with an overdose; 
 Is another important medical event  
Refer to Table 10 for additional details regarding each of the above criteria. Note: In addition to 
the above criteria, adverse events meeting either of the below criteria, although not serious per 
ICH definition, are reportable to the Merck in the same timeframe as SAEs to meet certain local 
requirements. Therefore, these events are considered serious by Merck for collection purposes: 
 
Is a new cancer (that is not a condition of the study); 
 
Is associated with an overdose. 
 
Unanticipated problem - An unanticipated problem is any event/experience that meets ALL 3 
criteria below: 
 
Is unexpected in terms of nature, severity or frequency given the research 
procedures that are described in the protocol-related documents AND in the 
characteristics of the subject population being studied. 
 
Is related or possibly related to participation in research.  This means that there is a 
reasonable possibility that the incident may have been caused by the procedures 
involved in the research study.  
 
The incident suggests that the research placed the subject or others at greater risk of 
harm than was previously known or recognized OR results in actual harm to the 
subject or others. 
 
Protocol Violation-  A protocol violation is defined as any change, deviation, or departure from 
the study design or procedures of a research project that is NOT approved by the institution’s 
IRB prior to its initiation or implementation, OR deviation from  standard operating procedures, 
Good Clinical Practices (GCPs), federal, state or local regulations. Protocol violations may or 
may not be under the control of the study team or UVa staff. These protocol violations may be 
major or minor violations. 


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Suspected Adverse Reaction (as defined in 21 CFR 312.32 (a))- Any adverse event for which 
there is a reasonable possibility that the drug caused the adverse event. 
7.2.2 Attribution Assessment 
Attribution – The determination of whether an adverse event is related to a medical treatment 
or procedure.  The attribution groups are: 
Definite – Applies to those adverse events which, the investigator feels are incontrovertibly 
related to study drug.  An adverse event may be assigned an attribution of definitely related if or 
when (must have all of the following): 
 
It follows a reasonable temporal sequence from administration of the test drug. 
 
It could not be reasonably explained by the known characteristics of the subject’s 
clinical state, environmental or toxic factors, or other modes of therapy administered 
to the subject. 
 
It disappears or decreases on cessation or reduction in dose with re-exposure to 
drug.  (Note: This is not to be constructed as requiring re-exposure of the subject; 
however, the group of definitely related can only be used when a recurrence is 
observed.) 
 
It follows a known pattern of response to the test drug. 
 
Probable – Applies to those adverse events for which, after careful consideration at the time 
they are evaluated, are felt with a high degree of certainty to be related to the test drug.  An 
adverse event may be considered probably related if or when (must have three of the 
following): 
 
It follows a reasonable temporal sequence from administration of the test drug. 
 
It could not be reasonably explained by the known characteristics of the subject’s 
clinical state, environmental or toxic factors, or other modes of therapy administered 
to the subject. 
 
It disappears or decreases on cessation or reduction in dose.  There are important 
exceptions when an adverse event does not disappear upon discontinuation of the 
drug, yet drug-relatedness clearly exists (e.g. bone marrow depression, fixed drug 
eruptions, tardive dyskinesia). 
 
It follows a known pattern of response to the test drug. 
 
Possible – Applies to those adverse events for which, after careful consideration at the time 
they are evaluated, a connection with the test drug administration appears unlikely but cannot 
be ruled out with certainty.  An adverse event may be considered possibly related if or when 
(must have two of the following): 
 
It follows a reasonable temporal sequence from administration of the test drug. 
 
It could not readily have been produced by the subject’s clinical state, environmental 
or toxic factors, or other modes of therapy administered to the subject. 
 
It follows a known pattern of response to the test drug. 
 
Unlikely – Applies to those adverse events for which, after careful consideration at the time 
they are evaluated, are judged to be unrelated to the test drug.  An adverse event may be 
considered unlikely if or when (must have two of the following): 
 
It does not follow a reasonable temporal sequence from administration of the test 
drug. 


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 
It could readily have been produced by the subject’s clinical state, environmental or 
toxic factors, or other modes of therapy administered to the subject. 
 
It does not follow a known pattern of response to the test drug. 
 
It does not reappear or worsen when the drug is re-administered. 
 
Unrelated – Applies to those adverse events, which after careful consideration, are clearly and 
incontrovertibly due to extraneous causes (disease, environment, etc.). 
7.2.3 
Evaluating Adverse Events 
An investigator who is a qualified clinician will evaluate all adverse events according to the NCI 
Common Terminology for Adverse Events (CTCAE), version 4.0. Any adverse event which changes 
CTCAE grade over the course of a given episode will have each change of grade recorded on the 
adverse event case report forms/worksheets. 
All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 


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Table 10.  Evaluating Adverse Events 
An investigator who is a qualified clinician, will evaluate all adverse events as to: 
V4.0 
CTCAE 
Grading 
Grade 1 
Mild; asymptomatic or mid symptoms; clinical or diagnostic observations only; intervention not indicated. 
 
Grade 2 
Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental ADL. 
 
Grade 3 
Severe or medically significant but not immediately life-threatening; hospitalization or prolongation or hospitalization indicated; disabling; 
limiting self-care ADL. 
 
Grade 4 
Life threatening consequences; urgent intervention indicated. 
 
Grade 5 
Death related to AE 
Seriousness 
A serious adverse event is any adverse event occurring at any dose or during any use of Merck product or 6MHP vaccine that: 
 
†Results in death; or 
 
†Is life threatening; or places the subject, in the view of the investigator, at immediate risk of death from the event as it occurred (Note: This does not include an 
adverse event that, had it occurred in a more severe form, might have caused death.); or 
 
†Results in a persistent or significant disability/incapacity (substantial disruption of one’s ability to conduct normal life functions); or 
 
†Results in or prolongs an existing inpatient hospitalization (hospitalization is defined as an inpatient admission, regardless of length of stay, even if the 
hospitalization is a precautionary measure for continued observation. (Note: Hospitalization for an elective procedure to treat a preexisting condition that has not 
worsened is not constitute a serious adverse event..  A pre-existing condition is a clinical condition that is diagnosed prior to the use of investigational product and is 
documented in the patient’s medical history.); or 
 
†Is a congenital anomaly/birth defect (in offspring of subject taking the product regardless of time to diagnosis);or 
 
Is a new cancer; (that is not a condition of the study); (although not serious per ICH definition, is reportable to the Sponsor-Investigator within 24 hours and to Merck 
within 2 working days to meet certain local requirements); or 
 
Is an overdose (whether accidental or intentional).  Any adverse event associated with an overdose is considered a serious adverse event for collection purposes. An 
overdose that is not associated with an adverse event is considered a non-serious event of clinical interest and must be reported within 24 hours to the Sponsor and to 
Merck within 2 working days. 
 
Other important medical events that may not result in death, not be life threatening, or not require hospitalization may be considered a serious adverse event when, 
based upon appropriate medical judgment, the event may jeopardize the subject and may require medical or surgical intervention to prevent one of the outcomes listed 
previously (designated above by a †). 
Duration 
Record the start and stop dates of the adverse event. If less than 1 day, indicate the appropriate length of time and units 
Action taken  
Did the adverse event cause the Merck product or 6MHP to be discontinued? 
Relationship 
to 
investigational 
drug  
Did the Merck product or 6MHP cause the adverse event? The determination of the likelihood that the Merck product or 6MHP caused the adverse event will be 
provided by an investigator who is a qualified physician. The investigator’s signed/dated initials on the source document or worksheet that supports the causality noted 
on the AE form, ensures that a medically qualified assessment of causality was done. This initialed document must be retained for the required regulatory time frame. 
The criteria below are intended as reference guidelines to assist the investigator in assessing the likelihood of a relationship between the test drug and the adverse 
event based upon the available information.  
The following components are to be used to assess the relationship between the Merck product and 6MHP and the AE; the greater the correlation with the 
components and their respective elements (in number and/or intensity), the more likely the Merck product or 6MHP caused the adverse event (AE): 
 
Exposure 
Is there evidence that the subject was actually exposed to the Merck product or 6MHP such as: reliable history, acceptable compliance assessment 
(pill count, diary, etc.), expected pharmacologic effect, or measurement of drug/metabolite in bodily specimen? 
 
Time Course 
Did the AE follow in a reasonable temporal sequence from administration of the Merck product or 6MHP?  
Is the time of onset of the AE compatible with a drug-induced effect (applies to trials with investigational medicinal product)? 
 
Likely Cause 
Is the AE not reasonably explained by another etiology such as underlying disease, other drug(s)/vaccine(s), or other host or environmental factors 
 


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Relationship 
The following components are to be used to assess the relationship between the test drug and the AE: (continued) 
to Merck 
product or 
6MHP 
(continued)  
Dechallenge 
Was the Merck product or 6MHP discontinued or dose/exposure/frequency reduced? 
If yes, did the AE resolve or improve? 
If yes, this is a positive dechallenge. If no, this is a negative dechallenge. 
(Note: This criterion is not applicable if: (1) the AE resulted in death or permanent disability; (2) the AE resolved/improved despite 
continuation of the Merck product or 6MHP; or (3) the trial is a single-dose drug trial); or (4) Merck product(s) or 6MHP is/are only used 
one time.) 
 
Rechallenge 
Was the subject re-exposed to the Merck product or 6MHP in this study? 
If yes, did the AE recur or worsen? 
If yes, this is a positive rechallenge. If no, this is a negative rechallenge. 
(Note: This criterion is not applicable if: (1) the initial AE resulted in death or permanent disability, or (2) the trial is a single-dose drug 
trial); or (3) Merck product(s) or 6MHP is/are used only one time). 
NOTE: IF A RECHALLENGE IS PLANNED FOR AN ADVERSE EVENT WHICH WAS SERIOUS AND WHICH MAY HAVE BEEN 
CAUSED BY THE MERCK PRODUCT or 6MHP, OR IF REEXPOSURE TO THE MERCK PRODUCT OR 6MHP POSES ADDITIONAL 
POTENTIAL SIGNIFICANT RISK TO THE SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE U.S. 
CLINICAL MONITOR AS PER DOSE MODIFICATION GUIDELINES IN THE PROTOCOL. 
 
Consistency 
with Trial 
Treatment 
Profile 
Is the clinical/pathological presentation of the AE consistent with previous knowledge regarding the Merck product or 6MHP drug class 
pharmacology or toxicology? 
The assessment of relationship will be reported on the case report forms /worksheets by an investigator who is a qualified physician according to his/her best clinical 
judgment, including consideration of the above elements. 
Record one of the following 
Use the following scale of criteria as guidance (not all criteria must be present to be indicative of a Merck product or 6MHP 
relationship). 
Yes, there is a reasonable 
possibility of Merck product or 
6MHP relationship. 
There is evidence of exposure to the Merck product or 6MHP.  The temporal sequence of the AE onset relative to the administration of 
the Merck product or 6MHP is reasonable.  The AE is more likely explained by the Merck product or 6MHP than by another cause. 
No, there is not a reasonable 
possibility of Merck product or 
6MHP relationship 
Subject did not receive the Merck product or 6MHP OR temporal sequence of the AE onset relative to administration of the Merck 
product or 6MHP is not reasonable OR the AE is more likely explained by another obvious cause than the Merck product or 6MHP.  
(Also entered for a subject with overdose without an associated AE.) 


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7.2.4 
Adverse Event Classifications 
Adverse events (AEs) are classified into sections, specified in the CTCAE v4.03.  For specific 
classifications pertaining to the protocol, we specify the following: 
Hematologic/Metabolic- Any AE coded under one of the following CTCAE v4.03 categories 
should be reported under the Hematologic/Metabolic adverse event classification:  
Table 11.  Hematologic/Metabolic Classifications 
Section 
AE 
Blood and lymphatic 
Anemia 
Leukocytosis 
Investigations 
ALL EXCEPT:  
Carbon monoxide diffusing capacity decreased 
Ejection fraction decreased 
Forced expiratory volume decreased 
Vital capacity abnormal 
Weight gain 
Weight loss 
Metabolism and nutrition 
disorders 
ALL EXCEPT: 
Alcohol intolerance 
Anorexia 
Dehydration 
Glucose intolerance 
Iron overload 
Obesity 
Tumor lysis syndrome 
 
Non-hematologic/Non-Metabolic- Any AE not reported under hematologic/metabolic, ocular, 
or allergic/autoimmune, should be reported under the non-hematologic/non-metabolic 
adverse event classification. 
Ocular – Any AE coded under one of the following CTCAE v4.03 Adverse Event Terms 
should be reported under the Ocular adverse event classification: 
 
Eye Disorders: Night blindness (nyctalopia) 
 
Eye Disorders: Papilledema 
 
Eye Disorders: Retinopathy 
 
Eye Disorders: Blurred vision 
 
Eye Disorders: Flashing lights 
 
Eye Disorders: Floaters 
 
Allergic/Autoimmune – Only AEs coded as Immune System Disorder: Allergic reaction, 
autoimmune disorder, or anaphylaxis should be reported under the Allergic/Autoimmune 
adverse event classification. Other AEs coded under Immune System Disorder should be 
reported under Non-hematologic/Non-metabolic 


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7.2.5 Agent-Specific Expected Adverse Events List 
7.2.5.1 6MHP 
The following toxicities are those greater than grade 1 that are to be considered expected:   
Table 102.  Expected Toxicities for 6MHP vaccines 
 
Grade 2 
Grade 3 
Injection site reaction 
+ 
+a 
Ulceration 
+ 
 
Fatigue 
+ 
 
a Note:  Injection site reaction with ulceration ≤2 cm is expected. This is consistent 
with the CTCAE v4.0 coding for ulceration (Grade 2).  Other grade 3 injection site 
reactions are not expected. 
7.2.5.2 
Pembrolizumab 
Treatment-related adverse reactions are described in Section 7 of the Investigator’s 
Brochure. 
 
7.2.5.3 
Tumor Biopsies, Vaccine Site Biopsies, and Sentinel Immunized Node Biopsies 
The following are toxicities that are greater than grade 1 and that are to be considered 
expected (up to grade 2):  
 
Bleeding 
 
Bruising 
 
Pain 
 
Infection 
 
Lymphedema 
 
Delayed wound healing 
 
Scarring 
 
Numbness 
 
7.2.6 
Dose-Limiting Toxicities 
6MHP 
A DLT of 6MHP vaccine is defined as any Grade 3 or greater hematologic or non-
hematologic toxicity that is definitely, probably, or possibly related to the administration of the 
vaccine.  Small ulcerations of the skin at vaccine sites are expected in a subset of subjects 
and are not considered DLTs.  Ulcerations will be considered DLTs only if the ulcers are > 2 
cm in diameter, require antibiotics or surgical debridement. 
Pembrolizumab 
A DLT of pembrolizumab is defined as any toxicity requiring permanent 
discontinuation per Table 6:  Dose Modification Guidelines for Drug-Related Adverse 
Events. 
 
Pembrolizumab and/or 6MHP 
≥ Grade 2 ocular adverse events as defined below, regardless of the agent to which the 
event may be attributed:  


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1) 
A single ≥ Grade 2 treatment-related experience of the following adverse events will be 
classified as a DLT: 
 
Eye Disorders: Night blindness (nyctalopia) 
 
Eye Disorders: Papilledema 
 
Eye Disorders: Retinopathy 
Subjects will be referred for an ophthalmologic exam if any of these ocular adverse events 
occur. 
2) 
For ≥ Grade 2 of the following, treatment will be held and subjects will be referred for 
an ophthalmologic exam.  Evidence of eye inflammation will be a basis for 
discontinuation of pembrolizumab and 6MHP.  If no inflammation is noted and subjects 
improve to ≤ Grade 1 by the next scheduled visit, subjects can resume treatment with 
both agents. 
 
Eye Disorders: Blurred vision 
 
Eye Disorders: Flashing lights 
 
Eye Disorders: Floaters 
 
7.2.7 
Recording and Reporting Adverse Events 
7.2.7.1 
Time Span for Reporting Adverse Events 
Reporting of AEs will begin when the subject is administered the study drug or has a study 
related biopsy. Reporting will continue through 30 days following cessation of treatment and at 
each examination on the Adverse Event case report forms/worksheets. The reporting timeframe 
for adverse events meeting any serious criteria is described below. The investigator will make 
every attempt to follow all subjects with non-serious adverse events for outcome. 
 All adverse events that occur after the consent form is signed, but before treatment allocation 
must be reported by the investigator if they cause the subject to be excluded from the trial, or 
are the result of a protocol-specified intervention, including but not limited to washout or 
discontinuation of usual therapy, diet, placebo treatment or a procedure. 
Adverse events will not be collected for subjects during the pre-screening period (for 
determination of archival tissue status) as long as that subject has not undergone any protocol-
specified procedure or intervention.  If the subject requires a blood draw, fresh tumor biopsy 
etc., the subject is first required to provide consent to the main study and AEs will be captured 
according to guidelines for standard AE reporting. 
7.2.7.2 Process for Recording Adverse Events 
Dose-limiting toxicities 
DLTs will be entered into OnCore within 5 calendar days of the study team learning of the 
event. DLT’s that are deemed serious and unexpected will be submitted to the IRB per 
institutional guidelines (see below). 
Other AEs 
 
 
 
AEs must be recorded into the University of Virginia Cancer Center OnCore database per the 
guidelines in Table 113. 
 
 


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Table 113.  AE reporting 
 High Risk Studies  
Reporting requirements for AEs that occur within 30 days of the last dose of protocol specified treatment 
 
Grade 1 
Grade 2 
Grade 3 
Grade 4 & 5 
Expected 
and 
unexpected 
 
Expected 
 
Unexpected 
Expected 
Unexpected 
Expected 
and 
Unexpected 
Without 
hospitalization 
With 
hospitalization 
Without 
hospitalization 
With 
hospitalization 
Unrelated 
Unlikely 
OnCore 
30 daysa 
OnCore 
30 days 
OnCore 
30 days 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
7 days 
Possible 
Probable 
Definite 
OnCore 
30 daysa 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
30 days 
OnCore 
15 days 
OnCore 
7 days 
OnCore 
7 days 
OnCore 
(24-hrs)* 
7 days 
*Enter into OnCore database within 24 hours if unexpected and definitely related to protocol specified treatment 
Hospitalization defined as an inpatient hospital stay or prolongation of a hospital stay equal to or greater than 24 hours 
a Grade 1 unexpected or expected hematologic/metabolic events will be recorded in the Cancer Center Database; however, regardless of 
attribution, these events do not have to be reported. 
 
7.2.7.3 
Recording Laboratory Values 
The following laboratory values will be recorded in the UVA Cancer Center database, 
graded using the CTCAE v4.03 (if a grading category exists), and reported as described in 
Section 7.2.8.3. 
1. 
Alk Phosphatase 
2. 
ALT (SGPT) 
3. 
ANA 
4. 
AST (SGOT) 
5. 
Bilirubin, total  
6. 
Creatinine 
7. 
Eosinophil #  
8. 
Hepatitis B virus  
9. 
Hepatitis C virus 
10. beta-HCG 
11. Hgb 
12. HgbA1C 
13. HIV 
14. HLA type 
15. LDH 
16. Potassium 
17. RF 
18. Urinalysis 
19. WBC 
20. T3 
21. TSH 
22. Free T4 
23. PT/INR and aPTT 
 


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Any abnormal laboratory values captured which are not included in the above list, but are 
considered to be pertinent positive clinical signs/symptoms, and laboratory results obtained 
as part of routine care of patients will be recorded in the UVA Cancer Center database and 
reported.  If there is any doubt on the part of study personnel concerning what constitutes a 
pertinent positive finding, sponsor-investigator will be consulted. 
7.2.7.4 UVA IRB Reporting Requirements 
The University of Virginia is responsible for reporting to the UVA IRB-HSR per the following 
guidelines: 
Table 124.  UVA IRB-HSR Reporting Guidelines 
Type of Event 
To whom will it be 
reported: 
Time Frame for Reporting 
How reported? 
Any internal event resulting 
in death that is deemed 
DEFINITELY related to 
(caused by) study 
participation 
(Note:  An internal event is 
one that occurs in a subject 
enrolled in a UVa protocol.) 
IRB-HSR 
Within 24 hours 
IRB Online and phone call 
 
www.irb.virginia.edu/ 
 
Internal, Serious, 
Unexpected adverse event. 
 
IRB-HSR 
Within 7 calendar days from the 
time the study team received 
knowledge of the event. 
 
Timeline includes submission of 
signed hardcopy of AE form. 
IRB Online 
 
www.irb.virginia.edu/ 
 
Unanticipated Problems 
that are not adverse events 
or protocol violations  
This would include a Data 
Breach.   
IRB-HSR 
 
 
Within 7 calendar days from the 
time the study team received 
knowledge of the event.  
Unanticipated Problem 
report form.  
http://www.virginia.edu/vpr
gs/irb/HSR_docs/Forms/R
eporting_Requirements-
Unanticipated_Problems.d
oc ) 
 
  
Protocol 
Violations 
(The 
IRB-HSR only requires that 
MAJOR 
violation 
be 
reported, unless otherwise 
required by your sponsor, if 
applicable.) 
 
Or Enrollment Exceptions 
IRB-HSR 
 
 
Within 7 calendar days from the 
time the study team received 
knowledge of the event.  
 
Protocol 
Violation 
and 
Enrollment 
Exception 
Reporting Form 
 
http://www.virginia.edu/vpr
gs/irb/hsr_forms.html 
Data Breach  
 
 
The UVa Corporate 
Compliance and 
Privacy Office and 
 
ITC:  if breach 
involves  electronic 
data-  
 
UVa Police if breach 
includes such things 
as stolen computers.  
As soon as possible and no 
later than 24 hours from the 
time the incident is identified. 
 
As soon as possible and no 
later than 24 hours from the 
time the incident is identified. 
 
IMMEDIATELY. 
UVa Corporate 
Compliance and Privacy 
Office- Phone 924-9741 
 
ITC:  Information Security 
Incident Reporting 
procedure,  
http://www.itc.virginia.edu/
security/reporting.html 
 
Ph(434) 924-7166 


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7.2.7.5 Reporting to the FDA 
The Sponsor-Investigator for the study (the UVA PI or designee) is responsible for providing 
safety updates to the FDA per the following guidelines.  The reporting times refer to the time 
the study team received knowledge of the AE. 
 
Table 135.  FDA Reporting Requirements 
UVa PI HELD IND 
Type of Event 
To whom will it 
be reported: 
Time Frame for 
Reporting 
How reported? 
Life-threatening and/or 
fatal unexpected events 
related or possibly related 
to the use of the 
investigational agent. 
FDA 
Within 7 calendar 
days of the study 
team learning of the 
event 
Form FDA 3500A (MedWatch) or 
narrative 
Serious, unexpected and 
related or possibly related 
adverse events 
FDA 
Within 15 calendar 
days after the study 
team receives 
knowledge of the 
event 
Form FDA 3500A (MedWatch) or 
narrative 
All adverse events 
FDA 
Annually 
IND annual report 
 
 
7.2.7.6 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 
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. 
Pregnancies and lactations that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be 
excluded from the trial, or are the result of a protocol-specified intervention, including but not 
limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure.  
 
Pregnancies and lactations that occur from the time of treatment allocation/randomization 
through 120 days following cessation of Sponsor’s product, or 30 days following cessation of 
treatment if the subject initiates new anticancer therapy, whichever is earlier, must be reported 
by the investigator.  All reported pregnancies must be followed to the completion/termination of 
the pregnancy.  Pregnancy outcomes of spontaneous abortion, missed abortion, benign 
hydatidiform mole, blighted ovum, fetal death, intrauterine death, miscarriage and stillbirth must 
be reported as serious events (Important Medical Events).  If the pregnancy continues to term, 
the outcome (health of infant) must also be reported. 
Such events must be reported within 24 hours to the Sponsor-Investigator and within 2 working 
days to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215-661-6229) 


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7.2.7.7 Definition of an Overdose for This Protocol and Reporting of Overdose to the Sponsor-
Investigator and to Merck 
For purposes of this trial, an overdose will be defined as any dose exceeding the prescribed 
dose for pembrolizumab by 20% 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. 
If a dose of Merck’s product meeting the protocol definition of overdose is taken without any 
associated clinical symptoms or abnormal laboratory results, the overdose is reported as a non-
serious Event of Clinical Interest (ECI), using the terminology “accidental or intentional 
overdose without adverse effect.” 
All reports of overdose with and without an adverse event must be reported within 24 hours to 
the Sponsor-Investigator and within 2 working days hours to Merck Global Safety. (Attn: 
Worldwide Product Safety; FAX 215-661-6229) 
7.2.7.8 Immediate Reporting of Adverse Events to the Sponsor-Investigator and to Merck 
Serious Adverse Events 
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, any serious adverse event, or follow up to a serious adverse event, 
including death due to any cause other than progression of the cancer under study (see section 
7.2.8.8) that occurs to any subject must be reported within 24 hours to the Sponsor-Investigator 
and within 2 working days to Merck Global Safety if it causes the subject to be excluded from 
the trial, or is the result of a protocol-specified intervention, including but not limited to washout 
or discontinuation of usual therapy, diet, placebo treatment or a procedure. 
 
For the time period beginning at treatment allocation/randomization through  90 days following 
cessation of treatment, or 30 days following cessation of treatment if the subject initiates new 
anticancer therapy, whichever is earlier, any serious adverse event, or follow up to a serious 
adverse event, including death due to any cause other than progression of the cancer under 
study  whether or not related to the Merck product, must be reported within 24 hours to the 
Sponsor and within 2 working days to Merck Global Safety. 
Non-serious Events of Clinical Interest related to the Merck product will be forwarded to Merck 
Global Safety and will be handled in the same manner as SAEs.  
Additionally, any serious adverse event, considered by an investigator who is a qualified 
clinician to be related to Merck product that is brought to the attention of the investigator at any 
time following consent through the end of the specified safety follow-up period specified in the 
paragraph above, or at any time outside of the time period specified in the previous paragraph 
also must be reported immediately to the Sponsor-Investigator and to Merck Global Safety. 
All subjects with serious adverse events must be followed up for outcome. 


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SAE reports and any other relevant safety information are to be forwarded to the Merck 
Global Safety facsimile number:  +1-215-661-6229 
A copy of all 15 Day Reports and Annual Progress Reports is submitted as required by FDA, 
European Union (EU), Pharmaceutical and Medical Devices agency (PMDA) or other local 
regulators. Investigators will cross reference this submission according to local regulations to 
the Merck Investigational Compound Number (IND, CSA, etc.) at the time of submission.  
Additionally investigators will submit a copy of these reports to Merck & Co., Inc. (Attn: 
Worldwide Product Safety; FAX 215-661-6229) at the time of submission to FDA. 
All subjects with serious adverse events must be followed up for outcome. 
7.2.7.9 
Protocol-Specific Exceptions to Serious Adverse Event Reporting  
Efficacy endpoints as outlined in this section will not be reported to Merck as described in 
Section 7.2.7.8.- Immediate Reporting of Adverse Events to the Sponsor and to Merck, unless 
there is evidence suggesting a causal relationship between the drug and the event. Any such 
event will be submitted to the Sponsor within 24 hours and to Merck Global Safety within 2 
working days either by electronic or paper media. 
Specifically, the suspected/actual events covered in this exception include any event that is 
disease progression of the cancer under study. 
The Sponsor will monitor unblinded aggregated efficacy endpoint events and safety data to 
ensure the safety of the subjects in the trial. Any suspected endpoint which upon review is not 
progression of the cancer under study will be forwarded to Merck Global Safety as a SAE within 
2 working days of determination that the event is not progression of the cancer under study 
Hospitalization related to convenience (e.g.transportation issues etc.) will not be considered an 
SAE. 
7.2.7.10 Events of Clinical Interest 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest 
(ECI) and must be recorded as such on the Adverse Event case report forms/worksheets and 
reported within 24 hours to the Sponsor-Investigator and within 2 working days to Merck Global 
Safety. (Attn: Worldwide Product Safety; FAX 215-661-6229) 
For the time period beginning when the consent form is signed until treatment 
allocation/randomization, any ECI, or follow up to an ECI, that occurs to any subject must be 
reported within 24 hours to the Sponsor and within 2 working days to Merck Global Safety if it 
causes the subject to be excluded from the trial, or is the result of a protocol-specified 
intervention, including but not limited to washout or discontinuation of usual therapy, diet, 
placebo treatment or a procedure. 
For the time period beginning at treatment allocation/randomization through 90 days following 
cessation of treatment, or 30 days following cessation of treatment if the subject initiates new 
anticancer therapy, whichever is earlier, any ECI, or follow up to an ECI, whether or not related 
to Merck product, must be reported within 24 hours to the Sponsor and within 24 hours to 
Merck Global Safety. 
Events of clinical interest for this trial include: 


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1. 
An overdose of Merck product, as defined in Section 7.2.7.7 - Definition of an 
Overdose for This Protocol and Reporting of Overdose to the Sponsor-Investigator, 
that is not associated with clinical symptoms or abnormal laboratory results.  
2. 
An elevated AST or ALT lab value that is greater than or equal to 3X the upper limit 
of normal and an elevated total bilirubin lab value that is greater than or equal to 2X 
the upper limit of normal and, at the same time, an alkaline phosphatase lab value 
that is less than 2X the upper limit of normal, as determined by way of protocol-
specified laboratory testing or unscheduled laboratory testing.* 
*Note:  These criteria are based upon available regulatory guidance documents. 
The purpose of the criteria is to specify a threshold of abnormal hepatic tests that 
may require an additional evaluation for an underlying etiology. 
7.2.8 Sponsor Responsibility for Reporting Adverse Events 
All Adverse Events will be reported to regulatory authorities, IRB/IECs and investigators in 
accordance with all applicable global laws and regulations.  
8.0 
STATISTICAL CONSIDERATIONS 
8.1 
Design 
This is an early phase trial to assess the safety and immunogenicity of the combination therapy 
of a helper peptide vaccine (6MHP) plus PD-1 blockade (pembrolizumab) in patients with 
advanced melanoma.  In addition, exploratory analysis of clinical benefit will be described.   
8.2 
Evaluation of Sample Populations and Criteria  
8.2.1 Safety 
All participants receiving any protocol treatment will be evaluated for safety. The 6MHP vaccine 
has been safe, with lower toxicities than with class I peptides, in particular with lower 
autoimmune or hyperimmune toxicities. Based upon reported results in the patient population 
treated with pembrolizumab (51), drug-related serious adverse events occurred in 7/89 (7.9%, 
95% CI(3.2, 15.5%)) of participants treated at the 2mg/kg dose every 3 weeks. These results 
are assumed to be reflective of the safety profile for the 200 mg study dose, as described in 
section 4.3.2.  Thus, this trial will be designed with stopping rules for observed toxicities beyond 
those expected with pembrolizumab alone. Specifically, formal safety bounds based upon 
monitoring dose-limiting toxicities (DLT) attributed to 6MHP or pembrolizumab will guide 
decisions about early stopping due to potential safety concerns.  
DLTs will be defined based on the agent to which they are attributed, as specified in section 
7.2.6.  If a stopping bound is crossed then accrual to the study will be suspended until the study 
PI, co-investigators and the DSMC can review the data, and determine if the study should  
continue, be amended or be closed to further accrual.  
8.2.2 Immunogenicity 
All eligible participants receiving any protocol treatment will be evaluated for the following 
immune response parameters. 
Primary: 


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CD4+ T cell response to 6MHP peptides  
CD4+ T cell responses to the 6MHP peptides will be evaluated in the blood using the direct 
ELIspot assay.  In order to be classified as achieving a high durable immune response in the 
blood, at least two 5-fold increases over baseline must be observed in the blood.   
 
Secondary: 
Tumor Microenvironment (in the subset of participants for which tumor biopsies are obtained) 
Infiltration of CD4+ and CD8+ T cells in the tumor microenvironment and Th1-dominant immune 
signatures will be evaluated by immunohistochemistry/immunofluorescence and/or by flow 
cytometry. 
 
Evaluated in the blood and in the SIN (in the subset of participants for which SINs are 
obtained): 
CD4+ T cell responses to the 6MHP peptides in the SIN. 
Epitope-spreading for CD8+ T cells reactive to a panel of defined melanoma antigens will be 
evaluated by ELIspot assay. 
IgG antibody responses to 6MHP will be evaluated by ELISA. 
 
8.2.3 Clinical efficacy 
All participants receiving any protocol treatment will be evaluated for clinical benefit to treatment 
as defined by the following measures.  
 
Clinical response by RECIST 1.1  
 
Clinical response by irRC  
 
Progression-free survival (PFS), defined as the time from the date of start of treatment 
to the date of progression or death from any cause, whichever occurs first. A participant 
who dies without a reported progression will be considered an event on the date of 
death. Participants who have neither progressed nor died will be censored on the date 
of last evaluable tumor assessment. 
 
Overall survival (OS), defined as the time from the date of start of treatment to the date 
of death from any cause. Participants who do not experience an event (death) will be 
censored at date of last follow-up/contact. 
 
8.3 
Sample Size and Accrual 
Conditional on safety bounds not being crossed, maximum target sample size is based upon 
having sufficient information to obtain preliminary information on whether combined treatment 
with 6MHP vaccine plus pembrolizumab increases the immunogenicity of 6MHP alone in the 
entire study population. Data from Mel44 on immune response as measured by direct ELIspot 
in blood through month 12 for arms C and D (which included vaccination with 6MHP) resulted in 
a high durable response rate in the blood (at least two 5-fold increases) of 20% with an upper 
bound 90% CI of 26.7%. Lower responses (at least two 2-fold increases) occurred in 32% of 
subjects (upper bound 90% CI of 39.1%). Based upon these prior results, for this study we 
would be interested in detecting an improvement in the percent of high durable responders in 
the blood from a null rate of 20% to 45% (above the low responder upper limit) using a using a 
fixed sample design with approximate type I and type II error rates of 10% (α=β=0.10). Note, 
Mel44 did not include assessments in the SIN thus sample size determination is based upon 
prior results for the blood only. 
Accrual of a total of 22 eligible participants provides 90% power to test for a null high immune 
response rate of 20% vs an alternative high immune response rate of 45% with a one-side 10% 
level binomial test. At study conclusion the null hypothesis will be rejected and the treatment 


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regimen considered worthy of further study if at least 8/22 (36%) eligible participants 
experience a high durable immune response. 
Maximum target sample size is estimated to be 25 participants, which assumes a 10% 
dropout/ineligibility/lost to follow-up adjustment. Accrual is estimated at approximately 12 
participants per year.  Considering enrollment as of May 2018, accrual to the study should be 
completed in June 2019.  
8.4 
Stratification 
Participants will be monitored for post entry stratification by whether or not biopsies are 
obtained at baseline and day 22; (yes/no).  Target sample size for participants for whom 
biopsies are obtained is set at a minimum of 12 eligible participants. If increased infiltration of 
CD4+ response on day 22 compared to day 1 is observed in the tumor in 9/12 participants then 
the lower limit of a one-sided 90% confidence interval exceeds 50% and this would be 
considered a promising result and supportive of further study of the treatment regimen. 
Similarly, if increased infiltration of CD8+ response on day 22 compared to day 1 is observed in 
the tumor in 9/12 participants then this would be considered a promising result and supportive 
of further study of the treatment regimen.  
 
8.5 
Safety Monitoring 
Toxicities will be monitored using CTCAE 4.03 criteria. Stopping rules will be based on the 
serious adverse events rate of 7.9% (95% CI(3.2, 15.5%)) reported by Roberts, 2014.  
Significant increases over these rates are not expected but would be a reason for early 
discontinuation. Thus, formal safety bounds based upon the observed number of participants 
who experience a DLT related to 6MHP or pembrolizumab as defined in Section 7.2.6 will guide 
decisions about early stopping due to potential safety concerns. The rate of DLTs for early 
stopping will include assessment up to the day 43 treatment.  DLTs will be monitored up to 30 
days after the last study treatment and late observed rates that cross the bound would be 
reason to suspend accrual for a safety review by the Sponsor-Investigator and the DSMC.  A 
sequential probability ratio test (SPRT) based upon a binomial test of proportions for DLTs will 
be used.  Only the upper boundary will be used for monitoring to protect against excessive 
failure rates.  The stopping boundary are for a SPRT contrasting a 15% versus 30% DLT rate, 
with nominal type I and II errors of 10% and 10%, respectively.  The slope of the parallel lines 
for monitoring is 0.219 and the intercept for the upper bound is 2.476. 
 
Table 146.  Stopping guideline for DLTs 
Number of participants 
Boundary 
4-6 
≥ 4 
7-11 
≥ 5 
12-15 
≥ 6 
16-20 
≥ 7 
21-25 
≥ 8 
 
8.6 
Analyses 
Study populations and evaluation criteria are noted in Section 8.2.  Adverse events will be 
summarized by frequency and magnitude of event. Incidence of DLTs will be monitored against 
the safety bounds above. The bounds are non-binding, and provide a guideline that may result 
in study modification or closure 


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Previous methods used to measure responses to 6MHP include ELIspot assays, proliferation 
assays, and flow cytometry (Mel41, Mel44, E1602 trials).  In the proposed trial, the study 
hypothesis will be tested using the direct ELIspot assay results from the blood.  The criteria for 
defining immune responses have been reported for ELIspot assays (54).  The circulating CD4+ 
T cell response rate to 6MHP peptides in participants treated with 6MHP vaccine plus PD-1 will 
be assessed at each time noted in the study calendar. Hypothesis testing will be based upon 
the number of participants that satisfy the criteria of high durable immune response in the 
blood. The proportion of participants with high immune response overall as measured in the 
SIN or blood will be calculated along with 90% confidence intervals.      
Secondary measures will also be used to evaluate 6MHP specific CD4+ T cell responses.  Flow 
cytometry has value in defining the responding cell population and the function of responding 
cells using multi-parameter staining.  CyTOF mass cytometry also is evolving as a valuable 
method. Additional methods may be incorporated over time as new technologies are developed 
and validated; however, for the purposes of testing the study hypothesis, the direct ELIspot 
assay will used as the primary measure. A secondary endpoint will also be to assess the CD4+ 
T cell response to 6MHP in the sentinel immunized node, using methods used for assessment 
of circulating responses. 
Our prior measures of immune response in the blood to the 6MHP resulted in high durable 
immune response rates of 20%. An observed high immune response rate of 36% overall would 
support further study of the treatment regimen.  Other measures assessed over time in the 
blood include a) epitope-spreading for circulating CD8+ T cells reactive to a panel of defined 
melanoma antigens by ELispot assay, and b) production of serum IgG reactive to 6MHP, by 
ELISA assay.   
Assessments in the tumor microenvironment include assessment of CD4+ and CD8+ T cells 
into melanoma by immunohistochemistry/immunofluorescence and/or by flow cytometry. Each 
participant will be assessed for the endpoints of interest and the proportion of participants 
experiencing an event (immune response, IgG antibody response to 6MHP, presence of CD8+ 
T cell infiltrates into the tumor (a subset), etc) will be estimated along with 95% confidence 
intervals. Repeated measure models will be used to estimate changes over time in interval 
measurements in the blood and tissue. 
Participants will be assessed for clinical response and will be classified by best overall 
response by week 52 and at final assessment. ORR will be estimated along with a 95% 
confidence interval around the point estimate. 
TTR, PFS, DFS and OS distributions will be estimated by the product limit method of Kaplan 
and Meier. Other summary measures for time to event distributions will include estimates and 
95% CIs for median and 1-year estimates to assess relative to published data. Exploratory 
proportional hazard models will be used to obtain preliminary estimates of potential 
associations with T cell and antibody responses to melanoma antigens and survival. 
 
9.0 LABELING, PACKAGING, STORAGE AND RETURN OF CLINICAL SUPPLIES 
9.1 Investigational Product  
The investigator shall take responsibility for and shall take all steps to maintain appropriate 
records and ensure appropriate supply, storage, handling, distribution and usage of 
investigational product in accordance with the protocol and any applicable laws and 
regulations. 


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Clinical Supplies will be provided by Merck and UVA-HITC as summarized in Table 15.  The 
peptide vaccine will undergo stability testing as described in Appendix 12.6. 
Table 158.  Product Descriptions 
Product Name & Potency 
Dosage Form 
Supplier 
pembrolizumab 100 mg/ 4mL 
Solution for Injection 
Merck 
6MHP 
Lyophilized Powder for Injection 
UVA 
Montanide ISA-51 
Solution for Injection 
Seppic, Inc. (purchased by UVA) 
 
9.2 
Packaging and Labeling Information 
Clinical supplies will be affixed with a clinical label in accordance with regulatory requirements. 
9.3 
Clinical Supplies Disclosure 
This trial is open-label; therefore, the subject, the trial site personnel, the Sponsor-Investigator 
and/or designee are not blinded to treatment. Drug identity (name, strength) is included in the 
label text; random code/disclosure envelopes or lists are not provided. 
9.4 
Storage and Handling Requirements 
Clinical supplies must be stored in a secure, limited-access location under the storage 
conditions specified on the label.   
Receipt and dispensing of trial medication must be recorded by an authorized person at the trial 
site. 
Clinical supplies may not be used for any purpose other than that stated in the protocol. 
9.5 
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.  
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. 
10.0 ADMINISTRATIVE AND REGULATORY DETAILS 
10.1 Study Conduct and Ethical Considerations 
This study will be conducted in accordance with the standards of Good Clinical Practice, all 
applicable federal, state, and local laws, and in accord with the ethical principles that originated 
in the Declaration of Helsinki.  The PI will ensure that staff are trained and carry out the study in 
accord with the protocol specifications.  The PI will ensure that all study site personnel are 
aware that the study protocol and all data generated are confidential and should not be 


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disclosed to third parties (with the exception of local and national regulatory bodies which 
require access for oversight purposes).  
10.2 UVA Institutional Review Board for Health Sciences Research  
The UVA Institutional Review Board for Health Sciences Research (UVA IRB-HSR) will 
approve all aspects of this study, including the clinical trial protocol, informed consent 
documents, and patient materials.  Modifications to the protocol or consent form will be 
reviewed and approved by the UVA IRB-HSR prior to implementation, except when necessary 
to eliminate apparent immediate hazards to the study subjects. The study will undergo 
continuing IRB review based on the level of risk as assessed by the IRB.  This review will take 
place no less than annually. Reporting to the UVA IRB-HSR will occur as specified in Section 
7.2. 
10.3 Consent Forms and the Consenting Process 
Consent forms will be written in accord with 21 CFR 50 and will be reviewed and approved by 
the UVA IRB-HSR prior to use. Subjects will be given an approved consent form to review.  A 
member of the study team will explain the study and study procedures to each subject and will 
be available to answer questions.   Informed consent will be obtained from each subject prior to 
conducting any study-specific procedures or administering study drug. 
10.4 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 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.  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 trial site contact information.     
10.5 Maintenance of Study Documents 
Signed consent forms and other research records will be retained in a confidential manner. 
Study records will be kept for at least 6 years after completion of the study.  
10.6 Data Collection 
Data will be collected using a centralized electronic case report form called ON-line Clinical 
Oncology Research Environment = Oncore. 
10.6.1 Endpoint Data 
 
Endpoint data will be collected using HITC IML data forms, subject-specific binders, and 
the HITC laboratory database. 
 
The HITC laboratory database, which has password-restricted access, is stored on the 
UVA Health System Computing Services secured server. 


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10.7 Monitoring Plan 
The University of Virginia Cancer Center Data and Safety Monitoring Committee (CC DSMC) 
will provide oversight of the conduct of this study.  The CC DSMC will report to the UVA 
Protocol Review Committee (PRC). 
The UVA CC DSMC will review the following: 
 
All adverse events 
 
Audit results 
 
Application of study designed stopping/decision rules 
 
Whether the study accrual pattern warrants continuation/action 
 
Protocol violations 
 
10.7.1 Monitoring Schedule 
The UVA CC DSMC will meet every month for aggregate review of data.  Tracking reports of 
the meetings are available to the PI for review.  Issues of immediate concern by the DSMC are 
brought to the attention of the Sponsor-Investigator (and if appropriate to the PRC and IRB) 
and a formal response from the Sponsor-Investigator is requested.  Per the UVA Cancer Center 
NIH approved institutional plan, this study will be audited approximately every 6 months.  The 
audit may include direct access to source data/documents. 
 
 


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infiltrating immune cells are associated with clinical outcome in metastatic melanoma. Cancer 
Res. 72: 1070-1080. 
 56.  Balch, C. M., A. C. Buzaid, S. J. Soong, M. B. Atkins, N. Cascinelli, D. G. Coit, I. D. Fleming, J. 
E. Gershenwald, A. J. Houghton, J. M. Kirkwood, K. M. McMasters, M. F. Mihm, D. l. Morton, D. 
S. Reintgen, M. I. Ross, A. Sober, J. A. Thompson, and J. F. Thompson. 2001. Final version of 
the American Joint Committee on Cancer staging system for cutaneous melanoma. [Review] 
[83 refs]. J. Clin. Oncol. 19: 3635-3648. 
 
 
 


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12.0 APPENDICES 
12.1 ECOG Performance Status 
Grade 
Description 
0 
Normal activity. Fully active, able to carry on all pre-disease performance 
without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous activity, but 
ambulatory and able to carry out work of a light or sedentary nature (e.g., 
light housework, office work). 
2 
In bed <50% of the time. Ambulatory and capable of all self-care, but 
unable to carry out any work activities. Up and about more than 50% of 
waking hours. 
3 
In bed >50% of the time. Capable of only limited self-care, confined to bed 
or chair more than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-care. 
Totally confined to bed or chair. 
5 
Dead. 
* As published in Am. J. Clin. Oncol.:  Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., 
Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria Of The Eastern 
Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982. The Eastern Cooperative 
Oncology Group, Robert Comis M.D., Group Chair. 
 
 
 


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12.2 
Common Terminology Criteria for Adverse Events V4.0 (CTCAE) 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse 
Events 
(CTCAE) 
version 
4.0 
will 
be 
utilized 
for 
adverse 
event 
reporting. 
(http://ctep.cancer.gov/reporting/ctc.html) 
 
 


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12.3 Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 Criteria for Evaluating 
Response in Solid Tumors 
RECIST version 1.1* will be used in this study for assessment of tumor response. While either CT or 
MRI may be utilized, as per RECIST 1.1, CT is the preferred imaging technique in this study. 
* As published in the European Journal of Cancer: 
E.A. Eisenhauer, P. Therasse, J. Bogaerts, L.H. Schwartz, D. Sargent, R. Ford, J. Dancey, S. Arbuck, 
S. Gwyther, M. Mooney, L. Rubinstein, L. Shankar, L. Dodd, R. Kaplan, D. Lacombe, J. Verweij. New 
response evaluation criteria in solid tumors: Revised RECIST guideline (version 1.1). Eur J Cancer. 
2009 Jan;45(2):228-47. 4 
 
 
 


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12.4 
AJCC Staging System 
Melanoma TNM Classification 
T Classification 
Thickness 
Ulceration Status 
T1 
≤ 1.0 mm 
a:  without ulceration or mitoses 
b:  with ulceration or mitoses  1 
T2 
1.01 – 2.0 mm 
a:  without ulceration 
b:  with ulceration 
T3 
2.01 – 4.0 mm 
a:  without ulceration 
b:  with ulceration 
T4 
> 4.0 mm 
a:  without ulceration 
b:  with ulceration 
 
 
 
N Classification 
# of Metastatic Nodes 
Nodal Metastatic Mass 
N1 
1 node 
a:  micrometastasis* 
b:  macrometastasis† 
N2 
2 – 3  nodes 
a:  micrometastasis* 
b:  macrometastasis† 
c: in 
transit 
met(s)/satellite(s) 
without metastatic nodes 
N3 
4 or more metastatic nodes, 
or matted nodes, or  
in transit met(s)/satellites(s) 
with metastatic node(s) 
 
 
 
 
M Classification 
Site 
Serum Lactate Dehydrogenase 
M1a 
Distant skin, subcutaneous 
or nodal mets 
Normal 
M1b 
Lung metastases 
Normal 
M1c 
All other visceral metastases 
Normal 
Any distant metastasis 
Elevated 
* 
Micrometastases are diagnosed after sentinel or elective lymphadenectomy. 
† 
Macrometastases are defined as clinically detectable nodal metastases confirmed by therapeutic 
lymphadenectomy or when nodal metastasis exhibits gross extracapsular extension. 
 
 
 
 


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Stage Groupings for Cutaneous Melanoma 
 
Clinical Staging 
Pathologic Staging 
 
T 
N 
M 
T 
N 
M 
0 
Tis 
N0 
M0 
Tis 
N0 
M0 
IA 
T1a 
N0 
M0 
T1a 
N0 
M0 
IB 
T1b 
T2a 
N0 
N0 
M0 
M0 
T1b 
T2a 
N0 
N0 
M0 
M0 
IIA 
T2b 
T3a 
N0 
N0 
M0 
M0 
T2b 
T3a 
N0 
N0 
M0 
M0 
IIB 
T3b 
T4a 
N0 
N0 
M0 
M0 
T3b 
T4a 
N0 
N0 
M0 
M0 
IIC 
T4b 
N0 
M0 
T4b 
N0 
M0 
III‡ 
Any T 
N1-3 
M0 
 
IIIA 
 
T1-4a 
T1-4a 
N1a 
N2a 
M0 
M0 
IIIB 
 
T1-4b 
T1-4b 
T1-4a 
T1-4a 
T1-4a/b 
N1a 
N2a 
N1b 
N2b 
N2c 
M0 
M0 
M0 
M0 
M0 
IIIC 
 
T1-4b 
T1-4b 
Any T 
N1b 
N2b 
N3 
M0 
M0 
M0 
IV 
Any T 
Any N 
Any M1 
Any T 
Any N 
Any M1 
* 
Clinical staging includes microstaging of the primary melanoma and clinical/radiologic evaluation 
for metastases.  By convention, it should be used after complete excision of the primary 
melanoma with clinical assessment for regional and distant metastases. 
† 
Pathologic staging includes microstaging of the primary melanoma and pathologic information 
about the regional lymph nodes after partial or complete lymphadenectomy.  Pathology stage 0 or 
stage 1A patients are the exception; they do not require pathologic evaluation of their lymph 
nodes. 
‡ 
There are no stage III subgroups for clinical staging. 
 
 
Staging for Mucosal Melanomas 
This system is based on the staging of cutaneous melanomas. 
 
Stage IIB: Clinically localized primary melanoma > 4mm thick 
Stage III: 
Lymph node metastases 
Stage IV: 
Distant metastases 
 
 


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12.5 
New York Heart Association Disease Classification 
Functional Capacity 
Objective Assessment 
Class I.  Patients with cardiac disease but 
without resulting limitation of physical activity. 
Ordinary physical activity does not cause undue 
fatigue, palpitation, dyspnea, or anginal pain. 
No 
objective 
evidence 
of 
cardiovascular 
disease. 
Class II.  Patients with cardiac disease resulting 
in slight limitation of physical activity. They are 
comfortable at rest. Ordinary physical activity 
results in fatigue, palpitation, dyspnea, or 
anginal pain. 
Objective evidence of minimal cardiovascular 
disease 
Class III.  Patients with cardiac disease 
resulting in marked limitation of physical activity. 
They are comfortable at rest. Less than ordinary 
activity causes fatigue, palpitation, dyspnea, or 
anginal pain. 
Objective evidence of moderately severe 
cardiovascular disease. 
Class IV.  Patients with cardiac disease 
resulting in inability to carry on any physical 
activity without discomfort. Symptoms of heart 
failure or the anginal syndrome may be present 
even at rest. If any physical activity is 
undertaken, discomfort is increased. 
Objective evidence of severe cardiovascular 
disease. 
* The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of 
Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256 
 
 


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12.6 
Vaccine Lot Release and Stability Testing 
A. Preparation of the synthetic melanoma and tetanus peptides 
All peptides were synthesized under GMP conditions by Multiple Peptide Systems (San Diego, 
CA).   
Peptide preparation and vialing were performed under GMP conditions by Clinalfa (Merck 
Biosciences AG, Laufelfingen, Switzerland).  Documentation relating to the procedures used to 
prepare and vial the peptides were included in the Chemistry and Manufacturing Section of prior 
IND application applications (10825 and 12191).   
B. Quality Assurance Testing 
Prepared peptides were subjected to the following tests: 
1. Identity.  Identity was confirmed by structural studies.  The individual peptides were tested for 
identity by mass spectrometry (to define molecular mass and amino acid sequence) and 
HPLC (to confirm purity) in a GMP laboratory (Polypeptide Group).  
2. Purity.  Purity was assessed before and after vialing the peptide mixtures.  Before vialing the 
peptide mixtures, each synthetic peptide was evaluated for the presence of a single dominant 
species by high pressure liquid chromatography (HPLC) in a GMP laboratory (Polypeptide 
Group).  Purity of each peptide component exceeded 90%. Variants of the original peptide 
may have included incomplete products of synthesis, minor degradation products due to 
oxidation of methionine residues, and dimerization of cysteine-containing peptides.  After 
vialing the peptide mixture, purity was reconfirmed by HPLC in a GMP laboratory (Clinalfa). 
3. Trifluoroacetic acid (TFA).  The amount of total fluorine in each peptide preparation was less 
than 0.5% or 5000 ppm as determined by Multiple Peptide Systems. 
4. Potency.  Peptides are synthesized under GMP conditions and the net peptide content 
calculated for each.  The amounts of each peptide (mcg quantities) added to the vaccine vials 
are calculated based on the net peptide content of the original stock of lyophilized peptides. 
5. Pyrogenicity.  Pyrogenicity testing was conducted by Clinalfa in accordance with USP 
guidelines. 
6. General Safety.  General safety testing was conducted by Clinalfa in accordance with USP 
guidelines. 
7. Sterility.  Sterility testing was conducted by Clinalfa in accordance with USP guidelines. 
8. Stability.  The peptide preparations were assayed for stability at months 3, 6, 12, 24, and 36 
and were shown to be stable. The peptides will continue to be assessed yearly for stability 
while subjects are on active treatment.  The following analyses will be performed to confirm 
stability. 
a. HPLC:  HPLC will be performed to confirm purity.  An optical comparison to previous 
HPLC data will be performed.  Ideally, the purity of each peptide component will exceed 
90% (94%-98%).  Variants of the original peptide may include incomplete products of 
synthesis, minor degradation products due to oxidation of methionine residues, and 
dimerization of cysteine-containing peptides.  Such minor variants will be tolerated as 
long as the peptide represents at least 75% of the intended peptide species.  Because 
measures of peptide quantity are subject to variability, a peptide lot will be rejected only if 
two sequential measures fail to meet the criterion stated above 


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b. Sterility.  One vial of peptide will be submitted to the Clinical Microbiology Laboratory at 
the University of Virginia or Microbiology Research Associates, Inc. (Acton, MA) for 
sterility testing.   
 
 


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12.7 
Summary of Changes 
Version Date 
Description of Changes 
7-13-18 
1. Section 5.2.1.3: removed text “or baseline” from the general instructions in 
Table 6. Dose Modification and Toxicity Management Guidelines for 
Immune-related AEs Associated with Pembrolizumab. 
6-14-18 
1. Updated Merck safety fax number through the protocol document. 
2. Removed references for draft text not used in version 6-01-18. 
6-01-18 
1. Study team updated to reflect personnel changes. 
2. Signature page edited to reflect Sponsor-Investigator role. 
3. Updated table of contents pages numbers.  
4. Updated hyperlinks and corrected minor typographical errors throughout 
protocol document. 
5. Sections 1, 2.1, 8: target enrollment reduced from 47 to 25 (22 eligible). 
6. Sections 2, 3.1, 4.3.3.1, 6.1, 7.1.4.1, 7, 8.2.2: requirement for sentinel 
immunized node removed. 
7. Sections 2.1, 5.2.1.4, 6: tumor imaging schedule was revised to match 
standard clinical care: 
-required scans at baseline, days 57 and 127 (with a window of ± 14 Days) 
and per standard care thereafter,  
-head scans at baseline and as clinically indicated thereafter.  
8. Sections 3, 4.3.3.1: study endpoints modified to focus more on immune 
response and effects of therapy on the tumor microenvironment. 
9. Section 4.3.1: added statement regarding factors associated with 
increased risk of recurrence. 
10. Section 4.3.2: added statement regarding 2 year treatment duration. 
11. Section 4.3.3.1: added text regarding measurement of T cell response, 
epitope spreading and the identification of neo antigens. 
12. Section 5.1.1: clarified staging timing, use of AJCC v7, and that subjects 
should be eligible to receive pembrolizumab per clinician judgement.  
13. Section 5.1.3: exclusion criteria 20 revised to indicate HGBA1C >8.5% as 
exclusionary. 
14. Section 5.2.1.3: replaced Table 6 with revised Merck provided table “Dose 
Modification and Toxicity Management Guidelines for Immune-related AEs 
Associated with Pembrolizumab” 
15. Section 5.2.1.4: edited table 7 to include biopsy and to indicate that scans 
 8 to 14 days from day 57 would not be considered a protocol violation. 
Section 5.4 
16. Section 7.1.3: removed bulleted list of labs and updated table 9 for 
consistency. Removed redundant Table 10 and renumbered later tables.  
17. Section 8: reduced number of subjects required to have biopsiable disease 
from 14 to 12. 
04-04-17 
1. Section 5.1.3: corrected exclusion criteria 4 regarding immunosuppressive 
therapy to within 7 days of registration to match inclusion criteria 6. 
2. Section 5.8.: referenced section 7.1.5.3.1 and 7.2.7.8 regarding adverse 
event monitoring after study treatment discontinuation. 
3. Section 6.1: removed comprehensive chemistry and CBC on days 8 & 15, 
and medication review at follow up visits after the safety follow up. Clarified 
biopsies may be collected at progression for research purposes or as part 
of clinical care in footnote “n”. 
4. Section 7.1.2.8.2: added section describing optional biopsies. 


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5. Section 7.1.2.8.3: added section to address tissue removed as part of 
clinicanl care. 
6. Section 7.2.5.1: clarified that an ulceration of 2 cm or less is considered an 
expected toxicity for the 6MHP. 
10-24-16 
1. Updated study personnel 
2. Updated Table of Contents 
3. Section 5.1.2 #3a:  revised to clarify the entry criteria for patients who had 
previously received a PD-1/PD-L1 antibody and progressed during or after 
that therapy. 
Section 5.1.2 #3b: revised to broaden the patient population to include 
patients who have not experienced an objective clinical response after 
anti-PD1 antibody or anti-CTLA4/anti-PD1 combination therapy, and who 
are candidates to receive pembrolizumab therapy. 
4. Section 5.1.3 #5: revised treatment window for prior monoclonal antibody 
treatment from 4 weeks to 3 weeks.   
5. Section 7.1.3.1: clarified that LDH would be tested every 6 weeks. 
09-07-16 
1. Section 5.1.3: updated exclusion criteria of pneumonitis per Merck 
investigator letter dated 7/25/16. 
2. Section 5.2.1.2: under 6MHP added “within” to clarify that the vaccine 
should be administered within 1-2 hours after mixing. 
3. Section 5.2.1.4: removed extra “2 years” in table 7 next to last row. 
4. Section 5.8: removed “up to one year of”, “study” and incorrect section 
reference, clarifying possible extended pembrolizumab treatment as part of 
clinical care. 
5. Section 6.1: added safety labs on days 8 & 15, indicated concomitant 
medication review at all clinic visits, and removed LDH from end of 
treatment/post-treatment table as it is included in the comprehensive 
chemistry panel. 
6. Section 7.1.5.2.2: removed “Phase” from heading as the second course 
treatment is not considered part of the study. 
03-21-16 
1. Editorial changes and typographical and formatting corrections were made 
throughout the study document. 
2. Updated investigator list. 
3. Section 1.0:  added estimated average length of treatment per patient to 
the trial summary table in accordance with Merck updates to the protocol 
template. 
4. Section 3.0:  revised the objectives based on the expansion of the patient 
population to include both patients who are naïve for or received 
ipilimumab or other anti-CTLA-4 antibody in the adjuvant setting or in the 
therapeutic setting for advanced melanoma.  The primary objectives have 
been changed to include safety and immunogenicity.  Exploratory 
objectives have been revised to include estimates of clinical response. 
5. Section 4.1:  revised background to include text to address the 
immunologic objectives and removed text related to the clinical objectives 
that were previously listed as primary objectives. 
6. Section 4.3.1:  revised rationale to include text to address the new primary 
objective of immunogenicity. 
7. Section 4.3.3.1:  added the ELIspot assay, proliferation assay, and/or flow 
cytometry as techniques that will be used to measure immune response. 
8. Section 4.3.3:  added a phrase clarifying that this study is the first 
evaluation of and PD-1/PD-L1 antibody in combination with a helper 
peptide vaccine. 
9. Section 5.1.2:  revised (#3) to broaden the patient population.  Subjects 
may be naïve for immunotherapy agents or have received interferon-alpha, 


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ipilimumab or other CTLA-4 antibody, PD-1 antibody (or anti-PD-L1 
antibody), interleukin-2, or prior cancer vaccines other than the 6MHP 
vaccine; however, patients who have received a PD-1/PD-L1 antibody 
must have experienced progression of melanoma after that therapy.   
10. Section 5.1.2:  revised (#5) to clarify that biopsies will be completed on 
sites that can be accessed safely. 
11. Section 5.1.2:  revised (#6).  Combined exclusion criterion #8 with 
inclusion criterion #6.  Added the following 3 bullet points to inclusion 
criterion #6:  
 
Neurologic symptoms have returned to baseline,  
 
There is no evidence of new or enlarging brain metastases,  
 
Subjects are not using steroids for at least 7 days prior to 
registration 
 
Removed the following bullet point from entry criteria (#6) 
 
 The total number of brain metastases ever ≤ 3. 
12. Section 5.1.2:  revised (#11) to specify that female subjects of childbearing 
potential must use an adequate method of contraception.  This change 
was based on updates to the Merck protocol template. 
13. Section 5.1.2:  revised (#12) to specify that male subjects of childbearing 
potential must use adequate method of contraception. A note clarifying that 
abstinence is acceptable has been added.  This change was based on 
updates to the Merck protocol template. 
14. Section 5.1.3:  deleted exclusion criteria for anti-PD-1, anti-PD-L1, anti-PD-
L2, or anti-CD137 (or any other antibody or drug specifically targeting T-
cell co-stimulation or checkpoint pathway, with the exception of 
ipilimumab). 
15. Section 5.2.13:  added the revised dose modification guidelines for drug-
related adverse events.  This change was based on updates to the Merck 
protocol template. 
16. Section 5.2.1.4:  corrected Table 7  
a. to specify “safety” follow-up and to remove scans at the safety 
follow-up visit. 
b. Correct description of the timing of the follow-up visits 
17. Section 5.2.1.4:  corrected 
18. Section 5.5.2:  clarified that investigational agents (with the exception of 
pembrolizumab and 6MHP during active treatment) are not permitted. 
19. Section 5.6:  added a statement to clarify utilization of the treatment 
guidance (section 5.2.1). 
20. Section 5.7.2:  updated the contraception section of the protocol to clarify 
the criteria for non-reproductive potential, the conditions for using 
contraception and the acceptable methods of contraception.  These 
changes were based on updates to the Merck protocol template. 
21. Section 5.8:  deleted the note referring to section 5.2.2 for unconfirmed 
disease progression. 
22. Section 5.8:  Clarified the length of time of treatment with pembrolizumab 
for the purposes of discontinuing from the study protocol. 
23. Section 6.1:  Deleted footnote “f” PT/INR and aPTT and removed PT/INR 
and aPTT from footnote “f” as these labs are not completed as part of the 
day 1 assessment. 
24. Revised footnote “l” to specify that the safety follow-up visit for subjects 
who discontinue 6MHP will occur at the time of their next infusion of 
pembrolizumab. 
25. Section 7.1.2.1:  removed reference to the separate ECI guidance 


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document.  This document is no longer required (per Merck) as the criteria 
for capturing events of clinical interest have been modified (see section 
7.2.7.10).  This change was based on updates to the Merck protocol 
template. 
26. Section 7.1.3.1:  added LDH to the clinical lab list to be consistent with 
Table 9. 
27. Section 7.2:  revised the ordering of this section to improve readability. 
28. Section 7.2.1:  added a statement to clarify that progression of the cancer 
is not considered to be an adverse event. 
29. Section 7.2.1:  Revised description of collection of adverse events during 
pre-allocation baseline period and moved this paragraph to section 7.2.7.1. 
30. Section 7.2.1:  Added adverse events that are reportable to Merck within 
the same timeframe as SAEs, according to the Merck protocol template. 
31. Section 7.2.3,Table 11: 
a. Added a statement to define pre-existing condition. 
b. Clarified reporting guidelines for the development of new cancers. 
c. Clarified reporting guidelines for an overdose. 
d. Added the term “investigational” when describing the relationship 
to the drug. 
e. Clarified the description of how to determine whether there is a 
reasonable possibility of Merck product or 6MHP relationship to an 
adverse event. 
32. Section 7.2.6:  Reordered this section to improve readability 
a. Revised the DLT definition for pembrolizumab to be consistent 
with guidelines for discontinuing treatment as outlined in table 6. 
b. Revised definition for ocular DLTs. 
c. Removed Grade 1 ocular toxicities as DLTs  
33. Section 7.2.7.1:  Added the second paragraph to describe the 
requirements for adverse event reporting after the consent form is signed, 
but before treatemt allocation/randomization occurs. This change was 
based on the language provided in the Merck template. 
34. Section 7.2.7.6: Revised to describe the requirements for reporting 
pregnancies and lactation. Changes were based on the updated language 
provided in the Merck template. 
35. Section 7.2.7.8:  Revised the description for reporting SAEs to the 
Sponsor-Investigator and to Merck.  These changes were based on the 
updated language provided in the Merck template. 
36. Section 7.2.7.9:  This section has been added.  These changes were 
based on the updated language provided in the Merck template. 
37. Section 8:  The statistical section was revised based on the changes made 
to the study objectives. 
38. Summary of changes:  reordered list beginning with the most recent 
changes. 
39. Summary of changes:  corrected version date from 07-29-15 to 07-30-15. 
07-30-15 
1. Updated study personnel. 
2. Updated Table of Contents 
3. Updated Table Numbers. 
4. Editorial changes throughout the document. 
5. Added IND # to the protocol document. 
6. Section 3.3:  removed durable clinical response and durable disease 
control as exploratory objectives as these objectives were not meant to be 
included as part of the study design. 
7. Section 5.1.2 (#7):  deleted “and ≤ 6 months” as this time frame was 
incorrect for the intended population. 


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8. Section 5.1.3 (#3):  Added wording to clarify the window for receiving 
nitrosureas. 
9. Section 5.1.6 (#6):  Deleted reference to gamma knife administration as the 
timing of gamma knife administration is covered in the inclusion criteria. 
10. Section 5.2.1.2:  Revised to specify that vaccines 4-6 will be administered 
at the same site. 
11. Section 6.1:  Added footnotes “u” and “v” to the study flow chart to clarify 
reference to timing of the pregnancy test and to refer the reader to Table 9 
for details on the comprehensive chemistry panel. 
12. Section 6.1:  Revised footnote “f” to include clarification for timing of 
PT/INR and aPTT 
13. Section 6.1:  Removed LDH as a separate line item as LDH is included as 
part of the chemistry panel (see Table 9). 
14. Section 7.1.2.8.1:  Added a statement to clarify that image guidance may 
be used during the biopsy procedures.  This is consistent with section 
5.1.2(#5). 
15. Section 7.1.2.8.1:  Revised the number of core biopsies from five to six.  
The intent was to include six core biopsies as described under the 
“Procedure” section of this portion of the protocol. 
16. Section 7.2.5:  Revised this section to move the language describing ocular 
dose-limiting toxicities to section 8.2.1.1 of the protocol. 
17. Section 7.2.7.2:  Changed the cross-reference for reporting from protocol 
section 9.6 to section 7.2.7.3. 
18. Section 8.2.1.1:  Revised the DLT section to : 
a) Clarify that small ulcerations are expected in a subset of subjects and 
are not considered DLTs. 
b) Reformat DLT list and the “Exceptions to DLT” list for pembrolizumab 
to include information in a table, per the suggestion from the IRB. 
c) Added a category of “Other drug-related toxicities not specified in 
8.2.1.1” to the DLT Table 17.  
d)  Moved the definition of ocular DLTs from section 7.2.5 to this section 
of the protocol. 
19. Section 8.5: Added a statement to the Safety Monitoring section to clarify 
the timing of DLT monitoring. 
05-20-15 
1. Revised Table of Contents 
2. Section 7.2.5:  Added definitions for adverse event classifications for 
clarification. 
3. Section 7.2.6.2:  Revised this section to refer the reader to the tables in the 
investigator brochure for a description of treatment-related adverse events. 
4. Section 7.2.6.3:  Added delayed wound healing, scarring, and numbness 
to the list of expected toxicities for the biopsies. 
5. Section 8.2.1.1:  Revised the definitions of dose-limiting toxicities for 6MHP 
and pembrolizumab.  The pembrolizumab definition has been based on 
unacceptable toxicity requiring discontinuation, per table 6. 
6. Editorial changes have been made throughout the study. 
05-18-2015 
7. Updated header 
8. Updated study personnel 
9. Added the Investigator Statement page 
10. Updated Table of Contents 
11. Section 5.1.1:  entry criteria revised for clarification of disease stage in 
response to PRC review. 
12. Section 5.1.2 (#3):  revised for clarification for subjects who fail ipilimumab 
in response to PRC review. 
13. Section 5.1.3 (bullet point 8):  revised for clarification of brain metastases 


Product:  Pembrolizumab (MK-3475)  
88 
Protocol: UVA-Mel-64  
Version Date:   07/13/18 
 
 
 
  
 
University of Virginia Human Immune Therapy Center --Confidential  
 
 
in response to PRC review 
14. Section 5.5.1:  revised to include nasal corticosteroids and to be consistent 
with entry criteria. 
15. Section 5.5.2:  1) revised to specify 6MHP and 2) revised to allow inhaled 
steroids at low doses and to be consistent with entry criteria. 
16. Section 6.1:  removed ECGs as part of the required testing as ECGs are 
not required with pembrolizumab treatment. 
17. Section 7.2.2:  1) added “study drugs or protocol-specified procedures” for 
clarification of the definition of adverse event, 2) clarified the definition of 
serious AE to include events that occur during the study. 
18. Section 7.2.6.2:  added this section to specify the lab values that are 
required to be recorded in the UVA Cancer Center database.  
19. Editorial comments were made throughout the study protocol.